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Phase 3a - Women's Health > Women's Health : Antepartum Haemorrhage > Flashcards

Women's Health : Antepartum Haemorrhage Flashcards

1
Q

What is placenta praevia?

A

Placenta covers internal os of the cervix

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2
Q

What defines a low-lying placenta?

A

Within 20 mm of internal os (placenta lies within 20 mm of the internal os (but does not cover it)

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3
Q

What is aetiology of placenta praevia?

A

Blastocyst implants in the lower segmentof the uterus

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4
Q

Causes of bleeding due to placental trauma?

A

Placental Trauma (or spontaneous) : sexual intercourse, vaginal examination, cervical dilation in labour

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5
Q

What are risk factors for bleeding due to placental trauma?

A

Previous C-section, IVF, previous placenta praevia

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6
Q

When is antepartum haemorrhage diagnosed?

A

> 24 weeks

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7
Q

If bleeding < 24 weeks - what do you suspect?

A

Threatened miscarriage

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8
Q

What is the presentation of antepartum haemorrhage?

A

Painless bleeding, soft, non-tender uterus

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9
Q

When is bleeding usually diagnosed without symptoms?

A

20 week anatomy scan

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10
Q

When is a follow up scan indicated for if praevia/ low lying?

A

At 32 weeks

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11
Q

When is a follow up scan indicated for if not resolved?

A

36 weeks

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12
Q

What is used to diagnose antepartum haemorrage when symptomatic?

A

Transvaginal ultrasound

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13
Q

Investigation of antepartum haemorrhage steps?

A
  1. Full blood count, group + save
  2. Kleihauer test
  3. Transvaginal / transabdominal ultrasound 4. CTG for foetal monitoring
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14
Q

Kleihauer test is for?

A

Fetomaternal haemorrhage in Rhesus -ve women

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15
Q

Differentials for antepartum haemorrhage?

A

Placental abruption, onset of labour, cervical ectropion, vasa praevia

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16
Q

Management for placenta praevia antenatally?

A

Conservative follow-up, oral corticosteroids (Conservative management with follow up scanning as described above. PP often spontaneously resolves as the uterus grows and lower pole
stretches in later pregnancy.
○ Single course of oral corticosteroids is indicated between 34 and 36 weeks.)

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17
Q

Management for placenta praevia via delivery?

A

Placenta praevia: Aim to deliver by caesarean section at 36-37 weeks for uncomplicated placenta praevia. ■ High risk of massive obstetric haemorrhage (12x background risk). ○ Low-lying placenta: trial of labour is offered, particularly if 10-20mm from os; caesarean section is also offered.

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18
Q

When is delivery by caesarean section recommended for uncomplicated placenta praevia?

A

36-37 weeks

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19
Q

What is the risk associated with massive obstetric haemorrhage?

A

12x background risk

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20
Q

What is offered for low-lying placenta?

A

Trial of labour or caesarean (particularly if 10-20mm from os;
caesarean section is also offered)

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21
Q

What is Vasa Praevia?

A

Malformation of foetal vessels (umbilical vein + arteries), leading them to run through placental membranes instead of the umbilical cord.

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22
Q

What happens to exposed foetal vessels in Vasa Praevia during labour?

A

Rupture and haemorrhage (Exposed foetal vessels are liable to rupture and haemorrhage in labour due to cervical
dilatation or movement of the presenting part, particularly if they overlie the cervical os)

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23
Q

Risk of vasa praevia in pregnancies?

A

uncommon, estimated between 1 in 1200 to 1 in 5000 pregnancies

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24
Q

Mortality rate if undiagnosed vasa praevia and SROM occurs?

A

Foetal mortality is 60%

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25
Q

Presentation of vasa praevia before birth?

A

Antepartum haemorrhage ; resulting in antenatal dx

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26
Q

Presentation of vasa praevia during labour?

A

Vaginal bleeding after SROM at onset of labout with foetal distress

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27
Q

What scan is used in antenatal detection of vasa praevia?

A

Transvaginal ultrasound

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28
Q

What Ix is used for vasa praevia during labour?

A

Vaginal examinations (palpable foetal vessels overlying os)

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29
Q

What is given at 32 weeks for high risk of prematurity post antenatal detection?

A

Corticosteroids

30
Q

What is the recommended timing for elective CS?

A

34-36 weeks, although optimal timing is contested

31
Q

If the vasa praevia were undetected, what is the management?

A

Category 1 caesarean section

32
Q

What is the classification of vasa praevia?

A

split into either type 1 or type 2

33
Q

What classification of vasa praevia type involves foetal vessels connected to velamentous umbilical cord)?

A

Type 1

34
Q

What is the type 2 classfication of vasa praevia?

