Obstetric haemorrhage Flashcards
Placenta accreta
a) Should be assumed if…?
b) Types of adherent placenta
c) Management: care bundle (6 things: MBCHB)
d) Management of delivery
a) Praevia + previous CS
b) Accreta: chorionic villi penetrate the decidua basalis to attach to the myometrium
- INcreta; villi penetrate deeply INto the myometrium
- PERcreta: villi PERforate the myometrium into the peritoneum
c) MBCHB:
- Multidisciplinary team pre-operative management
- Blood and blood products available
- Consultant obstetrician and anaesthetist at delivery
- Hysterectomy discussed and consented
- Bed available in CCU
d) - CS at 36-37 weeks
- Conservative: leave placenta in place +/- UAE, internal iliac artery ligation or methotrexate therapy (may preserve future fertility)
- Elective hysterectomy (may be required)
- NB. Do not manually remove placenta - will lead to emergency hysterectomy in 100% cases
APH.
a) Define
b) Causes
c) Classification
d) Complications - maternal and foetal
a) PV bleed from 24 weeks gestation, up until the end of the 2nd stage of labour (delivery of the baby)
- Bleeding post-delivery of the baby = PPH
- Bleeding before 24 weeks = threatened miscarriage
b) Causes:
- PLACENTA PRAEVIA
- PLACENTAL ABRUPTION
- Trauma (e.g. sexual) / domestic abuse
- Vasa praevia
- Uterine rupture
- Bleeding disorder
c) - Minor APH: < 50 ml
- Major APH: 50 - 1000 ml (with no signs of shock)
- Massive APH: > 1000 ml (or signs of shock)
d) - Maternal: shock, DIC, infection, AKI, PPH
- Foetal: hypoxia, growth restriction, prematurity, death
APH: initial management
note: further management depends on cause
- Admit to labour ward for A-E assessment
- Estimate blood loss (note: may be concealed)
- Do NOT perform PV exam (very bad in praevia)
- Position in left lateral position
- IV access: FBC, UEs, LFTs, clotting, group/save, X-match FOUR UNITS, IV fluids +/- blood transfusion
- Kleihaeur test (Rh status - anti-D if mother Rh negative)
- Foetal monitoring (CTG): if distressed, deliver* (irrespective of foetal age; mother’s life takes priority)
- Risk of preterm birth (24 to 35+6 weeks): maternal steroids
- delivery of baby will usually stop the bleeding
Placenta praevia.
a) Define
b) Classification
c) Risk factors
d) Clinical features
e) Diagnosis
a) Low-lying placenta
b) - Major: covers internal os
- Minor/partial: does not cover internal os
c) - Hx of: praevia, CS, multiparity, abortion
- Current: older age, smoking, cocaine use
d) - Often incidental finding (at 20-week anomaly scan)
- Painless bleeding after 24 weeks gestation (APH)
- Bleeding may be provoked by intercourse
- Preterm labour
- Abnormal lie/high presenting part
e) - Confirmed by TVUS
Placenta praevia: management
a) Asymptomatic minor praevia on 20-week scan
b) Asymptomatic major praevia on 20-week scan
c) Symptomatic praevia (bleeding) at any stage
d) In SEVERE - 2 definitive management techniques to arrest bleeding
e) If previous CS - ?
a) TVUS at 36 weeks
- If < 2cm from cervical os - CS at/before 38 weeks
- If > 2cm from os - may have NVD (unless RFs, eg. previous CS)
b) TVUS at 32 weeks - if no migration, need to plan for delivery:
- Require CS: ideally at 38 weeks (36-37 for accreta; may need to be earlier if any PV bleeding)
- Abstain from penetrative sex
c) - Admit to labour ward, manage as for APH
- Encourage to stay in hospital from 34 weeks
- Do NOT perform PV exam
- Acute bleed: A-E, resuscitation, foetal monitoring, etc.
d) Delivery of baby and hysterectomy
e) Assume accreta
- Accreta care bundle (MBCHB)
Placental abruption.
a) What is it?
