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Y4 - GOSH > Placenta Praevia / Abruption > Flashcards

Placenta Praevia / Abruption Flashcards

1
Q

What is placenta praevia?

A
  • occurs when the placenta is attached to the lower portion of the uterus
  • this is lower than the presenting part of the foetus
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2
Q

What is the difference between placenta praevia and low-lying placenta?

A

low-lying placenta:

  • when the placenta is within 20mm of the internal cervical os

placenta praevia:

  • used only when the placenta is OVER the internal cervical os
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3
Q

What is the major effect associated with placenta praevia?

A

it is associated with antepartum haemorrhage

placenta praevia occurs in around 1% of pregnancies

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4
Q

What are the differences in the causes of antepartum haemorrhage & minor bleeding in pregnancy?

A

antepartum haemorrhage:

  • placenta praevia
  • placental abruption
  • vasa praevia

minor bleeding in pregnancy:

  • cervical ectropion
  • infection
  • vaginal abrasions from intercourse / procedures
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5
Q

What are the risks associated with placenta praevia?

A
  • antepartum haemorrhage
  • emergency C-section / hysterectomy
  • maternal anaemia + transfusions
  • preterm birth + low birth weight
  • stillbirth
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6
Q

What are the risk factors for placenta praevia?

A
  • maternal smoking
  • previous C-section
  • previous placenta praevia
  • older maternal age
  • structural uterine abnormalities (e.g. fibroids)
  • assisted reproduction (e.g. IVF)
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7
Q

How is placenta praevia diagnosed?

A
  • it is identified on the 20-week anomaly scan
  • this is used to assess the position of the placenta
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8
Q

What are the symptoms of placenta praevia?

A
  • most women are asymptomatic
  • it can present with painless vaginal bleeding in pregnancy
  • bleeding usually occurs later in pregnancy (around 36 weeks)
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9
Q

What are the RCOG guidelines for repeating scans in placenta praevia?

A
  • placenta praevia should be diagnosed at the 20-week foetal anomaly scan
  • transvaginal US scan is repeated at 32 weeks gestation
  • and then again at 36 weeks gestation
  • the latter scan is used to guide decisions about delivery
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10
Q

What medication may be given to women with placenta praevia?

A

corticosteroids

  • these are given to mature the fetal lungs as there is a risk of preterm delivery
  • these are given between 34 and 35 + 6 weeks gestation
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11
Q

What plans are put in place for delivery in placenta praevia and why?

A
  • a planned C-section is considered between 36 and 37 weeks gestation
  • it is planned early to reduce the risk of spontaneous labour and bleeding

planned C-section is required for BOTH placenta praevia and low-lying placenta

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12
Q

How is a planned C-section different in placenta praevia?

A
  • US is used to determine the location of the placenta
  • different incisions may be made in the skin / uterus depending on the position of the foetus / placenta
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13
Q

When might emergency C-section be required in placenta praevia?

A
  • premature labour
  • antenatal bleeding
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14
Q

If haemorrhage occurs before, during or after delivery, what urgent management may be required?

A
  • emergency C-section
  • blood transfusions
  • intrauterine balloon tamponade
  • uterine artery occlusion
  • emergency hysterectomy
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15
Q

What is meant by vasa praevia?

A
  • the fetal vessels run through the free placental membranes (chorioamniotic membranes)
  • they pass over the internal cervical os

fetal vessels = 2 umbilical arteries + 1 umbilical vein

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16
Q

Where are the fetal vessels found normally?

A
  • the umbilical cord contains the fetal vessels
  • the umbilical cord inserts directly into the placenta
  • the fetal vessels are always protected - either by the placenta or umbilical cord

the umbilical cord contains Wharton’s jelly which gives protection to the fetal vessels

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17
Q

How is the protection of the fetal vessels different in vasa praevia?

A
  • the fetal vessels are exposed
  • they are outside of the protection from the umbilical cord or placenta
18
Q

What 2 situations can result in vasa praevia?

A
  • velamentous umbilical cord
  • multi-lobed placenta
19
Q

What is meant by a velamentous umbilical cord?

A
  • the umbilical cord inserts into the chorioamniotic membranes
  • the fetal vessels travel unprotected through the membranes before joining the placenta

the umbilical cord attaches to the membranes surrounding the placenta rather than the central mass

20
Q

How does a multi-lobed placenta result in vasa praevia?

