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REPRODUCTION & GYNAECOLOGY > Bleeding in Late Pregnancy > Flashcards

Bleeding in Late Pregnancy Flashcards

1
Q

What is the cut off for bleeding in early vs late pregnancy?

A

Early <24 weeks

Late >24weeks (after this point a baby is considered viable)

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2
Q

Maternal mortality due to haemorrhage in the UK is mainly static. TRUE/FALSE?

A

TRUE

around 9 in 100,000

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3
Q

The placenta is entirely foetal tissue. TRUE/FALSE?

A

TRUE

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4
Q

What are the functions of the placenta?

A
  • Gas transfer
  • Metabolism/waste disposal
  • Hormone production (Human placental lactogen etc)
  • Protective ‘filter’
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5
Q

What is the definition of antepartum haemorrhage (APH)?

A
  • Bleeding from the genital tract
  • after 24 weeks gestation
  • and before the end of the 2nd stage of labour.
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6
Q

What are the potential sources of an antepartum haemorrhage?

A 
Placental problem - previa/abruption
Uterine problem - rupture
Vasa previa
Local causes - ectropion, cervical, vaginal
indeterminate
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7
Q

What are the potential differential diagnoses for APH?

A

Heavy Show
Cystitis
Haemorrhoids

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8
Q

How can APH be quantified?

A

Spotting - staining, streaking, wiping
Minor - <50ml
Major - 50-1000ml (No shock)
Massive - >1000ml (+/- shock)

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9
Q

What is placental abruption?

A
  • Separation of a normally implanted placenta before birth of the fetus
  • Can be partially separated or totally separated
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10
Q

Placental abruption is diagnosed clinically. TRUE/FALSE?

A

TRUE

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11
Q

Describe the pathology involved in placental abruption

A
  • Vasospasm
  • Then arteriole rupture into the decidua
  • blood escapes into amniotic sac OR under placenta AND into myometrium
  • Tonic contraction
    => interrupts placental circulation
    => causing hypoxia

Results in Couvelaire (Bruised) uterus

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12
Q

What are the risk factors for a placental abruption?

A
  • Pre-eclampsia / Hypertension
  • Trauma/ Domestic Violence /RTA
  • Smoking
  • Drugs e.g. Cocaine/Amphetamine
  • Medical Conditions (Thrombophilias/Renal/Diabetes)
  • Polyhydramnios
  • Multiple pregnancy
  • Preterm-Prelabour Rupture Of Membranes
  • Abnormal placenta
  • Previous Abruption
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13
Q

What symptoms do patients suffering a placental abruption usually present with?

A
  • CONTINUOUS Severe Abdominal Pain (Labour pain = intermittent)
  • backache if posterior placenta
  • Bleeding (may be concealed)
  • Preterm labour
  • maternal collapse
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14
Q

WHat clinical signs may indicate a placental abruption?

A
  • Unwell/ distressed patient
  • Uterus Large for dates/normal
  • Uterine tenderness (Woody hard uterus)
  • Foetal parts difficult to identify
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15
Q

Describe the foetal heart rate and CTG abnormalities seen in a placental abruption?

A
  • Foetal Heart: bradycardia/ absent (IUD)

- CTG shows irritable uterus (1 contraction/minute) and Foetal HR abnormality (tachy, loss variation, decelerations)

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16
Q

How should a mother be resuscitated after a placental abruption?

A
  • 2 Large bore IV access
  • Emergency bloods
    => FBC, clotting, LFT, U/E, Cross match 4-6 units, Kleihauer (for FMH, checks if Anti D needed)
  • IV fluids (take care with Pre-eclampsia/ heart failure)
  • Catheterise- hourly urine volumes
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17
Q

How should the foetus be managed in a placental abruption?

A
  • Assess Fetal Heart: CTG then US if not heard
  • Delivery:
    => Urgent C/section
    OR => Assisted Rupture Membranes and IOL
    => Conservative Management (if minor)
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18
Q

What are the potential complications of placental abruption for the mother?

A
  • Hypovolaemic shock
  • Anaemia due to blood loss
  • PPH (25% )
  • Renal failure (renal tubular necrosis)
  • Coagulopathy
  • Infection
  • Psychological (PTSD)
  • Complications of blood transfusion
  • Thromboembolism
  • Mortality rare
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19
Q

What are the potential complications of placental abruption for the foetus?

A
  • Intrauterine death(IUD)
  • hypoxia
  • prematurity
  • Small for gestational age (SGA) and fetal growth restriction (IUGR)
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20
Q

HOw can placental abruption be prevented in high risk groups?

A
  • Antiphospholipid Syndrome = LMWH + Low Dose Aspirin
  • Smoking cessation
  • Low Dose Aspirin
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21
Q

What is the difference between placenta praevia and a low lying placenta?

A

Placenta Praevia = placenta lies directly over internal os.

