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Obstetrics & Gynaecology > Obstetric haemorrhage > Flashcards

Obstetric haemorrhage Flashcards

1
Q

Definition of APH?

A

Bleeding from the genital tract after the 24th week of pregnancy

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2
Q

What are the causes of APH?

A 
Placenta praviae 
Placental abruption 
Vasa praeviae 
Uterine rupture 
Local causes- cervical polyp, cervical ectropion, cervical carcinoma, cervicitis, vaginitis
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3
Q

How is placenta praeviae classified?

A

May be anterior or posterior
Marginal- placenta in front of the fetal presenting part but doesnt cover the os
Major- placenta completely or partially covers the os

Note a LLP <2cm away from internal cervical os, and in 2nd trimester but only 1 out of 10 will be praevia at term

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4
Q

What are the risk factors for placenta praviae

A
  • Multiparity, multiple pregnancy
  • C-section scar
  • Submucous fibroids
  • Increasing maternal age
  • Maternal smoking
  • Reproductive techniques
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5
Q

What are the complications of placenta praviae

A
  • Prevents engagement of head and causes transverse lie
  • Massive haemorrhage and fetal hypoxia, also cause PPH
  • 10% association with placenta accreta- may also cause PPH and pre-term delivery
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6
Q

Which examination must you never conduct in placenta praevia?

What are finding on abdominal examination?

A

vaginal examination- may cause bleeding

Fetal head not engaged, transverse lie and head in not centre of pelvic brim

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7
Q

How do you diagnose a placenta praviae?

A
  1. Transabdominal ultrasound at 20 weeks
  2. Confirm with TVS at 32 weeks
  3. Follow up TVS at 36 weeks if asymptomatic
  4. At 34 weeks, if cervical length short then high risk of preterm and haemorrhage at C-section
  5. CTG to look for fetal distress
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8
Q

What is the management of placenta praeviae?

A
  1. If pre-term <34 weeks or 34-35+6 then cortiscosteroids
  2. If asymptomatic then elective C-section at 36-37 weeks
  3. If bleeding or risk factors for pre-term then admit to hospital: 34 weeks to 36+6 weeks but if CTG show fetal distress then do

Hameorrhage controlled by Rusch ballon or hysterectomy and resus patient

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9
Q

How do you classify placental abruption?

A

Group 1: mild bleeding and no retroplacental bleeding

Group 2 and 3: Retroplacental bleeding and moderate and severe haemorrhage ( ie <1500ml and >1500ml)

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10
Q

What are the complications of placental abruption? (clue due to coagulation defects)

A
  • Renal failure- oligouria, tubular necrosis
  • DIC
  • Death
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11
Q

What are the risk factors for placental abruption (major and minor)

A

Major:

  • Pre-eclampsia
  • Maternal smoking
  • Previous placental abruption
  • Intrauterine growth restriction

Minor:

  • Cocaine/amphetamine usage
  • autoimmunity
  • maternal parity
  • thrombophillia
  • Intrauterine infections
  • trauma or sudden drop in uterine volume eg ROM in polyhydroamnios
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12
Q

What is a couvelaire uterus in placental abruption?

A
  • When bleeding severe goes in between myometrial fibres resulting in bruised, oedematous uterus
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13
Q

What are the examination findings of placental abruption?

A

Tender, contracting uterus
Woody hard uterus
Evidence of bleeding if coaugulation failure
CTG- fetal heart rate abnormalities

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14
Q

Investigations of abruption?

A

Transvaginal ultrasound exclude PP
CTG
- FBC, coag screen, cross match 4 units of blood

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15
Q

Management of abruption according to baby?

A

> 37 weeks no fetal distress- induction via amniotomy
Fetal distress- C section
Resuscitation ABCDE- with catheter, blood tranfusion
If major then 1500ml transfusion if severe then 2500ml

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16
Q

What is vasa praevia, and when does bleeding occur?

How do you manage it

A

Velementious insertion of cord to membranes, fetal blood vessel below fetal presenting part and attached to membranes

Amniotomy and ROM have hameorrhage of fetal blood vessel

C-section not quick enough, neonate resus blood transfusion

17
Q

What are the causes of Uterine rupture?

