Week 4 - I - Bleeding in Late Pregnancy, APH - Placental abruption, praevia, accreta, uterine rupture, vasa praevia - PPH Flashcards
What is the cut off for bleeding in early pregnancy to bleeding in late pregnancy? What is bleeding in late pregnancy known as?
Bleeding in early pregnancy is a bleeding occuring before 24 weeks
Bleeding in late pregnancy is bleeding occuring from 24 weeks gestation
Bleeding late pregnancy is known as an antepartum haemorrhage - genital tract bleeding from 24 weeks gestation
Globally, obstetric haemorrhage is a major cause of death but remains relatively uncommon in the UK What are some of the causes of antepartum haemorrhage?
- Placental praevia
- Placental abruption
- Vasa praevia
- Bloody show - this is benign and normal
- Bloody show is the passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It can occur just before labor or in early labor as the cervix changes shape, freeing mucus and blood that occupied the cervical glands or cervical os.
When does the placenta become the sole source of nutrition for the foetus? What are its function?
The placenta becomes the sole source of nutrition for the foetus from week 6 of gestation It is important for nutrition/waste exchange and gas exchange from foetus to mother Also involved in hormone production during pregnancy
Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour. Bleeding from or into the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby What are these two definitions talking about?
These are the definitions for Antepartum haemorrhage
Placenta praevia, placental abruption, vasa praevia and the benign blood show are all causes of APH Name any other causes?
Local causes eg polyps, cervical cancer, cervicitis Uterine rupture
There are different ways to quantify an APH Spotting Minor Major Massive Describe each of these
Spotting - staining or streaking noticed on underwear or sanitary protection Minor - blood loss less than 50ml that has settled Major - blood loss of 50-1000ml with no signs of clinical shock Massive - blood loss of greater than 1000mls and/or signs of clinical shock
What is the volume of blood lost in a post-partum haemorrhage?
Volume of blood lost in post-partum haemorrhage is greater than 500mls in the first 24 hours after delivery
The most common cause of APH is blood (heavy) show which is benign What is the most common pathological cause?
The most common pathological cause of APH is placenta abruption
What is placental abruption?
Placental abruption is when there is partial or complete separation of the placenta from the uterine lining
Placental abruption occurs in 1% of pregnancies but 40% of APH What is the pathophysiology of placental abruption? The exact cause is unkown
• Vasospasm of small arteries bleeding into muscle layers. This causes bleeding between muscle fibres making the uterus contract until it becomes rock hard. It interrupts the placental circulation causing hypoxia for the baby.
When the blood from placental abruption penetrate the myometium what can this cause? This is a life threatining condition that can result in foetal hypoxia and death
This can cause tonic uterine contractions interrupting the placental circulation resulting in couvelaire uterus Couvelaire uterus is a life-threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity.
Couvelaire uterus is an emergency condition and what is its treatment?
The treatment would be to have emergency delivery of the baby The increase in intrauterine pressure associated with the uterine contractions risks a uterine rupture
What are the risk factors for placental abruption? (large for gestational dates causes are causes of abruption)
Pre-eclampsia/hypertension Smoking/cocaine/amphetamine Trauma - blunt force Polyhdramnios, multiple pregnancy, diabetes
What are the symptoms of placenta abruption? If the placenta lies posteriorly what is the symptom?
Severe continous abdominal pain Backache if posterior placenta Bleeding - which may be concealed Preterm labour Maternal collapse
If the placental abruption is concealed, this can potentially lead to maternal shock and should beware of renal failure and sheehan syndrome here What is sheehan syndrome?
In sheehan syndrome, there is a massive post partum haemorrhage resulting in the pituitary gland not receiving enough blood This leads to hypopituitarism (decreased functioning of the pituitary gland), due to ischaemic necrosis of the gland and therefore the hormones produced by the pituitary gland will show symptoms due to their absence Lack of ACTH, TSH, GnRH, LH, FSH, Prolactin (ADH and oxytocin)
What is another name for bloody show? it signifies that the patient is actually in preterm labour?
This would be heavy show The passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It can occur just before labor or in early labor as the cervix changes shape, freeing mucus and blood that occupied the cervical glands or cervical os. Bloody show is a relatively common feature of pregnancy, and it does not signify increased risk to the mother or baby
What are the different signs of placental abruption?
A tender tense uterus Inconsistent signs in proportion to the amount of blood lost Foetal heart - bradycardia/absent
What is the immediate management of placental abruption?
Resussitae mother Assess and deliver the baby Manage the complications
The first thing to do in a placental abruption incident is to resuscitate the mother (The baby cannot be saved if the mother is collapsed. Then make a plan to deliver baby. ) What is done in the rapid assessment of the mother?
Oxygen - 15l/min non rebreather 2large bore cannulas (grey) IV access Full blood count, U&Es, cross match the blood, coagulation studies also Give IV fluids Kliehaur test Foetal heartbeat Catheterisation of mother
When should be careful if giving IV fluids to treat placental abruption?
