obstetric haemorrhage -ILA Flashcards
What is a minor vs major vs massive antenatal haemorrhage?
Minor haemorrhage –50ml and stopped
Major haemorrhage- 50-100ml and no signs of shock
Massive haemorrhage- >100ml/ signs shock
What are causes of antepartum bleeding?
Domestric violence, placenta praevia, placenta accreta, placenta abruption, vasa praevia, incidental eg cervical carcinoma, cervical ectopy, cervical polyp, erosions, cervicitis, vaginitis
What is antepartum bleeding?
Bleeding after 24 weeks but before birth.
What is placental abruption?
premature separation of a normally placed placenta
What are risk factors for placental abruption?
pre-eclampsia, smoking, (biggest risk factors) PROM, multiple pregnancy, geriatric mother, thrombophilia, drug use, IVF, infection, previous abruption, trauma, htn, folic acid deficiency, spasm uterine vessels, anaemia
What is the presentation of placental abruption?
abdo pain- severe and constant, woody feeling, uterine contraction, shock, fetal distress, uterine tender, blood if apparent
Why does placental abruption present the way it does?
due to uterine blood- the more concealed the blood the worse the painas trapped between the uterus and the placenta
(conceleaed vs apparent)
What are some differentials for placental abruption?
excessive show of a normal labour, fibroid, peritonism eg peptic ulcer or appendicitis, acute polyhydramnios
What are the investigations for placental abruption?
low platelets, tense and tender uterus, U/S (unreliable), HR abnormal on CTG for fetus – is a clinical diagnosis mainly.
What is placenta praevia?
insertion of the placenta in the lower segment of the uterus
What are the investigations for placenta praevia?
doppler U/S, transvaginal US, speculum exam (this can be picked up on U/S)
What is the presentation for placenta praevia?
SNT abdomen, patients condition reflects blood loss, the formation of the lower segment by stretching leads to separation of the placenta and blood escape from maternal sinuses. Blood loss is recurrent. No pain as not retained in uterine cavity.
What are the differences between placenta praevia and abruption?
- placenta praevia features blood loss in proportion with shock patient is in whereas this may not be the case in abruption due to blood concealment
- placental praevia typically does not feature pain but abrutpion has constant pain
- In placenta abruption the uterus is tender and tense
- In placenta praevia the fetus may not have normal lie and presentation
- The fetal heart is less likely to be distressed in praevia
What are the risk factors for placenta praevia?
c-section, sharp curette TOP (causes deficiency in endometrium), multiparity, multiple pregnancy, older mother, IVF, fibroids, endometriosis (deficiency in endometrium), previous placenta praevia
What is the management for placenta praevia?
If is major ie completely covers cervical os then do c-section. If minor and does not cover os and is 2cm away or more then aim for normal delivery.
What is vasa praevia?
fetal blood vessels that connect to placenta and are unprotected by umbiblical cord cross the os
causes: bleeding from foetal vessels in the foetal membranesthat is diagnosed with a doppler
how does vasa praevia present?
Triad of: membrane rupture, painless vaginal bleeding and foetal bradycardia or foetal death.
What is a minor vs major PPH bleed?
Minor- <1500mls
Major-1500mls +
What is primary vs secondary PPH?
Primary= >500ml loss post birth Secondary= excess bleeding between 24hrs and 12 weeks postpartum – usually due to retained placental tissue or clot often with infection. - give abx
What are the four main causes of PPH? (the four Ts)
Tone –uterine atonia
Tissue –retained products on conception eg accretia or due to atonia uterus can’t contract fully to push out placenta
Trauma –genital tract trauma eg c-section, macrosomia
Thrombin –clotting disorder eg DIC
Other: endometritis, Subinvolution of the placental site (delayed closure and sloughing of the spiral arteries at the placental site), AVM
If there is placenta praevia what should be avoided?
penetrative sex and vaginal exams as more initiate bleeding
What is the acute management of an obstetric bleed?
Admit unless is just spotting that has stopped and there is no sign of placenta being low lying
Give IVI
do blds- Hb, crossmatch, coagulation studies, U&E, group and save
Fetal monitoring
manually massage uterus to try and get it to contract and try to manually remove placenta, clots and retained tissue
Determine gestational age, presentation and position via abdo exam
Give oxygen
Give blood until systolic is over 100mmHg
Catheterise
C-section – do as late as possible with placenta praevia
Vaginal delivery is preferred if fetus is already dead
u/s to exclude placenta praevia
If preterm birth then give corticosteroids to assist with fetal lung development
What can be done post birth to manage blood loss?
Do acute management
Give drugs to contract uterus- synometrine, oxytocin, ergometrine, misoprostol, carboprost
Repair tears
If continues take to theatre and do examination via laparotomy, insert rusch balloon which will exert pressure in uterus if this fails then can do a B-lynch suture
Consider internal iliac or uterine artery ligation
Consider uterine artery embolisation
Hysterectomy if blood loss cannot be controlled and mother is too far gone
Why does bleeding decrease when the uterus is contracted?
as blood vessels are inside the uterus so when it is contracted it lowers bleeding
What are the different types of placenta accreta?
Placenta accreta: chorionic villi penetrate the decidua basalis to attach to the myometrium.
Placenta increta; the villi penetrate deeply into the myometrium.
Placenta percreta: the villi breech the myometrium into the peritoneum.
What are risk factors for placenta accreta?
previous c-section, placenta praevia
Is there a link between antepartum and postpartum haemorrhage?
YES
Placental abruption, accreta and praevia are associated with risk of PPH.
What is the most common cause of PPH?
Tone
why do retained products of placenta result in PPH?
It prevents effective uterine contraction and the partial placenta separation causes bleeding
Give some examples of oxytocicis
misoprostol and carboprost (PG analogues)
syntocinon