“low‐lying placenta” = placental edge <20 mm from internal os on transabdominal or transvaginal US

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22
Q

Why is the placenta lying in the lower segment of the uterus a problem?

A
  • Obstructs passage during labour

- Located in the part of the uterus which dilates to accommodate labour rather than contracting

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23
Q

Previous caesarean section and multiple caesarean sections increase the risk of Placenta praevia. TRUE/FALSE?

A

TRUE

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24
Q

What other risk factors exist for placenta praevia?

A
  • Previous placenta praevia
  • Smoking
  • Age (>40 years)
  • Assisted reproductive technology
  • Previous termination
  • Multiparity
  • Multiple pregnancy
  • Deficient endometrium (endometritis, curettage, submucous fibroid)
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25
Q

How is placenta praevia screened for?

A
  • Foetal anomaly scan includes placental localisation
  • Rescan at 32 + 36 weeks if persistent placenta praevia or Low lying placenta
  • Assess cervical length <34 wks for risk of preterm labour
  • MRI if placenta accreta suspected
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26
Q

What are the usual presenting symptoms of placenta praevia?

A
  • Painless bleeding >24 weeks
  • Usually unprovoked (check for post-coital bleeding)
  • Patient’s condition directly proportional to amount of observed bleeding
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27
Q

WHat clinical signs may indicate placenta praevia?

A
  • Uterus soft non tender
  • Presenting part high
  • Malpresentations (as placenta is obstructing space to turn) => Breech/Transverse/Oblique
  • CTG usually NORMAL
28
Q

How is placenta praevia diagnosed via investigation?

A
  • Recheck anomaly scan!
  • Confirm by Trans-Vaginal ultrasound
  • MRI for excluding placenta accreta
29
Q

How is a mother with placenta praevia treated?

A
  • Resuscitation if large blood loss
  • Assess Baby
  • Conservative management if stable
  • Admit if PV Bleeding OR distant from hospital OR Jehovah’s Witness
  • Prevent + treat anaemia
  • Delivery plan in place
30
Q

If a patient with placenta praevia is not currently bleeding but the risk has been identified, how should she be managed?

A
  • Advise pt to attend immediately if bleeding/spotting, contractions/pain (including vague suprapubic period‐like aches)
  • Antenatal corticosteroids < 34+0weeks of gestation in women at higher risk of preterm birth.
  • Mg SO4 (neuro-protection 24-32 weeks- if planning delivery)
31
Q

If a mother has an uncomplicated placenta praevia with no PV bleeding, when should the baby ideally be delivered?

A

consider delivery between 36 and 37weeks

32
Q

How should a mother with placenta praevia and a history of bleeding be resuscitated?

A
  • 2 Large bore IV access,
  • Emergency bloods => FBC, clotting, LFT, U/E , Kleihauer (Rh Neg), Cross match 4-6 units blood
  • Major Haemorrhage protocol (if needed)
  • IV fluids or transfuse Blood
  • Anti D (if Rh Neg)
33
Q

Which method of delivery of the baby is preferred in placenta praevia?

A

C/section = If placenta covers os or <2cm away from os

Vaginal delivery = if placenta >2cm from os and no malpresentation

34
Q

What further consent do you need before completing a c-section in placenta praevia?

A
  • Consent to include hysterectomy and risk of General Anaesthesia
  • Cell salvage (collects blood from operating site)
35
Q

What surgical techniques are used in a placenta praevia c-section?

A
  • Vertical skin and uterine incisions if <28weeks and baby is lying transverse
  • Aim to avoid cutting through the placenta
36
Q

What is placenta accreta?

A

morbidly adherent placenta

=> abnormally adherent to the uterine wall

37
Q

What are the major risk factors for placenta accreta?

A
  • placenta praevia

- prior caesarean delivery.

38
Q

What other names are given to placenta accreta if it is either invading the myometrium or penetrating to the bladder?

A

Invading myometrium: INCRETA

Penetrating uterus to bladder/: PERCRETA

39
Q

How can placenta accreta be treated?

A
  • Prophylactic internal iliac artery balloon
  • Caesarean hysterectomy
  • Conservative Management (no surgery just Methotrexate)
40
Q

What is meant by a uterine rupture?

A

Full thickness opening of uterus

41
Q

What are the potential risk factors for a uterine rupture?

A
  • previous caesarean section/ uterine surgery e.g. myomectomy
  • Multiparity and use of prostaglandins/ syntocinon
  • Obstructed labour
42
Q

How do patients normally present with uterine rupture?

A

Severe abdominal pain
Shoulder-tip pain
Maternal collapse
PV bleeding

43
Q

What clinical signs may indicate uterine rupture?

A
  • Loss of contractions during labour
  • Acute pain in abdomen (Peritonism)
  • Presenting Part rises
  • Foetal distress / IUD
44
Q

How is uterine rupture urgently managed?