b) 2 types
c) Risk factors
d) Triad of clinical features
- if severe: other possible features
e) Management
- decision on delivery?
a) Premature separation of a normally placed placenta before delivery of the fetus, with blood collecting between the placenta and the uterus.
b) Concealed (20%): haemorrhage contained within the uterus; generally worse outcomes
- Revealed (80%): PV bleed; generally better outcomes
c) - Usually no risk factors (difficult to predict)
- Previous abruption
- Previous CS
- Multiple pregnancy
- Threatened miscarriage in current pregnancy
- Pre-eclampsia, HTN, trauma
d) Abdominal pain, vaginal bleeding (if revealed) and uterine contractions (tense, woody uterus)
- Severe: shock, collapse, foetal distress/death
e) - Admit urgently to labour ward
- A-E assessment - oxygen, IV access: FBC, clotting, UEs, LFTs, group/save, X-match 4 units, Kleihaeur test (Rh status and anti-D if Rh negative)
- Position in left lateral position
- Infuse IV fluids up to 2L until blood available
- Then infuse 4 units of FFP
- Foetal monitoring and decide on delivery:
1. if dead - NVD;
2. if alive and active bleeding - emergency CS;
3. if alive and bleeding has stopped - maternal steroids and monitor until delivery
Uterine rupture.
a) Definition and classification
b) Risk factors
c) Presentation
c) Management
a) - Occult/incomplete rupture: separation of surgical scar (from previous CS) but intact visceral peritoneum
- Complete rupture: full-thickness uterine muscle rupture, leading to expulsion of foetus into the peritoneum
b) - Usually occur in labour, but may be 3rd trimester
- Previous CS, grand-multiparity, trauma, induced labour (especially if VBAC), inappropriate delivery
c) Sudden tearing uterine pain, vaginal haemorrhage (APH), cessation of uterine contractions, regression of the fetus
d) - Admit urgently to labour ward and A-E assessment
- May confirm with TVUS: abnormal fetal position, haemoperitoneum or absent or thin uterine wall
- Foetal monitoring
- If maternal or foetal condition poor - emergency CS
- Will require uterine repair or hysterectomy
Vasa praevia.
a) What is it?
b) Risk factors
c) Presentation
d) Management
a) Foetal vessels cross the internal os; will rupture and kill foetus if SROM and normal delivery is allowed
b) Placenta praevia, IVF, multiple pregnancy
c) - APH (PV bleed) - risk is to foetus, not mother
- Incidental finding on TVUS
d) - Bleeding: emergency CS
- Asymptomatic: elective CS
A 26 year old woman in her 1st pregnancy presents to the labour ward with vaginal bleeding. No antenatal care in her pregnancy so far.
- O/E: uterus at full term, brisk active vaginal bleeding
and the estimated blood loss is 300 ml. Abdomen moderately tender and evidence of contractions.
The fetal heart is present.
a) How would you initially assess and manage this patient?
b) What are the differential diagnoses for this patient’s symptoms? Which diagnosis is the most likely
and why?
c) What further management including counselling for her next pregnancy will you offer this patient?
a) APH:
- Admit to labour ward
- A-E assessment: estimate blood loss
- Left lateral position
- IV access (FBC, UEs, LFTs, clotting, X-match 4 units)
- Kleihaeur test for Rh status (anti-D Ig for Rh negative mother)
- IV fluids and transfuse blood
- Foetal monitoring - if compromised, immediate delivery
(No need for steroids as she is at term)
- Decide on delivery
b) Likely placenta praevia as no pain
c) Risk of praevia in subsequent pregnancies; also if she required a CS - risk of praevia and accreta much higher
Primary PPH.
a) Define
b) Classification: major and minor
c) Causes
d) Risk factors
a) PV bleeding > 500 ml in first 24 hours post-delivery
b) Minor: 500 - 1000 ml, Major > 1000 ml
c) Tone: uterine atony, distended bladder (often due to overdistended uterus: hydramnios, multiple gestation, macrosomia, high parity)
Trauma: lacerations of the uterus, cervix, or vagina
Tissue: retained placenta or clots
Thrombin: pre-existing or acquired coagulopathy
d) - Current pregnancy: APH, praevia, abruption, multiple pregnancy, pre-eclampsia or HTN
- Previous: PPH, grandmultiparity, bleeding disorder
- Delivery: CS (elective or emergency), retained placenta, prolonged labour, induced labour, instrumental delivery, macrosomia
Primary PPH: management (CRAMP)
Communication
- Midwife, obstetrician, anaesthetist, etc.
