Third Trimester Bleeding Flashcards
What is placenta praevia?
Placenta is lying at the bottom of the womb, covering the cervix, underneath the baby.
- Major placenta praevia: completely covers the cervix
- Minor placenta praevia: could just be touching the edge of the cervix
What is the likelihood of having placenta praevia at term?
- If major placenta praevia is seen at 20-22 weeks then 11% of those women will still have a low placenta at 32-36 weeks
- If placenta still covering cervix completely at 32-36 weeks - 90% will have a low placenta at term
What are the implications of placenta praevia?
- If placenta is blocking cervix - baby can’t come out during labour
- Heavy bleeding
- If follow-up scan still shows placenta praevia - needs C-section so no risk of baby coming out through placenta and less risk of placenta bleeding when cervix dilates
- Not guaranteed to bleed, so can carry on with daily activities; just acknowledge increased bleeding risk
- Women with lower placenta are more likely to go into labour slightly earlier - any signs of labour, any pains, then call hospital asap
When will the position of the placenta for birth be confirmed by USS?
If no bleeding/symptoms occur, then rescan at 32+36 weeks - transvaginal USS, won’t make the woman bleed but it’s more accurate than an abdominal USS.
- If it shows bleeding - call hospital. Might have to stay in overnight to make sure bleeding stops.
- If heavy bleeding, then more scans need to be done
How should the mode of delivery be determined with placenta praevia?
If placental edge <2cm away from internal os in 3rd trimester - likely need C-section delivery. But mode of delivery should be based on clinical judgement and USS information.
What is the management for placenta praevia?
If placenta praevia with bleeding (usually painless bleeding) - admit, treat, shock and cross match blood
What is the classic presentation of placenta praevia?
Non-painful bleeding and may be associated with an abnormal lie as the low lying placenta may prevent engagement of the presenting part.
What physiological changes occur during pregnancy?
WCC goes from 6000 to 16,000 iUL in 2nd trimester and from 20,000 to 30,000 in labour. Also, consider effects of radiation on foetus for investigations.
What are causes of abdominal pain in pregnancy?
- Preterm labour
- Placental abruption
- Chorioamnionitis - usually ascending bacterial infection of amniotic fluid/membranes/placenta. Preterm rupture of membranes is a major risk factor, as sterile environment exposed to pathogens. Deliver baby + IV abx = initial treatment
- Acute fatty liver of pregnancy - abdo pain, n+v, jaundice, headache, hypoglycaemia if severe > pre-eclampsia, ALT typically elevated, management via supportive care and once stable, delivery is definitive management
- Epigastric pain associated with pre-eclampsia
- Torsion of pregnant uterus
What are GI causes of abdo pain in pregnancy?
- Appendicitis, pancreatitis, peptic ulcer, gastritis, hepatitis, bowel obstruction, bowel perforation, hernias, constipation and irritable bowel, cholecystitis
- Ask about bowel movements, eating make it worse, yellowing/itching of skin, n+v
What are GU causes of abdo pain in pregnancy?
- Acute pyelonephritis; acute cystitis (more common in pregnancy so be aware of them); ovarian cyst rupture; adnexal torsion; renal stones, uteral obstruction (if UTI present, even asymptomatic > abx for 7 days)
- Ask about urine symptoms, genital pain/discharge
What are other causes of abdominal pain in pregnant women?
- Intraperitoneal haemorrhage
- Red degeneration of fibroid
- Trauma to abdomen (consider physical abuse)
- DKA
- Splenic rupture
- Respiratory disease like pneumonia or PE
What things later in pregnancy cause abdominal pain?
- Torsion of pedunculated fibroid
- Placental abruption
- HELLP syndrome - spontaneous rupture of liver
- Uterine rupture
What is pre-term labour and what are the risks of it?
- PTL 5-12%
- Regular painful contractions which result in cervical change prior to 37 weeks gestation
- Risks: increased perinatal morbidity and mortality particularly in extreme prematurity
What are the predisposing risk factors for pre-term labour?
- Maternal age (<20 or >35), low BMI, LLETZ, smoking
- Socio-economic factors
- Past reproductive history i.e. previous PTL increases risk 2-fold and up to 70% if more than 2 PT births
- Present history: uterine over distension such as polyhydramnios, multiple pregnancy
- Infection: bacterial vaginosis
What tests can you do to indicate whether PTL is going to occur?
- Foetal fibronectin: extracellular matrix glycoprotein produced by amniocytes which can be determine by cervical vaginal secretions - PPV (positive predictive value) 46-80% (46-80% that woman will go into labour)
- Actim partus detects IGFBP-1, a protein present in cervical secretions (PPV 40% and negative predictive value of 98% > if test negative, 98% sure the woman won’t go into PTL)
What medications can be given for pre-term labour?
