6: Bleeding in late pregnancy Flashcards by Ross Wilson

What is bleeding called after 24 weeks gestation?

Antepartum haemorrhage

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Bleeding before 24 weeks is a sign of what?

Miscarriage

threatened, inevitable etc.

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Which report accounts for maternal deaths and is published every year?

MMBRACE

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At what gestational age does the placenta develop?

6 weeks

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What is the function of the placenta?

Gas exchange

Nutrient and metabolite exchange

Hormone production

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What is an ante-partum haemorrhage?

PV bleeding from 2nd trimester (24 weeks) until the end of labour

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What are some placental causes of APH?

Placenta praevia

Placental abruption

Placenta accreta

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Name four placental causes of ante-partum haemorrhage.

Placental abruption

Placenta praevia

Placenta accreta

Vasa praevia

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Name a uterine cause of ante-partum haemorrhage.

Uterine rupture

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Name three cervical causes of ante-partum haemorrhage.

Cervical cancer

Cervical polyps

Infection

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What is spotting?

Minor staining of blood on underwear or pads

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What volumes of blood are lost in a

a) minor
b) major
c) massive APH?

a) < 50ml

b) 50 - 1000ml

c) > 1000ml

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What is placental abruption?

Separation of placenta from uterus BEFORE birth

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What are the symptoms of placental abruption?

Continuous abdominal pain - not intermittent as in labour

Bleeding

Pre-term labour

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What is the recurrence rate for placental abruption?

10%

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What does the uterus feel like on abdominal examination of a woman with placental abruption?

“Woody hard”

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If you check for a foetal heartbeat in a woman with placental abruption and there is one, how is it managed?

Resuscitate the mother

Caesarean section

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If you check for a foetal heartbeat in a woman with placental abruption and there isn’t one, how is it managed?

Resuscitate the mother

Spontaneous passage / manual removal of pregnancy? wasn’t explained

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How is placental abruption managed?

Resuscitate mother

Deliver baby

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Which investigations can be used to determine foetal heart rate?

Pinard stethoscope

Doppler ultrasound

CTG

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If a mother with placental abruption is pre-term, how is her baby delivered?

Either caesarean section

or artificial rupture of membranes and IOL

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What rheu condition may cause placental abruption?

Anti-phospholipid syndrome

Treated with LMWH and low dose aspirin

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What condition is caused by implantation of the placenta in the lower uterus?

Placenta praevia

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What terms are used when the placenta lies

a) close to the internal os
b) over the internal os

of the cervix?

a) Low-lying placenta

b) Placenta praevia

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What is the **lower segment of the uterus**?

**Thinner, non-contractile part of the uterus which is close to the internal os** Where the placenta goes in low-lying placenta / praevia and where you cut in a caesarean section

What is a **LSCS?**

**Lower segment Caesarean section**

What **percentage** of ante-partum haemorrhages are caused by placenta praevia?

**20%**

What percentage of deliveries are carried out by Caesarean section?

**25 - 30%**

What type of delivery is a risk factor for placenta praevia?

**Caesarean section**

Which investigation picks up placenta praevia?

**Ultrasound** which is part of the reason they're routinely done at 12 and 20 weeks

What are the symptoms of **placenta praevia**?

**Painless bleeding** **Post-coital bleeding**

What are some **signs of placenta praevia** on abdominal examination?

**High presenting part** (because placenta is inferior) **Malpresentation** and **malposition** more likely

Why shouldn't you do a PV exam in a woman with placenta praevia?

**Touching the placenta will trigger bleeding**

How is **placenta praevia** managed?

**Resuscitate mother** **Assess baby** **Deliver baby at term if stable** **Advise not to have intercourse, attend immediately if bleeding**

Which drugs are given to pregnant women if they are going to deliver pre-term? Why?

**Steroids** (speed up lung development) **Magnesium sulphate** (neuroprotection)

When should delivery happen if a woman's placenta praevia is uncomplicated i.e they're not bleeding?

**36 - 37 weeks**

When would you consider a) vaginal delivery b) C section in a woman with placenta praevia?

