Obstetric haemorrhage Flashcards
Definition of APH?
Bleeding from the genital tract after the 24th week of pregnancy
What are the causes of APH?
Placenta praviae Placental abruption Vasa praeviae Uterine rupture Local causes- cervical polyp, cervical ectropion, cervical carcinoma, cervicitis, vaginitis
How is placenta praeviae classified?
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
What are the risk factors for placenta praviae
- Multiparity, multiple pregnancy
- C-section scar
- Submucous fibroids
- Increasing maternal age
- Maternal smoking
- Reproductive techniques
What are the complications of placenta praviae
- 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
Which examination must you never conduct in placenta praevia?
What are finding on abdominal examination?
vaginal examination- may cause bleeding
Fetal head not engaged, transverse lie and head in not centre of pelvic brim
How do you diagnose a placenta praviae?
- Transabdominal ultrasound at 20 weeks
- Confirm with TVS at 32 weeks
- Follow up TVS at 36 weeks if asymptomatic
- At 34 weeks, if cervical length short then high risk of preterm and haemorrhage at C-section
- CTG to look for fetal distress
What is the management of placenta praeviae?
- If pre-term <34 weeks or 34-35+6 then cortiscosteroids
- If asymptomatic then elective C-section at 36-37 weeks
- 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
How do you classify placental abruption?
Group 1: mild bleeding and no retroplacental bleeding
Group 2 and 3: Retroplacental bleeding and moderate and severe haemorrhage ( ie <1500ml and >1500ml)
What are the complications of placental abruption? (clue due to coagulation defects)
- Renal failure- oligouria, tubular necrosis
- DIC
- Death
What are the risk factors for placental abruption (major and minor)
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
What is a couvelaire uterus in placental abruption?
- When bleeding severe goes in between myometrial fibres resulting in bruised, oedematous uterus
What are the examination findings of placental abruption?
Tender, contracting uterus
Woody hard uterus
Evidence of bleeding if coaugulation failure
CTG- fetal heart rate abnormalities
Investigations of abruption?
Transvaginal ultrasound exclude PP
CTG
- FBC, coag screen, cross match 4 units of blood
Management of abruption according to baby?
> 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
What is vasa praevia, and when does bleeding occur?
How do you manage it
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
What are the causes of Uterine rupture?
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
What are features/diagnosis of uterine rupture?
Constant lower abdo pain in between contraction
vaginal bleeding
Cessation of contractions
Maternal collapse
What is management of uterine rupture except ABCDE? How do you deliver the child (clue remember can’t cut into uterus because its ruptured)
- Laparatomy to deliver child
- Repair uterus or ligation of bleeding vessel
- Hysterectomy to stop bleeding
10-20% recurrence rate of uterine rupture
Complications of uterine rupture?
- Amniotic fluid embolus
- DIC
- post-op infection
Defintion of PPH
Defintion of secondary PPH?
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
Main causes of PPH?
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
Risk factors for PPH (antental and delivery)
- 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
What are features of PPH?
- Large uterus above the level of the umbilicus
- May not have overt bleeding as bleeding may be abdominal and may present with collapse