A
  • the separate lobes of placenta are connected by fetal vessels
  • these vessels travel through the chorioamniotic membranes
21
Q

What is the major consequence associated with vasa praevia?

A
  • the fetal vessels travelling through the chorioamniotic membranes are unprotected

AND

  • they pass across the internal cervical os
  • these exposed vessels are prone to bleeding, especially when the membranes are ruptured during labour
22
Q

What are the 2 types of vasa praevia?

A

type I:

  • fetal vessels are exposed as a velamentous umbilical cord

type II:

  • fetal vessels are exposed as they travel to an accessory placental lobe
23
Q

What are the risk factors for vasa praevia?

A
  • low lying placenta
  • IVF pregnancy
  • multiple pregnancy
24
Q

How is vasa praevia diagnosed?

A
  • ideally, it is diagnosed via an US scan
  • sometimes it is not possible to diagnose antenatally
  • it may be detected by vaginal exam during labour - pulsating fetal vessels are seen in the membranes through the dilated cervix
25
What are the symptoms associated with vasa praevia?
* it may be asymptomatic * it may present with **antepartum haemorrhage** in the 2nd/3rd trimester
26
How might vasa praevia be diagnosed during labour?
* **fetal distress** + **dark red bleeding** occur following rupture of the membranes ## Footnote this carries very high fetal mortality, even with emergency C-section
27
What is the management for vasa praevia?
* **corticosteroids** given from **32 weeks** gestation to mature the fetal lungs * **elective C-section** planned from **34 to 36 weeks** gestation ## Footnote * elective C-section reduces the risk of haemorrhage * if haemorrhage does occur, emergency C-section is required
28
What is a placental abruption?
* occurs when the **placenta separates from the wall of the uterus** during pregnancy * the site of attachment **bleeds excessively** after the placenta separates * it is a significant cause of **antepartum haemorrhage**
29
What are the risk factors for placental abruption?
* previous placental abruption * multiple pregnancy * multigravida * increased maternal age * smoking * *trauma (think domestic abuse)* * fetal growth restriction * pre-eclapmsia * cocaine or amphetamine use
30
What is the typical presentation of placental abruption?
* **sudden onset** severe abdominal pain that is **continuous** * a **woody abdomen** on palpation * shock (hypotension / tachycardia) * signs of fetal distress on **CTG** * **vaginal bleeding** ## Footnote a "woody" abdomen is associated with large haemorrhage
31
How can the severity of antepartum haemorrhage be divided into 4 categories?
**spotting:** * spots of blood noticed on the underwear **minor haemorrhage:** * less than 50ml lost **major haemorrhage:** * 50 - 1000ml lost **massive haemorhage:** * more than 1000ml lost OR signs of shock
32
What is meant by a concealed abruption?
* the cervical os remains closed * the **blood remains within the uterine cavity** * the severity of bleeding can be significantly underestimated ## Footnote this is opposed to ***revealed abruption*** in which there is **blood loss via the vagina**
33
How is placental abruption diagnosed?
* there are no tests for diagnosing placental abruption * it is a **clinical diagnosis** based on presentation
34
What is the management for placental abruption?
**it is an obstetric emergency !!** * it should be treated as a **major/massive haemorrhage** * the urgency depends on: 1. extent of bleeding 2. haemodynamic stability of the mother 3. condition of the fetus ## Footnote always consider concealed haemorrhage where vaginal bleeding is disproportionate to uterine bleeding
35
What is the role of US in placental abruption?
* US CANNOT diagnose abruption * it can be used to **exclude placenta praevia** as a cause of bleeding
36
What medications are given in placental abruption?
**antenatal steroids:** * offered between 24 and 34+6 weeks gestation to mature the fetal lungs **anti-D:** * given to rhesus-D negative women
37
What might be required if the mother is unstable due to placental abruption?
emergency C-section
38
What extra blood tests are required if there are concerns about antepartum haemorrhage?
* **group & save** * **crossmatch** * required when there has been **>1L of blood lost**
39
How does vasa praevia typically present?
* there is **rupture of the membranes** (clear fluid discharge be noticed) * followed ***IMMEDIATELY*** by continuous **bright red vaginal bleeding** * this is a result of **rupture of the fetal vessels** and subsequent **fetal haemorrhage**
40
What is the triad of symptoms associated with vasa praevia?
* fetal bradycardia (HR < 100bpm) * painless vaginal bleeding * rupture of the membranes

Y4 - GOSH (62 decks)

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