**a) Vaginal delivery if placenta \> 2cm from internal os** **b) C section if placenta covering os or malpresentation, ridiculous bleeding**

In which condition does the **placenta** remain stuck to the uterine wall?

**Placenta accreta**

What is **placeta accreta** called if the placenta a) **invades the myometrium** b) **penetrates the uterus**?

**a) Placenta increta** **b) Placenta percreta**

What happens if a woman with placenta accreta has a vaginal delivery?

**Massive APH**

How is **placenta accreta** managed?

If caught before birth: **Conservative** - curettage, ballooning and ligation if you want to spare the uterus **C section and hysterectomy** - effective but woman will be infertile

In which condition of pregnancy does a full-thickness tear occur in the uterus?

**Uterine rupture**

What increases your chances of **uterine rupture?**

**Previous uterine surgery** **Multiparity** **Obstructed labour**

What are the **maternal** **symptoms** of uterine rupture?

**Abdominal pain** **Shoulder-tip pain** - blood irritating the diaphragm, as in ruptured ectopic pregnancy **Syncope** - blood loss **PV bleeding**

What are the **foetal signs** of uterine rupture?

**Foetal distress** brady/tachycardia, late decelerations on CTG

What is **vasa praevia**?

**Unprotected foetal vessels lying over the internal os** **They rupture during labour, causing bleeding**

Which examination may rupture abnormal vessels in **vasa praevia?**

**PV exam**

How is **vasa praevia** investigated?

**Doppler ultrasound** but more often a clinical diagnosis with careful examination

How is **vasa praevia** managed?

**Caesarean section**

What is **post-partum haemorrhage**?

**\> 500ml blood loss following birth**

How can **post-partum haemorrhage** be categorised?

**Primary** - within 24h of delivery **Secondary** - within 6 weeks of delivery **Minor** - 500 - 1000ml blood loss **Major** - \> 1000ml blood loss; evident shock

The **causes of post-partum haemorrhage** can be described by the **Four Ts.** What are they?

**Tone** **Trauma** **Tissue** **Thrombin**

What does **tone** describe in the causes of post-partum haemorrhage?

**Atonic uterus** Most common cause of PPH - uterus doesn't contract properly and can't expel placenta

What does **trauma** describe in the causes of post-partum haemorrhage?

Trauma :)

What does **tissue** describe in the causes of post-partum haemorrhage?

Remnant placental or pregnancy tissue which causes haemorrhage

What does **thrombin** describe in the causes of post-partum haemorrhage?

**Coagulopathies** which cause increased bleeding risk in women e.g thrombocytopaenia, DIC and haemophilia

Why do you need to be careful with **Jehova's Witnesses** in the context of major haemorrhage?

**They refuse blood transfusions from donors** So you either don't do it or perform cell salvage - suck their own blood up with a machine, filter it and put it back in :/

What is **ergometrine**?

Drug which **induces uterine contractions** and **reduces bleeding by decreasing blood flow to the uterine arteries**

What is an important side effect of **ergometrine?**

**Hypertension**

Which drug can **ergometrine** be combined with to treat PPH? What is this combination drug called?

**Syntocinon** (synthetic oxytocin) - because it has a similar effect ## Footnote **Syntometrine**

When would you avoid using syntometrine and instead use syntocinon individually?

**Woman with hypertension** As hypertension is a side effect of ergometrine

How do you treat **PPH?**

**Stop the bleeding** (non-surgical or surgical methods) **Replace lost fluids**

Which **disease** is **APH** a **sensitising event** for?

**Rhesus disease**

**Antepartum haemorrhage** is a ___ event for **Rhesus disease.**

**sensitising event** if baby is Rhesus +ve and mother is Rhesus -ve, APH may be the trigger required for maternal antibody formation

What **test** determines the volume of **Anti D** a Rhesus -ve woman requires?

**Kleihauer test**

What is a **Kleihauer test**?

**Lab test which determines how much Anti-D a Rhesus -ve woman requires to prevent isoimmunisation**

6: Bleeding in late pregnancy Flashcards

(66 cards)