Obstetric Bleeding and Harmorrhage Flashcards
What is antepartum bleeding and is it ever normal?
This is bleeding after 24 weeks gestation (viability) prior to this miscarriage is more likely the diagnosis. Bleeding preterm is never normal. The only time we expect to see some spotting or bleeding are the two placental invasions at 8 weeks and 12-14 weeks.
What are the likely causes of bleeding the 1st, 2nd and 3rd trimesters respectively?
1st trimester
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
2nd trimester
Spontaneous abortion
Hydatidiform mole
Placental abruption
3rd trimester Bloody show Placental abruption Placenta praevia Vasa praevia
How should you assess antepartum bleeding in a history?
Investigate bleeding – fresh, brown, volume and when does it occur? Any provocation – e.g. coitus or trauma Foetal movements Rule out SROM Check for contractions Look for local causes Date of last smear test Previous surgery important
How should you investigate antepartum bleeding?
CTG Speculum exam to check if os open but must rule out placenta praevia first Vaginal swabs to rule out infection FBC and clotting profile Rhesus status Group and save Explore hypertension and pre-eclampsia Basic obs looking for hypovolaemia Look for local causes e.g. cervical cancer, local cuts and abrasions
What is placental abruption and what are the two types?
Definition – part or all of the placenta separates from the wall of the uterus prematurely. This occurs due to rupture of the maternal vessels within the basal layer of the endometrium. Blood splits the placental attachment and irritates the uterus.
Revealed – bleeding leaks down through the cervix and presents as vaginal bleeding
Concealed – blood remains in the uterus and forms a clot – not per vaginal bleeding and may present as shock
What are the risk factors for placental abruption?
Previous placental abruption Pre-eclampsia Abnormal lie – transverse Polyhydramnios Abdominal trauma Smoking or IVDU (especially cocaine) Underlying thrombophilia Multiple pregnancy
How does placental abruption typically present?
PV bleeding
Generalised sudden onset, constant, severe abdominal pain
Tender uterus on palpation due to blood irritation
Contractions (50% will be in labour)
Rock hard abdomen (woody)
Foetal distress e.g. bradycardias
Hypovolaemic shock symptoms leading to abnormal clotting and DIC
If in labour pain between contractions
How should a placental abruption be managed?
ABCDE if in shock
Establish foetal wellbeing with CTG and arrange USS
IV access and bloods
Emergency delivery if maternal or foetal compromise
IOL if no compromise or operative vaginal delivery
Conservative management – partial or marginal abruptions
Give Anti D within 72 hours of the onset of bleeding
What is placenta praevia and how can it be classified?
Definitions – placenta has attached to the lower section of the uterine wall. This could be anterior or posterior and is classified by how close to the internal os it is or if it actually covers the os.
Major – placenta lies over the internal os
Minor – placenta lies close to or encroaching on the internal os
What are the risk factors for placenta praevia?
High parity Maternal age > 40 Multiple pregnancy Previous history of placenta praevia Uterine infections history Curettage use Scarring of the uterus i.e. caesarean section Assisted reproductive technology
How is placental praevia usually picked up and how should it be investigated through out pregnancy?
First diagnosis usually made at the 18-20+6-week anomaly scan as low-lying placenta. Praevia diagnosed after 28th week when the lower segment of the uterus is formed.
Low lying placenta – within 20mm of the internal os
Placenta praevia – covering the internal os
Follow up TVS recommended at 32 weeks to diagnose if it is persistent
Again at 36 weeks if persistent to inform delivery mode
How should placenta praevia be managed?
If bleeding is light and settles after 24 hours, then discharge with safety netting. Elective Caesarean section at 38 weeks and give Anti D within 72 hours of the onset of bleeding. If worried check Umbilical artery doppler
If bleeding is heavy or wont’s stop then: ABCDE, Emergency Caesarean section.
What are the complications from placenta praevia?
Complications
As lower segment of the uterus doesn’t contract as much there is an increased risk of PPH
What is vasa praevia?
Definition – foetal vessels run in membranes below the presenting foetal part unsupported by placental tissue or umbilical cord.
How does vasa praevia usually present?
Presentation – PV bleeding shortly after membrane rupture followed by foetal bradycardia and other sign of foetal distress with resulting high foetal mortality.
What are the risk factors for vasa praevia?
Risk Factors: • Low-lying placenta • Multiple pregnancy • IVF pregnancy • Bilobed and succenturiate placentas
How should vasa praevia be managed?
Deliver baby immediately – Cat 1 CS
What is a morbidly adherent placenta and what are the different types?
