Module 3: bleeding in pregnancy Flashcards
Antepartum Haemorrhage: Definition and incidence
Any bleeding from the genital tract after 20 weeks gestation and before the onset of labour
Approx 6% of women have vaginal bleeding during the third trimester
Causes of APH
Placenta previa (25%)
Placental abruption (35%)
No specific cause (35%)
Other specific causes (5%)
* Vasa previa
* Uterine scar disruption
* Cervical ectropian/eversion
* Vaginal infections
* Post coital
* Heavy show
* Vulval variscosities
Placenta previa: Definition, incidence
Placenta is partially or completely implanted in the lower uterine segment on either the anterior or posterior wall
Incidence: 0.5% of pregnancies in third trimester
Placenta previa risk factors
Endometrial scarring:
* Previous LSCS, TOP, previous placenta previa (4-8% recurrence),
* Increased parity >4
* Closely spaced pregnancies
* ART
Impeded endometrial vascularisation:
* Hypertension
* Diabetes
* Drug use
* Smoking
* Increased maternal age
Increased placental mass:
* Multiple pregnancy
Abnormally shaped uterus:
* Fibroids
* Bicornuate
Placenta previa clinical features
The uterus is soft and non tender
Majority of women present with bright painless bleeding
Most common timing of first bleed is between 27-32 weeks
Malpresentation or abnormal lie
Management of placenta previa
Monitor maternal observations
CTG monitoring
Place woman in a lateral position
Palpation
Weigh pads
No vaginal examinations
IV cannulation and fluid replacement
Referral/timely consultation
U/S
Reassurance
No sex
Documentation
Placental abruption: definition and incidence
Premature separation of a normally implanted placenta. Maternal hemorrhage occurring in the decidua basalis and causing separation. The hemorrhage may be concealed, revealed or both.
Incidence 3-5% of all pregnancy
Mortality rate over 50%
Placental abruption risk factors
Hypertensive disorders in pregnancy
Previous abruption (10% risk of recurrence)
Trauma
Cigarette smoking
Cocaine and amphetamine use
PROM
Twins
Polyhydramnios
Following ECV
Unknown
Placental abruption clinical features
Dark vaginal bleeding
Abdominal or lower back pain
Uterine hypertonus
Uterine contractions: increased frequency and decreased amplitude
Uterine tenderness
Fetal lie normal
Fetal distress
Observations may be normal initially
Management of placental abruption
Monitor observations
Perform palpation
CTG
Lateral position
Monitor PV loss
Notify RMO
IV cannulation
Steroids if <34 weeks
Group and cross match, Kleihauer, FBC and clotting factors
U/S
Conservative versus LSCS
PPH risks
Documentation
Complication of abruption
Maternal shock
Anaemia
Couvelaire uterus
Infection
PPH
Prematurity
Fetal distress/Fetal death
Vasa previa
Occurs when a valamentous insertion of the umbilical cord crosses the cervical os ahead of the presenting part.
Usually presents with significant bleeding associated with ROM.
Mortality rate around 60%
Vasa previa management
If diagnosed prior to labour elective LSCS is performed
If in labour once vasa previa is confirmed in the presence of a live fetus LSCS is performed
Mortality rate around 60% as blood volume of fetus is approx 250mL and the bleeding comes from the fetal source
Isoimmunization: Definition
Sensitisation of a species with antigens from the same species.
Rhesus isoimmunisation
Occurs when a pregnant woman is sensitised to produce antibodies against fetal red blood cells. Usually from the Rh (neg, mum, pos baby) or ABO blood group.
