Obstetrical hemorrhage Flashcards
With antepartum vaginal bleeding you should never do a vaginal exam until you first rule out this condition.
How do you rule it out?
- Placenta Previa
- Rule out by transvaginal ultrasound
What is a threatened miscarriage?
- Vaginal bleeding associated with intrauterine pregnancy up to 24 weeks gestation
What is antepartum hemorrhage?
- Vaginal bleeding associated with intrauterine pregnancy from 24 weeks gestation until the onset of labour
What is intrapartum hemorrhage?
- Vaginal bleeding associated with intrauterine pregnancy from onset of labour until the end of the second stage of labour
What is postpartum hemorrhage?
- Vaginal bleeding associated with intrauterine pregnancy from the third stage of labour until the end of puerperium (6 wks after delivery)
What is placenta accreta?
- The placenta invade the myometrium and cannot be readily separated from the uterus following delivery
If the placenta covers part of or all of the cervical os is this minor or major placenta previa?
Major
What is a placental abruption?
retroplacental hemorrhage (between placenta and uterus)
What frequently co-occurs with placental abruption?
Placental separation (minor degree of)
Bleeding from placenta previa is it typically painful or painless?
Painless
What is vasa previa?
Babies blood vessels run over or near the cervical os putting them at risk of rupture
What is a primary post partum hemorrhage?
- Blood loss of 500mL or more within 24 hours of delivery
What is a secondary post partum hemorrhage?
- Any significant blood loss between 24 hours and 6 weeks after birth.
What is the most common cause of vaginal bleeding in the third trimester?
- Bloody show
> the shedding of the cervical mucous plug
What is the definition of an antepartum hemorrhage?
- Vaginal bleeding from 20 weeks until term
What are the risk factors for placenta privia?
- History of previous (4-8% recur)
- Multiparity
- Multiple gestation
- Increased maternal age
- Uterine tumour or anomalies (fibroids)
- Uterine scarring (c/s, d&c..)
What are the risk factors for abrupto placentae?
- Previous abruption (5-16% recur)
- Maternal HTN or vascular disease
- Smoking, EtOH, COCAINE
- Multiparity, increased age
- Maternal trauma
- Uterine tumour (Fibroid) or anomalies
What is placenta increta?
Placenta invades INto the myometrium
What is placenta percreta?
Placenta passes THROUGH the myometrium
When differentiating between placenta privia and placental abruption, shock/anemia that is out of proportion to the apparent blood loss would suggest which cause?
- Placental abruption
- 20% are internal or conceiled and the blood dissects upward
- Most cases are a mixed type where some blood dissects towards cervix and some towards fetus
How is placental abruption diagnosed?
- Clinical diagnosis
- U/S is not a sensitive test for it (15%)
How do you manage a placenta previa under 37 weeks? after stable
- Rhogam if Rh neg
- Admit
- limit activity, nothing into the vagina
- Corticosteroids for fetal lung development
- L/S ratio to assess fetal lung development (>2:1 can deliver)
- Deliver when mature or when hemorrhage dictates
How do you manage a placental abruption under 37 weeks? after stable
- Rhogam if Rh neg
- Serial Hct to assess for concealed bleeding
- Deliver when fetus mature of when hemorrhage dictates
You are trying to differentiate between placenta previa and vasa priva. The baby is in distress, which diagnosis does this steer you toward?
Vasa privia
- In placenta privia the baby is usually ok, in distress with vasa
- 50% perinatal mortality with vasa privia, increases to 75% if membranes rupture (most die from exangination)
What is the apt test? How do you interpret the results?
- Alkali denaturation test
- Uses NaOH to differentiate maternal blood from fetal blood
- Fetal hemoglobin is resistant to alkali denaturation and appears pink, maternal is not and appears yellow
How do you manage vasa privia?
- Emergency C-section
- The bleeding is from the fetus who has a small blood volume so small loss can result in death