A
  • Urgent Resuscitation + Surgical
  • 2 Large bore IV access,
  • Bloods => FBC, clotting , LFT, U/E , Kleihauer (if Rh Neg), Cross match 4-6 units Blood
  • Major Haemorrhage protocol
  • IV fluids or transfuse blood
  • Anti D (if Rh Neg)
45
Q

What is vasa praevia?

A
  • unprotected fetal vessels traverse the membranes below the presenting part
    => over the internal cervical os
  • These rupture during labour or at amniotomy
46
Q

HOw is vasa praevia diagnosed on investigation?

A

Transabdominal OR Transvaginal US (+doppler)

47
Q

How can vasa praevia be diagnosed clinically?

A

Assisted Rupture of Membranes and sudden dark red bleeding

=> foetal bradycardia / death

48
Q

What are the two types of vasa praevia that exist?

A

Type I = vessel is connected to a velamentous umbilical cord

Type II = connects the placenta with a succenturiate or accessory lobe.

49
Q

What factors increase the risk of vasa praevia?

A
  • placental anomalies
    => bi-lobed placenta, succenturiate lobes (foetal vessels run through membranes joining separate lobes together)
  • Hx of low-lying placenta in 2nd trimester
  • Multiple pregnancy
  • IVF
50
Q

How is vasa praevia managed?

A
  • Steroids from 32 weeks
  • Inpatient management if risk of preterm birth (32-34 weeks)
  • Deliver by elective c/section before labour (34-36 weeks)
  • Emergency c-section and neonatal resuscitation + blood transfusion if required
  • send placenta to histology
51
Q

What other causes are responsible for APH?

A

Cervical:

  • ectropion
  • Polyp
  • carcinoma

Vaginal causes
- e.g. post-coital bleeding

52
Q

What is a post-partum haemorrhage?

A

Blood loss equal to or > 500ml after the birth of the baby

53
Q

What is the difference between a primary and secondary post-partum haemorrhage?

A

Primary - within 24hrs of baby delivery

Secondary - >24hrs after and within 6 weeks post delivery

54
Q

What volume is considered a minor vs major PPH?

A

Minor: 500ml- 1000ml ( without shock)
Major: >1000ml or signs of cardiovascular collapse or on-going bleeding

55
Q

Why may blood loss may be underestimated in PPH?

A

Not all blood loss in visual

patient may be bleeding into vagina, but it is not visible except on examination

56
Q

What are the 4Ts which cause PPH?

A

Tone 70%
Trauma 20%
Tissue 10%
Thrombin <1%

57
Q

What are the risk factors for PPH?

A
  • anaemia
  • previous caesarean section
  • placenta praevia/accreta
  • previous PPH
  • Multiple pregnancy
  • Polyhydramnios/ Obesity/ Foetal macrosomia
58
Q

What do you need to make sure a patient who is a Jehova’s witness has in place in case of a PPH?

A 
Advanced Directive (due to not accepting transfusions of blood)
- Some MAY accept cell salvage material as this is their own blood
59
Q

What intra-partum risk factors can precipitate PPH?

A
  • prolonged labour
  • operative vaginal delivery
  • caesarean section
  • retained placenta
  • Active management of third stage (oxytocin drugs)
60
Q

HOw do you treat a mother with PPH who has lost between 500-1000ml of blood but is NOT in shock?

A
  • IV access
  • Bloods => FBC, coag. screen, + fibrinogen
  • Observations: pulse, RR, BP every 15 minutes
  • IV warmed crystalloid infusion
61
Q

HOw is the bleeding in PPH stopped?

A
  • Uterine massage- bimanual compression
  • Expel clots
    Give:
  • Oxytocin in Hartmann’s solution infused
    IF STILL BLEEDING
  • Ergometrine IV (Avoid if Cardiac Disease / Hypertension)
    IF STILL BLEEDING
  • Carboprost /Haemabate IM every 15min ( Max 8 doses)
  • Misoprostol and Tranexamic acid
    IF STILL BLEEDING
    Examine Under Anaethesia in theatre
62
Q

What other causes of PPH bleeding should be looked for in examination under anaethesia in theatre

A

? Vaginal / cervical trauma.
? Retained Products Of Conception
? Rupture
? Inversion

63
Q

How can PPH be managed after a patient has been taken to theatre?

A

Non-surgical

  • Packs / Balloons (Bakri)
  • Tissue Sealants
  • Interventional Radiology = Arterial Embolisation

Surgical

  • Undersuturing
  • Brace Sutures
  • Uterine/ Internal Iliac Artery Ligation
  • Hysterectomy
64
Q

If a patient presents with a secondary PPH what cause do we want to rule out?

A

Exclude Retained products of conception (RPOC) with USS

65
Q

Infection is likely to play a role in secondary PPH. TRUE/FALSE?

A

TRUE

REPRODUCTION & GYNAECOLOGY (58 decks)

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