Abnormal placentation is more common where there has been a previous C-section. Sometimes the placenta implants deep into uterine wall so that it is involved with the myometrium.
Accreta – placental villi are attached to myometrium
Increta – villi invaded into >50% of the myometrium
Percreta – villi pass through the whole myometrium and may involve other viscera – bladder and bowl etc.
What are the risk factors for morbidly adherent placentas?
Risk Factors
• Previous C sections and other uterine surgery
• Repeated surgical termination of pregnancy
Hows should morbidly adherent placentas be managed?
Heavy bleeding – blood replacement, tamponade with Rusch balloon or hysterectomy
Minimal bleeding – leave placenta in situ with close monitoring
What is primary post partum haemorrhage?
Primary – 500ml blood loss within 24 hours of delivery
Minor 500ml-1L
Major > 1L
What are the risk factors for primary post partum haemorrhage?
Hint think antenatal vs intrapartum risks
Antenatal • Maternal age > 40 • Maternal BMI > 35 • Asian • Uterine overdistension – multiple pregnancies, polyhydramnios and big baby • Previous PPH or retained placenta • Multiparous (>4) • Antepartum haemorrhage • Placental abnormalities – low lying, accreta etc.
Intrapartum
• Induced i.e. oxytocin use or prolonged labour
• Vaginal operative delivery
• CS
Anyone with these risk factors should not be considered for home birth
What can cause primary post partum haemorrhage?
Tone – uterine atony (most common)
Placental problems – Praevia, abruption and previous PPH
Tissue – retained placenta tissue – second most common
Trauma – such as tears, episiotomy or C section
Thrombin – vascular and clotting abnormalities VWB, haemophilia or acquired such as DIC or HELLP
Vascular – hypertension and pre-eclampsia
How should suspected primary post partum haemorrhage be investigated?
Abdominal examination
Vaginal examination and speculum
Check completeness of the placenta
FBC, cross match, clotting profile
How should primary post partum haemorrhage be managed if uterine atony is the likely cause?
ABCDE
IV access – 2 large bore cannula
Consider TXA and transfusions
Uterine Atony
Bimanual compression with hand formed as fist in anterior fornix and other hand giving abdominal pressure (ensure bladder emptied by catheterisation)
Pharmacological and surgical measures to increase contractions:
1. Syntocinon – contraindicated in hypertonic uterus and severe CVD and/or ergometrine – contraindicated in hypertension, eclampsia and vascular disease
2. IM Carboprost (prostaglandin analogue) – contraindicated in CVD and pulmonary disease e.g. asthma and untreated PID
3. Rectal or sublingual Misoprostol (prostaglandin analogue) – can cause diarrhoea
4. Surgical – intrauterine balloon tamponade or haemostatic suture. Hysterectomy last resort.
How should post partum haemorrhage be managed if tissue, trauma or thrombin are thought to be the cause?
ABCDE
IV access – 2 large bore cannulae
Trauma – primary repair, if uterine rupture then laparotomy or hysterectomy
Tissue – IV syntocinon, manual removal of placenta. IV syntocinon after removal as well.
Thrombin – correct coagulation abnormalities
How can primary post partum haemorrhage be prevented?
Vaginal delivery – active 3rd stage management – 5-10 units of oxytocin IM
C-section – 5 units of oxytocin IV
What is secondary PPH?
Bleeding from 24hours post-partum to 12 weeks post-partum. Nulliparity is a risk factor.
What causes secondary PPH?
Uterine infection (endometritis) – Risks include C-section, PROM and prolonged labour
Retained placental tissue fragments
Abnormal involution of the placental site
Trophoblastic disease (very rare)
How does secondary PPH usually present?
Spotting with occasional large gushes or massive haemorrhage. If endometritis, then may also have fever foul smelling discharge etc. Abdominal pain (endometritis)
How should secondary PPH be investigated?
Speculum examination
FBC, clotting profile, CRP, Group and save
USS for retained placental tissue
Rule out STDs and first period
How should secondary PPH be managed?
Antibiotics – (clindamycin and Gentamicin) if endomyometritis or sepsis is suspected.
Uterotonics as described for PPPH.
Surgical – balloon catheter, artery ligation or hysterectomy
Note high risk of uterine perforation at this stage due to how soft the uterus can be so senior consultant should be involved.
What is Sheehan’s syndrome?
Sheehan’s syndrome is a complication of severe postpartum haemorrhage (PPH) in which the pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism. The most common physical sign of Sheehan’s syndrome is a lack of postpartum milk production and amenorrhoea following delivery. Diagnosis of Sheehan’s is by inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe PPH.
