Placenta Problems Flashcards
When is the 3rd stage of labour considered delayed?
Not complete by 30 minutes with active management
Not complete by 60 minutes with physiological 3rd stage
What is the danger with retained placenta?
Haemorrhage
What are associations with retained placenta?
Previous retained placenta or uterine surgery Preterm delivery Maternal age > 35y Placental weight < 600g Parity >5 Induced labour Pethidine used in labour
How is retained placenta managed?
Check placenta is not in vagina
Palpate abdomen
Rub up a contraction, put baby to breast (to stimulate oxytocin production)
Give 20 units of oxytocin in 20ml saline into umbilical vein and proximally clamp cord
Empty bladder with catheter
If placenta is not delivered within 30 mins, offer examination to see if manual removal is needed
FBC, G&S
Transfer to theatre for regional anaesthesia and manual removal of placenta
Describe manual removal of placenta.
Lithotomy position Place one hand on abdomen Insert other hand into uterus Find placenta Separate gently Remove it by cord traction Oxytocic drugs and antibiotic - cefuroxime + metronidazole
What is uterine inversion?
Inversion of uterus
Due to mismanagement of third stage - e.g. cord traction in an atonic uterus and fundal insertion of placenta
How is uterine inversion managed?
Immediate replacement - push fundus through the cervix with palm
If this fails, 2 14 G cannulas and take blood for FBC, U&E, clotting and cross-match 4-6 units
IV fluids
Transfer to theatre
Tocolytic drugs e.g. terbutaline to relax the uterus and make replacement easier
If manual replacement fails, replace using hydrostatic pressure
What is vasa paraevia?
Fetal Kessels from velamentous (umbilical vessels go within the membranes before placental insertion) insertion or between lobes (succenturia or bilobe placenta) risk damage at membrane rupture causing fetal haemorrhage.
Caesarean delivery is needed.
Vaginal bleeding
Rupture of membranes
Fetal compromise
- bleeding occurs following membrane rupture when there is rupture of umbilical cord vessels leading to loss of fetal blood
What is placenta succenturia?
Separate (succenturiate) lobe away from the main placenta which may fail to separate normally and cause a PPH or puerperal sepsis.
What is placenta accreta, increase and percreta?
Placenta accreta is abnormal adherence of all or part of the placenta to the uterus
Placenta increta if myometrium infiltrated
Placenta percera if penetration reaches the serosa
Predispose PPH and increased need for C-section hysterectomy
What is placenta praevia? Minor/major?
Placenta is fully or partially attached to the lower uterine segment
Minor: placenta is low but does not cover internal cervical os
Major: placenta lies over the internal cervical os
What are risk factors for placenta praevia?
Previous C section
High paritiy
Maternal age > 40
Multiple pregnancy
Previous placenta praevia
History of uterine infection (endometritis)
Currettage to the endometrium after miscarriage or termination
What are clinical features of placenta praevia?
Antepartum haemorrhage
Painless vaginal bleeding
How should you assess antepartum bleeding?
How much bleeding, when did it start Fresh blood, old brown blood, mucus Provoked (post-coital) Abdo pain Fetal movements Risk factors for abruption
Look at pads
Cusco speculum - avoid until placenta praevia excluded by USS
Triple swabs to exclude infection
Digital examination should not be performed in known placenta praevia - can cause massive bleeding
What are ddx for antepartum haemorrhage?
Placenta abruption
Vasa praevia - fetal blodo vessels run near interna cervical os
Uterine rupture
Local genital causes - malignant, benign, infection - ectropion, polyps, candida, bacterial vaginosis
