Obstetrics: anti-partum haemorrhage Flashcards
What should you ask about in HxPC in a lady who comes to A&E with anti-partum haemorrhage?
- Onset, timing – has she had episodes before? (May happen with PP)
- Any trauma or trigger?
- Amount of blood, any clots?
- Colour – usually dark red in abruption, bright red in praevia
- Had she ever had any abnormal bleeding prior to pregnancy?
Any other/associated symptoms?
• PAIN – classically, abruption is painful whereas praevia is painless
• Has she felt foetal movements normally?
• Contractions
• Symptoms of shock
What background history (pregnancy and PMH) should you elicit for a pt who comes in with anti-partum haemorrhage?
- History of this pregnancy – gestation? Single pregnancy? Have previous USS shown a “low-lying” placenta? Baby engaged? Any complications?
- Past obstetric history – in particular, multiparity, any previous PP, abruption, or C-sections
•Past gynaecological history
o Had she ever had any abnormal bleeding prior to pregnancy? (Suggests a local cause)
o Is she known to have fibroids or uterine abnormalities (increases risk of abruption)
o Has she had infections?
o Are all her smears up to date? Has she ever had an abnormal smear?
- Past medical history – hypertension, clotting problems
- Family history
- DHx
- SHx – smoking
What is the definition of antepartum haemorrhage?
Bleeding PV after 24/40 weeks gestation (but before the onset of labour).
What are the causes of APH?
- 1/3: no underlying cause is found
- 1/3: placenta praevia
- 1/3 abruption
- Small proportion of cases: ectropion, vasa praevia, uterine scar rupture
How would you manage a pregnant lady who comes in with APH?
•Placenta praevia and placental abruption are both obstetric emergencies – admit patient, do A-E, 2 wide bore canulae and IV fluids started
•Examinations:
o NO PV exam until placental praevia has been excluded
oAbdominal exam: “woody hard” tonic contraction of abruption
• Ix:
o Observations (tachycardia and low BP consistent with visible blood loss = praevia)
o Bloods: FBC, clotting, X match at least 2 units of blood (4 in suspected abruption), LFTs, U&Es
o Urine output monitoring
o Urgent USS and CTG.
o Anti-D should be given to Rhesus-negative mothers.
o Corticosteroids if the baby if less than 34 weeks gestation.
o Urgent delivery by Caesarean section may be required to save the foetus.
What is placenta praevia?
- Placenta implants over the cervical os, or in the lower segment of the uterus (usually defined as <8cm from the os).
- It occurs in 1 in 200 pregnancies – is usually picked up on routine 20 week AUS
- Risk factors including multiparity, multiple pregnancy, advanced maternal age, prior PP, smoking and prior C-section.
What are the clinical features of placenta praevia?
- Shock in proportion to visible loss
- No pain
- Uterus non tender – lie and presentation may be abnormal
- FHR usually normal
- Coagulopathy is rare
- Small bleeds precede larger bleeds (warning sign)
What is the management of placenta praevia?
•Most PP is picked up as a “low-lying placenta” during the 2nd trimester USS. This is seen in around 5% of women, but with uterine growth the placenta usually rises up away from the cervix before term.
•Patient should have repeat USS at 32/40. If placenta remains low, repeat US fortnightly until 36 weeks - patient does not need to be admitted this stage if she has not had bleeding/has easy hospital access.
•At 37weeks, if the placenta remains low, she should be admitted and elective C-section performed at 39/40.
*If bleeding develops, she should be admitted from this point and monitored, with delivery at 37/40 by elective C section
What are complications of placenta praevia?
- Maternal mortality is rare in developed countries.
- PPH: common because the lower segment of the uterus is not contractile and so does not contract down to staunch bleeding. Can stop bleeding with oxytocics or an intrauterine balloon catheter; if this fails an emergency hysterectomy may be required.
- Foetal complications: relate mainly to prematurity and malpresentation
What is placental accreta? Name the types, risk factors and management
- Abnormal invasion of placental villi into the uterine wall due to defective decidua basalis.
- Can be accreta (chorionic villi attach to the myometrium), increta (chorionic villi invade myometrium) or percreta (chorionic villi invade through perimetrium – uterine serosa)
- Risk factors: PP and previous LSCS. (E.g. may implant over Caesarean scar and penetrate through the decidua and myometrium).
- Usually requires Caeasaren-hysterectomy with a high risk of DIC, and should be anticipated in any woman with a previous C-section and low-lying placenta (occurs in 10%)
What is placental abruption? What are the complications?
•Premature separation of the placenta from the uterine sidewall - causes antenatal bleeding.
•May be revealed (PV bleeding) or concealed (large retro-uterine blood collection may develop), and minor or major (affecting >1/3 of the placenta; foetal survival very unlikely).
•Occurs in 1% of pregnancies (though the ‘unknown origin’ bleeds may be small abruptions)
•Complications include:
- Fetal death in 30%
- mother needs blood transfusion, may have DIC & renal failure- rarely maternal death
What is the aetiology of placental abruption?
- Many women have no risk factors
- IUGR, pre-eclampsia, smoking, cocaine, past abruption, high parity and multiple pregnancy predispose
- Trauma/ sudden reduction in uterine volume (eg- rupture membranes in polyhydramnos)
What are important discriminatory points of history that point towards placental abruption?
- Painful bleeding. Pain due to blood behind placenta and in myometrium, blood often dark red.
- Degree of vaginal bleed does not reflect severity of abruption (not all blood may be visible)
What examination findings are present in placental abruption?
- Tachycardia suggests large blood loss, ?hypotension
- Uterus tender and contracting, labour usually ensues
- If severe, uterus is ‘woody’ hard and fetus hard to feel
- Fetal heart tones abnormal or absent
- Widespread bleeding if DIC
How would you manage a patient who has placental abruption?
- Admit, give IV fluid and steroids (if <34/40) Consider transfusion and opiate analgesia, give anti-D
- Delivery- if fetal distress, do urgent c-section
- If no distress, but at 37/40, induce labour with amniotomy. C-section if fetal distress ensues
- If fetus dead, give blood products and induce labour
Conservative- if no fetal distress & preterm & minor abruption, give steroids and close monitor. USS for fetal growth