Should be careful in patients with pre-eclampsia - driving the blood pressure too high can be very dangerous
Kleihauer test is done in patients whom present with APH symptoms What is this test? Who is it done in?
The Kleihauer test should be performed in rhesus D (RhD)-negative women to quantify fetomaternal haemorrhage (FMH) in order to gauge the dose of anti-D immunoglobulin (anti-D Ig) required.
Kliehauer’s test equates the number of foetal red cells/over the number of maternal red cells which gives the foetal volume/maternal volume For every 4mls of foetal red blood cells in the maternal blood, how much anti-D is given?
If the mother is over 20 weeks pregnant and there is blood tranfusion between baby and rhesus negative mother, give 500units antiD and do a Kleihauer test - for every 4mls of foetal red blood cells measured in the test, give 500units anti-D (500 units only can suppress immunisation by up to 4mL of foetal red cells)
In a women with placental abruption, it is important to catheterise the patient to measure hourly urine outputs - checks to measure sure patient is not entering acute renal failure How is the foetal heart beat assessed in this condition?
The foetal heartbeat is assessed using a pinard stethosocpe If you are unable t auscultate the baby then set up a CTG if the CTG does not register a foetal heart beat then use an ultrasound scan
What abnormalities on CTG tracing would suggest placental abruption for the foetus?
Late decelerations are indicative of foetal hypoxia and Foetal bradycardia due to the poor placental perfusion
Do ultrasound scans often detect a foetal heartbeat in placental abruption? Are ultrasound scans used for diagnosing the placental abruption?
USS are used to detect a foetal heartbeat if unable to on CTG USS scans are good for ruling out placenta praevia but are not good for diagnosing placental abruption - will only detect abruption inn 3/4cases
What should the urine production of the mother in the catheter be?
Hourly check ups to monitor urine production - want a 30ml/hour urine production
After resus of the mother FBC, U&Es, LFTs, crossmatching, coag screen, Kleihauers test, IV fluids Cathertisation Assessing foetal heartbeat It is important to decide what the management of the delivery will be What are the management options? When is conservative management carried out?
Conservative management - if no evidence of maternal coagulopathy, hypotension or severe ongoing blood loss- aim to conservatively manage and give birth to a term baby Can try artificial membrane rupture and induction of labour in mild cases If unstable fetal/maternal status - cesarean section
For all patients who experience placental abruption, what is given to help promote lung maturation in the foetus?
Give a steroid - betamethasone IM
What are some of the complications of antepartum haemorrhage due to placental abruption?
Hypovalaemia Coagulopathy - ie could have DIC due to thromboplastin release Anaemia PPH Infection
Due to placental abruption being a potential risk for coagulaopathy which could cause disseminated intravscular coagulation, what would be given if this was detected?
Would give fresh frozen plasma to return the patient the clotting factors
What is the percentage of foetal mortality in cases of placental abruption? What are other consequences to the foetus?
14% foetal mortality Foetal hypoxia Prematurity Small for gestational age and IUGR
What are the ways in which to prevent placental abruption? it is important to try and control the risk factors A known risk for placental abruption is anti-phospholipid syndrome, what is given for this?
Risk factor Preeclapmsia - give 75mg aspirin from Smoking - smoking cessation Anti-phospholipid syndrome - give LMWH and 75mg aspiring from week 12 Dont do drugs like cocaine and amphetamine
Placenta is partially or totally implanted in the lower uterine segment WHat is this condition?
This condition is placenta praevia
What is the lower segment of the uterus? What is the other name for placental praevia?
The lower segment of the uterus is the part of the uterus that lies below the utero-vesical pouch It contains less muscle fibres than the upper segment The other name for placental praevia low lying placenta
What are the different types of placenta praevia? What is used to classify the type of placenta praevia?
Major placenta praevia - this is where the placenta lies over the internal cervical os Minor placenta pravia - if the leading edge of the placenta lies in the lower uterine segment but does not cover the internal cervical os USS used to classify type
When placenta accreta invades into the myometrium what is it known as? What is it known as when it invades into the bladder?
Morbidly adherent placenta to the uterine wall is placental accreta
When the placenta invades the myometrium - placental increta
Placenta percreta when the placenta invades the uterine wall and serosa penetrating to the bladder
Placenta percreta is when the placenta reaches the uterine serosa What tests may help diagnose placenta accreta?
Transvaginal ultrasound and MRI
Why is there such a high mortality rate in vasa praevia pregnancies? - 60% rate
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When sent to theatre, rule out cervical trauma or retained tissue products What type of suture can be attempted to stop the bleeding before considering uterine and internal iliac artery ligation?
Consider a B-Lynch brace uterine suture The B-Lynch suture or B-Lynch procedure is a form of compression suture used in gynecology. It is used to mechanically compress an atonic uterus in the face of severe postpartum hemorrhage.
