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Reproduction Y3 > Antepartum haemorrhage > Flashcards

Antepartum haemorrhage Flashcards

1
Q

What roles does the placenta play for the foetus?

A

Sole source of nutrition from 6 weeks

Has functions including:
- Gas transfer
- Metabolism/waste disposal
- Hormone production (HPL & hGh-V)
- Protective ‘filter’

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2
Q

What is antepartum haemorrhage (APH)?

A

Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour

i.e. >24/40 and before baby delivered

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3
Q

Commonest causes of APH?

A

Placenta praevia
Placental abruption

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4
Q

Aetiology (causes) of APH?

A

Placental Problems - Placenta Praevia, Placental Abruption

Uterine problem - rupture

Vasa Praevia

Indeterminate

Local cause - ectropion, cancer, polyp, infection.

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5
Q

What can APH be mistaken for?

A

Bloody show (cervix preparing for labour, opening of cervix causes rupture of surrounding blood vessels).

Urinary tract related problems

Haemorrhoids

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6
Q

How is APH quantified?

A

By a measure of how much bleeding experienced by the woman after 24 weeks gestation.

Spotting = Staining, streaking, wiping.

Minor = <50ml settled

Major = 50-1000ml no shock

Massive= >1000ml and/or shock

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7
Q

What is placental abruption?

A

refers to when the placenta separates from the wall of the uterus during pregnancy.

The site of attachment can bleed extensively after the placenta separates.

Placental abruption is a significant cause of antepartum haemorrhage.

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8
Q

Risk factors for placental abruption?

A

Previous placental abruption
Pre-eclampsia
Bleeding early in pregnancy
Trauma (consider domestic violence)
Multiple pregnancy
Fetal growth restriction
Multigravida (pregnant for at least 2nd time)
Increased maternal age
Smoking
Cocaine or amphetamine use

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9
Q

Underlying pathology of placental abruption?

A

Vasospasm followed by arteriole rupture into the decidua; blood escapes into the amniotic sac or further under the placenta and into myometrium

Causes tonic contraction and interrupts placental circulation which causes hypoxia

Results in Couvelaire uterus

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10
Q

What is Couvelaire uterus?

A

When retroplacental blood after abruption penetrates through the uterine wall into the peritoneal cavity.

Uterus becomes tense and rigid.

Myometrium becomes weakened and may rupture due to increase in pressure from contractions. Both mother and baby lives at risk

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11
Q

Symptoms of placental abruption?

A

Sudden onset severe abdominal pain that is continuous

Vaginal bleeding (antepartum haemorrhage)

Shock (hypotension and tachycardia)

Abnormalities on the CTG indicating foetal distress

Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage

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12
Q

What is a concealed abruption?

A

The cervical os remains closed, and any bleeding that occurs remains within the uterine cavity.

The severity of bleeding can be significantly underestimated with concealed haemorrhage.

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13
Q

Difference between concealed and revealed abruption?

A

Revealed abruption is when the blood loss is observed via the vagina

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14
Q

There are some reliable tests that can be done to diagnose placental abruption. true/false?

A

False

Clinical diagnosis of placental abruption is based on patients clinical presentation

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15
Q

Placental abruption is an obstetric emergency, what factors influence urgency of treatment?

A

Depends on:

  • The amount of placental separation
  • Extent of the bleeding
  • Haemodynamic stability of the mother - Condition of the foetus
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16
Q

Initial management of major or massive haemorrhage?

A
  • Urgent involvement of a senior obstetrician, midwife and anaesthetist
  • 2 x grey cannula
  • Bloods include FBC, UE, LFT and coagulation studies
  • Crossmatch 4 units of blood
  • Fluid and blood resuscitation as required
  • CTG monitoring of the foetus
  • Close monitoring of the mother
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17
Q

Is USS useful in APH?

A

Can be useful in excluding placenta praevia as a cause for antepartum haemorrhage, but is not very good at diagnosing or assessing abruption.

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18
Q

What do rhesus-D negative women require when bleeding occurs and what test is used to quantify dose needed?

A

Rhesus-D negative women require anti-D prophylaxis when bleeding occurs.

A Kleihauer test is used to quantify how much foetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.

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19
Q

What is placenta praevia?

A

The placenta is attached in the lower portion of the uterus, lower than the presenting part of the foetus.

Praevia directly translates from Latin as “going before”.

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20
Q

What is the internal and external os(orifice)?

A

The internal os(orifice) is the opening between the cervix and the corpus.

The external os(orifice) is the opening between the cervix and vagina.

21
Q

When is the term “low-lying placenta” used?

A

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

22
Q

When is the term “placenta praevia” used?

A

used only when the placenta is over the internal cervical os

23
Q

What % of pregnancies does placenta praevia occur in?

A

1% of pregnancies. It is regarded as a notable cause of APH.

24
Q

3 major causes of APH?