Resuscitation
- A-E approach: oxygen, lie flat, IV access, transfuse fluids and 4 units of blood
Arrest bleeding
- Manual: bimanual uterine compression, empty bladder
- Medical: IV oxytocin, IV ergometrine, +/- IM carboprost
- Surgical (if required): balloon tamponade, B-lynch suture, artery ligation/embolisation, hysterectomy
Monitoring and investigation:
- FBC, BP, group and save, cross-match 4 units
- HR, BP, temperature, urine output
Prevention
- Active 3rd stage of labour: prophylactic IM oxytocin
Secondary PPH.
a) Define
b) 2 main causes
c) Risk factors
d) Presentation
e) Clinical sign with RPOC
f) Investigations
g) Management
a) PV bleeding from 24 hours - 6 weeks post-delivery
b) - Endometritis
- Retained POC
c) CS, PROM, meconium stained liqour, prolonged labour
d) PV bleed or discharge, fever, abdo pain, offensive smelling lochia, dyspareunia, dysuria
- Signs of sepsis +/- shock
e) Elevated boggy fundus
f) - Bedside: urine dip, MSU, HVS (chlam/gono)
- Bloods: FBC, cultures.
- Imaging: TVUS (?RPOC)
- Special tests: consider speculum
g) - Endometritis: admit and IV tazocin
- RPOC: admit and surgical curettage + ABx
A 34 year old patient with 4 previous normal deliveries presents to the labour ward with regular contractions. When examined she is 4cm dilated; an hour later she is fully dilated and after two pushes she proceeds to a normal vaginal delivery of a 4.2 kg baby.
Syntocinon IM is given for active management of the 3rd stage but following delivery of the placenta by controlled cord traction she experiences a brisk PV loss.
a) How will you initially assess and manage this patient?
b) Which of the four “T”s do you think is the main cause for this PPH and why?
c) Identify the risk factors for this patient’s PPH.
d) If bleeding does not settle after initial measures when would you consider transferring her to theatre? What are the surgical options for management of PPH?
a) Primary PPH (CRAMP)
- Communications
- Resuscitation: A-E assessment, administer 100% oxygen 15L/min via NRB, IV access: FBC, UEs, LFTs, clotting, X-match 4 units, IV fluids (warmed Hartmann’s) and blood transfusions, Kleihauer test and anti-D if rhesus negative
- Arrest bleeding (bimanual uterine compression, empty bladder, IV oxytocin and ergometrine, consider surgery
- Monitor and investigate (bloods, obs, etc.)
- Prevention (not relevant now - already had oxytocin for active 3rd stage)
b) TONE: macrosomic baby and very fast labour.
- Risk factors for atony: hydramnios, multiple gestation, use of oxytocin, fetal macrosomia, high parity, rapid or prolonged labor, intra-amniotic infection and use of uterine-relaxing agents
c) High parity
d) Balloon tamponade, B-lynch suture, artery ligation/embolisation, hysterectomy
Perineal tears.
a) Grading
b) Preferred episiotomy and why
c) Management
a) 1st - superficial (vaginal mucosa/perineal skin)
2nd - posterior vaginal wall and perennial muscles, but the anal sphincter is intact
3rd - anal sphincter involvement
4th - anal canal +/- rectal mucosa involvement
b) Mediolateral - if it extends, it misses the anal sphincter as the cut extends 45 degrees to it
c) Sutured repair (if 3rd/4th degree - should be done by obstetric registrar or consultant)