- Corticosteroids: develop foetal lungs - betamethasone 12mg - 2 doses 24hrs apart
- Tocolysis (anti-contraction meds): nifedipine, atosiban, indomethacin (don’t prevent PTL, only delay it to give time for steroids to work)
- Magnesium sulfate: for foetal neuroprotection > decreases risk of cerebral palsy
What is placental abruption?
- Premature separation of placenta from uterine wall
- <2% of pregnancies
- Risk factors: maternal thrombophilia, abdominal trauma, PET, smoking, cocaine use
- Bleeding within decidua basalis, causes further separation
What are the signs and symptoms of placenta praevia?
- Bleeding (though may not always be present as blood may pool up within uterus > if this happens, can cause significant abdominal pain)
- Abdominal pain
- Revealed may be minimal compared to the abruption - concealed (bleeding trapped behind placenta)
- Uterine tenderness (woody hardness)
- Vaginal bleeding > fetal compromise
- Maternal shock
- Coagulopathy
What is the management for placenta praevia?
- Depends on severity and complications
- Minor: expectant particularly if <37 weeks
- With monitoring and steroids for fetal lung maturity <36 weeks
- If maternal or foetal compromise > immediate delivery
What are the complications of massive placental abruption?
- Associated with ischaemia of overlying myometrium
- Couvelaire uterus > life-threatening condition where loosening of placenta causes bleeding that penetrates into uterine myometrium, forcing its way into peritoneal cavity > uterus may not contract properly > PPH
- Associated with foetal death in utero and maternal coagulopathy
What is uterine rupture?
- Generally hx of previous C-section
- Trial of vaginal delivery after CS: risk is around 7/1000
- Manual induction of labour increases risk 2-3x fold
- Significant maternal and perinatal morbidity and mortality
- Rupture of all the layers > blood flowing into abdomen
What are the signs and symptoms of uterine rupture?
- Abdominal pain
- Hypovolaemia shock i.e. tachycardia, pallor, decreased BP
- CTG abnormalities (typically shows prior to rupture happening)
- Uterine contractions may stop
- Palpation of foetus outside uterus
How does appendicitis present in pregnancy?
- Course and acuteness of onset
- Most common non-obstetric cause: 1/2000 to 1/6000
- 1st trimester: pain in right low quadrant
- 2nd trimester: appendix found at level of umbilicus
- 3rd trimester: pain is diffuse or in RUQ
- Rebound tenderness in 55-75% of patients
- Direct abdominal tenderness - most patients
- Pain at McBurney point is the same in pregnancy
What are the signs and symptoms of appendicitis in pregnant women?
- Perforation approx 25% more if delayed
- Nausea
- Vomiting
- Anorexia
- In appendicitis, fetal loss is >30% when ruptured appendix and 2% with unruptured appendix
What investigations should be done for appendicitis in pregnancy?
- FBC (raised WCC - polymorphonuclear leucocytosis)
- US and MRI (MRI more sensitive)
What is the management for appendicitis in pregnancy?
Surgical - open or laparoscopic (must be aware of uterus, particularly in 2nd and 3rd trimester) - liaise with obstetrician
How does acute cholecystitis present in pregnancy?
- Gallstones will be present in >95% of patients with acute cholecystitis
- Previous known history
- RUQ pain - radiates to right shoulder (Murphy’s sign on examination)
- Vomiting
- Fever, general malaise
- Differentials: appendicitis
What are the investigations for acute cholecystitis?
- USS (1st line)
- Blood tests - ALP (often raised in pregnancy) and ALT but often LFTs are normal
- Amylase may be raised
What are symptoms of pancreatitis?
- Acute epigastric pain + tenderness (may radiate to back)
- N+v
- Low grade fever
- Occasional jaundice
- Diminished bowel sounds
What would investigations show for pancreatitis in pregnancy?
- Raised serum amylase (only slightly elevated in pregnancy and doesn’t correlate to disease severity) - serum lipase more sensitive, specific and longer half life
- Hyperglycaemia (pancreas not releasing insulin)
- Hyperbilirubinaemia
- Hypocalcaemia (damaged pancreas releases lipase which releases free fatty acids which bind to Ca to form salts in the peritoneum)
- Haemoconcentration
- Electrolyte abnormalities
What is the treatment of pancreatitis?
- IV fluids
- Correction of electrolyte imbalances, glucose levels and calcium disturbances
- Withholding of oral intake with NG tube if necessary
What are the signs and symptoms of renal stones?
- Pain, usually in the flank
- N+v
- Dysuria, urgency, gross haematuria
- Fever
- Hx of prior episode - in 25%
What investigations can you do for renal stones?
- Microscopic haematuria
- USS of kidneys - look for obstruction
- However there is physiologic dilatation of right side particularly in late pregnancy (kidneys get bigger in pregnancy due to increased fluid)
What are the symptoms of ovarian torsion?