A

Vasa praevia
Placenta praevia
Placental abruption

Serious causes with high morbidity and mortality

25
Q

Placenta praevia is associated with increased morbidity and mortality for foetus and mother, what are the risks that it can cause?

A

Antepartum haemorrhage
Emergency caesarean section
Emergency hysterectomy
Maternal anaemia and transfusions
Preterm birth and low birth weight
Stillbirth

26
Q

How made grades of placenta praevia?

A

4 grades

27
Q

Grade 1 praevia or minor praevia description?

A

the placenta is in the lower uterus but not reaching the internal cervical os

28
Q

Grade 2 praevia or marginal praevia description?

A

the placenta is reaching, but not covering, the internal cervical os

29
Q

Grade 3 praevia or partial praevia description?

A

the placenta is partially covering the internal cervical os

30
Q

Grade 4 praevia or complete praevia description?

A

the placenta is completely covering the internal cervical os

31
Q

What puts a patient at risk of placenta praevia?

A
  • Previous caesarean sections
  • Previous placenta praevia
  • Older maternal age
  • Maternal smoking
  • Structural uterine abnormalities (e.g. fibroids)
  • Assisted reproduction (e.g. IVF)
32
Q

When during gestation is the position of the placenta assessed and placenta praevia diagnosed?

A

During the 20 week anomaly scan

33
Q

Many women with placenta praevia are asymptomatic. true/false?

A

True

May present with painless vaginal bleeding in pregnancy (antepartum haemorrhage).

Bleeding usually occurs later in pregnancy (around or after 36 weeks).

34
Q

For women with a low-lying placenta or placenta praevia diagnosed early in pregnancy (e.g. at the 20-week anomaly scan), when should a repeat transvaginal ultrasound scan be done?

A

32 weeks gestation

36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)

35
Q

Symptoms of placenta praevia?

A

Painless bleeding >24 weeks;

Usually unprovoked but coitus can trigger bleeding

Bleeding can be minor eg spotting/ severe

Fetal movements usually present

36
Q

Signs of placenta praevia?

A

General:
- Proportional to volume of bleeding ABCDE

Abdomen:
- Uterus soft non tender
- Presenting part high
- Malpresentations –Breech/Transverse/Oblique

Foetal Heart:
- CTG usually normal

37
Q

Management of placenta praevia?

A

Resuscitation Mother : ABCDE
Large bore IV Access and G+S

Assess Baby’s condition +/-
Steroids 24-35+6 weeks
MgSO4 if <32 weeks delivery likely for neuroprotection

Anti D if Rhesus Negative

Conservative management if stable and observe in hospital for at least 24-48 hours

38
Q

What is vasa praevia?

A

Condition where the foetal vessels are within the foetal membranes (chorioamniotic membranes) and travel across the internal cervical os.

The foetal membranes surround the amniotic cavity and developing foetus. The foetal vessels consist of the two umbilical arteries and single umbilical vein.

39
Q

Vasa praevia is where the vessels are placed over internal cervical os, before the foetus. True/false?

A

True

40
Q

Under normal circumstances, the umbilical cord containing the foetal vessels (umbilical arteries and vein) inserts directly into the placenta.

The foetal vessels are always protected, either by the umbilical cord or by the placenta. true/false?

A

True

41
Q

The umbilical cord contains Wharton’s jelly. What is this?

A

A layer of soft connective tissue that surrounds the blood vessels in the umbilical cord, offering protection.

42
Q

Risk factors for vasa praevia?

A
  • Low lying placenta
  • IVF pregnancy
  • Multiple pregnancy
43
Q

Diagnosis of vasa praevia?

A

Ultrasound TA (transabdominal) & TV (transvaginal) with doppler

44
Q

Clinical features of vasa praevia?

A

foetal distress and sudden dark red bleeding and foetal bradycardia / death

45
Q

How many types of vasa praevia?

A

2 types

46
Q

What is type 1 vasa praevia?

A

when the vessel is connected to a velamentous umbilical cord

Velamentous cord insertion = a pregnancy complication that happens when the umbilical cord from a foetus doesn’t insert into the placenta correctly

47
Q

What is type 2 vasa praevia?

A

when it connects the placenta with a succenturiate or accessory lobe.

The placenta can form into two or more separate lobes, becoming bilobed or multilobed.

A smaller, accessory lobe called a succenturiate lobe can also form. Foetal blood vessels traveling between these lobes may end up positioned above the cervix, causing vasa previa.

48
Q

Foetal mortality is around 30% in vasa praevia. true/false?

A

False

~60%

49
Q

Management of vasa praevia?

A
  • Antenatal diagnosis
  • Steroids from 32 weeks
  • Consider inpatient management if risks of preterm birth (32-34 weeks)
  • Deliver by elective c/section before labour (34-36 weeks)
  • APH from vasa praevia = Emergency caesarean delivery
  • Placenta for histology

Reproduction Y3 (78 decks)

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