A

Foetal vessel connected to succenturiate** placental lobe

35
Q

What is the velamentous cord?

A

cord inserted into foetal membranes, not placenta

36
Q

What is the succenturiate lobe?

A

accessory lobe connected to the main body of the placenta

37
Q

What is the placenta accreta spectrum?

A

Range of pathologic adherence of the placenta (accreta, increta, percreta)

38
Q

What does placenta accreta spectrum include?

A

Accreta, increta, percreta

39
Q

What is placenta accreta?

A

abnormal invasion of the placental villi through the decidua leading to adherence to the myometrium.

40
Q

What is placenta increta?

A

abnormal invasion of the placental villi through the decidua and into the myometrium, through to the outer serosa.

41
Q

What is placenta percreta?

A

abnormal invasion of the placental villi through the entire uterine wall; it may then invade other organs.

42
Q

What causes defective endometrial-myometrial interface in placenta percreta?

A

Scarring

43
Q

What does defective endometrial-myometrial interface in placenta percreta cause?

A

Defective endometrial-myometrial interface causes failure of normal decidualisation - this allows the placental villi (trophoblast) to invade further

44
Q

What leads to massive obstetric haemorrhage in placenta percreta?

A

Failure to detect and manage placenta accreta

45
Q

Common risk factor for placenta percreta?

A

Previous caesarean section

46
Q

Name 2 other risk factors for placenta percreta?

A

Other uterine surgery + Increased maternal age

47
Q

Presentation of placenta percreta

A

Typically detected in antenatal period: ○ Women with previous CS found to have low-lying placenta are specifically screened with ultrasound scanning

48
Q

What is the management for placenta percreta?

A

Caesarean section at 35-37 weeks (This may be uterus-preserving if the accreta is limited and placenta can be safely
separated.
○ Otherwise, RCOG guidelines recommend caesarean section hysterectomy with
placenta left in situ in the uterus.
)

49
Q

When is the caesarean section performed?

A

35-37 weeks

50
Q

What does RCOG recommend if placenta cannot be separated?

A

Hysterectomy

51
Q

What is placental abruption?

A

Premature separation of the placenta from the decidua

52
Q

What causes the placental abruption?

A

Chronic processes & acute trigger

53
Q

What are chronic processes involved in placental abruption?

A

Placental thrombosis & infection

54
Q

What does chronic processes like placental thrombosis and infection lead to?

A

Hypoperfusion & infarction, and shallow trophoblast invasion

55
Q

What predisposes the placenta to premature separation ?

A

Chronic processes such as placental thrombosis and infection cause hypoperfusion, placental infarction, and shallow trophoblast invasion.

56
Q

What happens after the placenta is predisposed to separation?

A

This is followed by a non-specific acute trigger (mechanical force within the abdomen) which causes the poorly adherent placenta to separate from underlying decidua.

57
Q

What does separation of the placenta from the decidua cause?

A

Maternal decidual vessels rupture

58
Q

What accumulates between placenta and decidua?

A

Blood

59
Q

What does normal placental separation depend on?

A

Placental contraction (- In normal placental separation, bleeding is stemmed by placental contraction; this
is not possible when the foetus is in situ and the myometrium is stretched.)

60
Q

What does decidual bleeding cause?

A

Excess thrombin production (due to tissue factor AKA clotting factor 3-mediated activation of the extrinsic clotting pathway). This leads to enhanced matrix metalloproteinase expression and endothelial injury, alongside release of proinflammatory cytokines.

61
Q

What effects does thrombin have?

A

Uterotonic effects - this would explain uterine contraction and rupture of membraines in response to abruption

62
Q

High levels of systemic thrombin can lead to?

A

consumptive coagulopathy i.e. disseminated intravascular coagulation.

63
Q

Strongest risk factor for abruption?

A

Previous abruption

64
Q

Name 3 other risk factors for abruption?

A

Pre-eclampsia, trauma, smoking, cocaine

65
Q

Types of abruption?

A

Concealed, Revealed, Mixed

66
Q

What is concealed placental abruption?

A
  • blood remains behind the placenta, preventing a PV bleed
67
Q

What is revealed placental abruption?

A

blood escapes from behind the placenta, causing a PV bleed.

68
Q

What is mixed placental abruption?

A
  • clot forms behind placenta alongside PV bleed.
69
Q

Presentation of abruption?

A

Antepartum haemorrhage , abdominal pain, woody hard, contracilte uterus

70
Q

Is ultrasound reliable for diagnosis placental abruption?

A

No

71
Q

How is the placental abruption diagnosed?

A

Clinically

72
Q

What is the first line management of placental abruption?

A

Category 1 caesarean section

Phase 3a - Women's Health (21 decks)

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