High risk pregnancy: Maternal medical condition( e.g. diabetes, obesity)

Question 1

Definiton of antepartum bleeding

Answer 1

Bleeding of the genital tract, occurring from 24 weeks of gestation until birth.

Question 2

Aetiology of APH

Answer 2

• placental abruption (30%)
• placenta praevia (20%)
• uterine rupture (rare) • vasa praevia (rare)
• Other causes include cervical lesions (such as polyps or ectropion), infection, trauma or malignancy.

Question 3

Definiton and aetiology of Placenta Praevia

Answer 3

• Placenta praevia is a placenta that is partially or wholly implanted into the lower uterine segment.
• 0.4% pregnancies at term
• 20 weeks- low placenta in many pregnancies but moves
upwards- 5% of pregnancies
Aetiology-
• More common in twins • High parity
• Advanced maternal age

Question 4

Classification of placenta previa

Answer 4

• Marginal (previously types 1-2) - placenta in lower segment not over the os
• Major( previously types 3-4)- placenta completely or partially covering the os

Question 5

Complications placenta previa

Answer 5

• Needs caesarean section as obstructs engagement of head
• Haemorrhage-severe bleeding during and after delivery
• If palcenta implants into previous caesarean scar and myometrium- placenta accreta
• If penetrates though uterine wall into surrounding structures- placenta percreta

Question 6

Clinical features: placenta previa

Answer 6

• History- intermittent painless bleeding in pregnancy
• Examination- breech/transverse lie are common
• Vaginal examination can provoke massive bleeding, hence avoided if placenta previa is suspected

Question 7

Investigations for placenta previa

Answer 7

Ultrasound- used to locate the placenta
If low lying placenta is found at 20weeks – scan id repeated at 32 weeks
Placenta <2cm from the internal os at term is placenta previa
If placenta is anterior with pre LSCS , 3D ultrasound or MRI is used to diagnose accreta

• Full blood count
• Cross match 6 units of blood • Clotting profile
• CTG (Cardiotocography)

Question 8

placenta previa management

Answer 8

• Admit
• Intravenous access
• Steroids if <34 weeks
• Blood kept available and ready • Anti D if rhesus negative

Question 9

Placenta accreta care bundle

Answer 9

• Consultant obstetrician planned and directly supervising delivery
• consultant anaesthetist planned and directly supervising anaesthetic at delivery
• blood and blood products available
• multidisciplinary involvement in pre-op planning
• discussion and consent includes possible interventions (such as hysterectomy, leaving the placenta in place,cell salvage and intervention radiology)

Question 10

Define Placental abruption

Answer 10

• When part or all of the placenta separates before delivery of the fetus
• 1% of pregnancies
• Considerable maternal bleeding occurs
• Fetal distress

Question 11

implications of Placental abruption

Answer 11

fetal distress
intrauterine death
disseminated intravascular coagulopathy

Question 12

Aetiology of placenta abruption

Answer 12

• IUGR
• Pre-eclampsia
• Autoimmune disease
• Smoking
• Cocaine abuse
• Previous history of abruption • Multiple pregnancy
• Multiparity
• Trauma
• Pre-existing hypertension

Question 13

Clinical features of placental abruption

Answer 13

• Painful bleeding
• Pain is due to blood behind placenta • Concealed- when bleeding is not seen • Revealed- bleeding is evident Examination-
• Tachycardia
• Hypotension
• Uterus is tender
• FHS- abnormal or absent
• Uterus can be woody hard

Question 14

Investigations of placental abruption

Answer 14

• Diagnosis is made on clinical grounds
• CTG -cardiotocography for fetal well being • FBC
• Clotting profile
• Cross match blood
• Catheter- hourly urine output
• Urea and creatinine

Question 15

Management of placental abruption

Answer 15

• Admission
• IV cannula
• IV Fluids / blood and blood products • Steroids if gestation<34 weeks
• Analgesia
• Anti D if rhesus negative • Early delivery

Question 16

Delivery in placental abruption

Answer 16

• Mother is stabilised first
• Depends on fetal state and gestation
• If fetal distress category one caesarean section
• If no fetal distress labour can be induced with amniotomy

Question 17

Differentiation between placental abruption and placenta previa

Answer 17

Abruption
painful bleeding, may be absent or concealed, severed tenderness woody hard uterus, fetes may be dead or distressed, ultrasound often normal placenta not low.

Placenta previa - no pain, red and profuse blood, tenderness is rare, placenta low son ultrasound

Question 18

what is Vasa previa?

Answer 18

• When fetal blood vessels runs in the membranes in front of the presenting part
• 1% of pregnancies
• Massive fetal bleeding occurs if these ruptures
• Usually severe fetal distress

Question 19

Other causes of bleeding apart from previa and abruption

Answer 19

• Uterine rupture

* Cervical carcinoma /polyp/ectropion/tears