- 20% of ovarian cysts occur in pregnancy
- Caused by ovary (usually enlarged) twists on its pedicle > impairs blood flow
- Sudden onset, severe, unilateral colicky abdominal pain
- N+v
- Fever: usually low grade
- Mass (present in ~90% of cases)
- In pregnant women can present with systemic symptoms, raised inflammatory markers (leucocytosis)
What would ovarian torsion show on USS?
Free fluid (whirlpool sign)
What is ovarian hyperstimulation syndrome (OHSS)?
Causes ovaries to swell and become painful > risk factor for ovarian torsion (causes exaggerated response to excess hormones) > complication of some forms of infertility treatment.
What are the lower ano-genital tract/cervical causes of ante-partum haemorrhage?
- Post-coital bleeding (either vaginal abrasion or cervical ectropions)
- Anal fissures
- Vaginal infections and associated damage - candidiasis
- Cervical dilation - as long as at term, no consequence, early > causes early labour
- Cancer (cervical/vaginal) - rare due to screening
What are the placental causes of ante-partum haemorrhage?
- Abruption (occurs in ~0.5% pregnancies) - commonest in: smokers, previous abruptions, >35yrs, multiple pregnancies, hypertensive disorders, drug abuse
- Placenta praevia: can be graded but judging severity depends more on position and associated factors - previous CS, multiple pregnancy, multiparity
- Vasa praevia: (rare) occurs when anomalous chorionic plate vessels run over surface of amniotic membranes > placental cord fails to fuse into placenta (usually see foetal bradycardia) - difficult to detect unless late USS performed
When would you get unexplained ante-partum haemorrhage?
For whatever reason ~1/3 of presentations of ante-partum haemorrhage are unexplained, diagnosis of exclusion so caution making this diagnosis.
What is the immediate management for antepartum haemorrhage?
- Does the woman need resuscitation? - does she look unwell, pale, clammy? Is there evidence of shock (tachycardia or hypotension)?
- If this is the case then proceed to ABC - help, breathing (high flow O2), circulation (2 large bore cannulas, FBC/cross match/clotting + fluid)
- Assess fetal heart
What questions do you want to ask in a history about ante-partum haemorrhage?
- Is this the 1st time the bleeding has happened?
- How heavy is the bleeding?
- Is there any associated abdominal pain, if so is this episodic?
- Is the vulva/vaginal itchy/sore and any discharge?
- Is is following sexual intercourse?
- Up to date with normal cervical smears?
- Has the woman had a placental localisation at 20 weeks?
What further investigations do you want to do for ante-artum haemorrhage?
- Examination - abdominal (tenderness, uterine contractions, uterine rigidity ‘woody’), vaginal (external introitus, speculum - blood, cervix), ?digital (caution in placental praevia
- General obs (HR +BP)
- FBC/GS (for rhesus and transfusion)
- Clotting screen (abruption frequently cause coagulopathy)
- Kleihaur
- CTG - fetal heart
- USS - only in non-acute scenario, main reason is to assess placental site and fetal growth as APH strongly associated with FGR
What is the management of ante-partum haemorrhage?
Minor bleeds:
- Investigate, treat any potential causes
- Observe
Major bleeds:
- Seek assistance
- Resuscitate
- Deliver - depending on viability of foetus
What is the Kleihauer test?
It detects the presence of fetal red cells in maternal circulation. If there is >5ml estimated feto-maternal haemorrhage then a further dose of anti-D will be needed.
What causes primary post-partum haemorrhage?
- Vaginal trauma (larger tears often associated with instrumental delivery can lead to rapid bleeding)
- Uterine atony
- Placenta - retained products, placenta accreta
Classified as minor (500-1000ml) or major (>1000ml)
What causes secondary post-partum haemorrhage?
- Retained products
- Infection
- Dysfunctional Uterine Bleeding (DUB)
What is uterine atony associated with in PPH?
- Prolonged labour
- Macrosomia
- Sepsis
- Multiple pregnancy
- Grand multiparity (>5 children)
- May lead to rapid and significant blood loss if unrecognised
How does placenta cause PPH?
- Occurs when whole or part of placenta remains in uterus, can recognise by examining the placenta or digital exam
- Increasingly may reflect placental implantation abnormalities - placenta accreta, increta, perceta (placenta has invaded beyond depth of endometrium into myometrium) - can be extremely difficult to remove placenta - strongly associated with previous CS or uterine ablative surgery
How do you treat PPH?
- Suture vaginal tears
- Remove retained products (unless adherent)
- Give uterotonic drugs
- Examination under anaesthetic +/or proceed to hysterectomy in cases where bleeding cannot be stopped or acreeta
What is the treatment for secondary PPH?
- Retained products and infection often go hand in hand with 2ndary PPH
- 1st line: broad spectrum abx e.g. co-amoxiclav
- 2nd line: EUA and removal of products
- Avoid USS as difficult to interpret
- If abx fail and no RPOC likely DUB - treat with COCP