A

Classical C-section sear, myomectomy, other pelvic surgery
Denovo tear
Neglected obstructed labour, innappropriate use of
- oxytocin in labour, vaginal delivery of breech baby when cervix not fully dilated
- RTA/ trauma
- Congenital uterine abnormalities- more likely to have rupture before labour
- Macrosomia, polyhydroamnios

18
Q

What are features/diagnosis of uterine rupture?

A

Constant lower abdo pain in between contraction
vaginal bleeding
Cessation of contractions
Maternal collapse

19
Q

What is management of uterine rupture except ABCDE? How do you deliver the child (clue remember can’t cut into uterus because its ruptured)

A
  • Laparatomy to deliver child
  • Repair uterus or ligation of bleeding vessel
  • Hysterectomy to stop bleeding
    10-20% recurrence rate of uterine rupture
20
Q

Complications of uterine rupture?

A
  • Amniotic fluid embolus
  • DIC
  • post-op infection
21
Q

Defintion of PPH

Defintion of secondary PPH?

A

PPH- blood loss of >500ml (vb) or >1000ml (CS) after 24 hours of delivery

Secondary- severe bleeding from genital tract after 24 hours delivery and until 12 weeks postpartum

22
Q

Main causes of PPH?

A

Atony
Retained tissue/placenta- causes atony
Coagulation defects (VWF, Hameophillia A or B, or abruptio placentae or DIC)
Trauma- perineal tears/episiotomy, high vaginal tears, cervical tears

23
Q

Risk factors for PPH (antental and delivery)

A
  • Placenta praevia
  • Placenta accreta
  • APH in the pregnancy
  • Pre-eclampsia!!!!!!!
  • Atony causes: prolonged labour, multiple pregnancy
  • High BMI
  • hypertension

Delivery- C-section, prolonged labour, instrumental delivery (will cause tears), idnuction of labour

24
Q

What are features of PPH?

A
  • Large uterus above the level of the umbilicus

- May not have overt bleeding as bleeding may be abdominal and may present with collapse

25
Q

How do you manage PPH where placenta not delivered? exlcuding ABCDE

A

1st- cord traction and rubbing contraction up
2nd line- if not delivered in >60 minutes and continue bleeding
- manual evacuation under GA, and vaginal examination under GA to look for cause of bleeding

26
Q

Management of atonic PPH where placenta delivered?

A

1st line: Bimanual uterine compression
2nd line: Slow IV oxytocin
3rd line: Im Ergometrine (not if hypertension
- if they’ve had C-section then IM carboprost
4th line: Rectal misoprostol or injectable Haemobate into myometrium

Surgical

  • Intrauterine balloon tamponade with rusch ballon
  • B linch suture
  • Uterine artery ligation/embolisation
  • Hsyterectomy
27
Q

What are causes of secondary PPH?

A
  • Retained placenta or POC
  • Endometrititis- increased if C-section, manual evacuation of placenta, prolonged rupture of membranes
  • Gestational trophoblastic disease
28
Q

How do you investigate and manage secondary PPH

A

IX- endocervical, HVS, MSU, blood cultures
FBC, ESR, CRP
- Pelvic ultraosund to look for retained placenta

Management

  1. IM Ergometrine
  2. Surgery if severe- do surgical curettage for retained tissue and send to histopathology to exclude GTD
  3. Broad spec ABX if endometritis suspected
29
Q

What is placenta accreta, increta, percreta

A

Chorionic villi invade superficial myometrium, deep myometrium, peritoneum eg bladder/rectum

30
Q

What is placenta accreta associated with?

A
  • Retained placenta- so causes PPH

- Pre-term delivery

31
Q

Risk factors for placenta accreta?

A
  • Previous C-section scar
  • placenta praeviae
  • endometrial curettage
  • advanced maternal age
32
Q

IX and TX of placenta accreta?

A

IX- 3d ultrasonography or pelvic MRI

TX- Csection with hysterectomy
or methotrexate, or leave placenta in palce with uterine artery embolisation and then elective C-section

33
Q

In placental abruption, will there always be visible bleeding?

A

No because there are two types of placental abruption haemorrhages:

  • Visible haemorrhage 80%
  • Concealed haemorrhage 20% (retroplacental clot is contained behind the placenta)

Obstetrics & Gynaecology (16 decks)

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