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Laura MRCOG Part 2 > 8A) Antenatal Care: Bleeding-related > Flashcards

8A) Antenatal Care: Bleeding-related Flashcards

1
Q

Definition of vasa praevia

A

Fetal vessels running in free placenta membrane (within 2cm of internal os)

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2
Q

Incidence of vasa praevia

A

1/1200-1/5000

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3
Q

Types of vasa praevia

A

Type 1: Vessels associated with velamentous card

Type 2: Vessels joining placenta to subcenturiate/accessory lobe

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4
Q

Type of bleeding seen with vasa praevia

A

Fetal blood.
Dark red. “Benckisers haemorrhage”.
Associated with feral distress.

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5
Q

What is average circulating fetal volume?

A

80-100mL

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6
Q

Mortality associated with vasa praevia

A

> 60% if diagnosed in labour due to bleeding + fetal distress.
<5% if diagnosed antenatally.

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7
Q

Treatment of vasa praevia if detected antenatally

A
  • Confirm diagnosis in third trimester
  • Consider admission 30-32 weeks
  • Steroids 32 weeks
  • ELCS 34-36 weeks
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8
Q

Percentage of vasa praevia which resolve by 30-32 weeks.

A

20%

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9
Q

Definition of placenta praevia

A

“Low lying” placenta has edge < 20mm from internal os.
“Praevia” has placenta lying directly over internal os.

After 16 weeks.

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10
Q

Incidence of placenta praevia

A

1 in 200

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11
Q

Risk factors for placenta praevia

A 
Previous placenta praevia
Previous CS
Maternal age
Multiparity
Multiple pregnancy
ART
Scarred uterus - fibroid, infection, TOP, MROP.
Smoking.
Second pregnancy within 1 year.
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12
Q

Risk of placenta praevia with increasing number of CS

A 
0 CS: 1 in 400
1 CS: 1 in 100
2 CS: 1 in 60
3 CS: 1 in 35
4 CS: 1 in 10
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13
Q

How to investigate low placenta?

A

If noted to be low on trans abdominal scan at 20 weeks then for TVS at 32 weeks and f still low then TVS 36 weeks.

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14
Q

What percentage of cases of low lying placentas will resolve before term?

A

5% of placentas will be low lying at 20 weeks and 90% of these will resolve by term.

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15
Q

What percentage of cases of low lying placentas resolve in twin pregnancies?

A

Majority resolve by 32/40. After 32/40 then a further 50% will resolve. No further change after 36/40.

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16
Q

What increases the risk of emergency Caesarean in cases of placenta praevia?

A
  • Short cervical length on TVS before 34/40
  • Recurrent APH
  • Antenatal blood transfusion
  • Previous CS
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17
Q

Management of placenta praevia

A
  • Steroids 34-36 weeks.
  • Weekly G&S for high risk women
  • If symptomatic, delivery 34-36 weeks.
  • If asymptomatic, delivery 36-37 weeks.
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18
Q

Risk of bleeding with placenta praevia at different gestation

A

5% by 35/40
15% by 36/40
30% by 37/40
60% by 38/40

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19
Q

Risk of requiring emergency hysterectomy at CS for placenta praevia

A

11 in 100 if isolated praevia
27 in 100 if praevia and previous CS
90 in 100 if abnormally invasive placenta
(Compared to 7-8/1000 if no praevia)

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20
Q

Risk of major obstetric haemorrhage at time of CS for placenta praevia

A

21 in 100

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21
Q

Risk of further laparotomy during recovery from CS for placenta praevia

A

7.5 in 100

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22
Q

Risk of bladder/ureteric injury at CS for placenta praevia

A

6 in 100

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23
Q

Risk of future placenta praevia after CS for placenta praevia

A

23 in 1000

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24
Q

Risk of VTE after CS for placenta praevia

A

3 in 100

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25
Q

Definition of placenta accreta/increta/percreta

A

Accreta: Villi adhere superficially to mayo myometrium without interposing decidua
Increta: Villi penetrate deeply into myometrium down to serosa
Percreta: Villi perforate through entire uterine wall and may invade surrounding pelvic organs.

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26
Q

Incidence of placenta accreta spectrum disorders

A

1/300-1/2000

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27
Q

Risk factors for placenta accretion

A 
Previous CS
Placenta praevia
Maternal age
ART
Uterine scarring
28
Q

Risk of placenta accreta in patient with placenta praevia and previous CS

A 
\+1 CS: 3%
\+2 CS: 11%
\+3 CS: 40%
\+4 CS: 61%
\+5 CS: 67%
29
Q

Diagnosis of placenta accreta

A

Diagnostic value of USS and MRI similar but MRI useful for depth of invasion and lateral extension of myometrial invasion.

30
Q

When to deliver placenta accreta?

A

34-35 weeks (and 20% still require emergency delivery before this)

31
Q

Definition of antepartum haemorrhage

A

Bleeding from, or in to, the genital tract between 24+0 weeks and delivery of baby.

32
Q

Incidence of antepartum haemorrhage

A

3-5% of pregnancies

33
Q

Categorisation of APH

A

Spotting
Minor (<50 mL)
Major (50-1000mL with no evidence of shock)
Massive (>1000mL or shock)

34
Q

Incidence of placental abruption after previous abruption

A

4.4% after one abruption

19-25% after two abruptions

35
Q

Risk factors for placental abruption

A

Previous history:
Previous abruption
Multiparity

Maternal characteristics:
Maternal age
Low BMI
Smoking and drug use
Thrombophilia - factor V Leiden, prothrombin mutation
Pregnancy features:
Fetal growth restriction
Polyhydramnios
Malpresentation
Assisted reproduction
PET
Trauma
1st trimester bleeding (particularly if haematoma present OR 6)
Intrauterine infection
PROM
36
Q

Rates of cervical cancer per 100,000 deliveries

A

7.5 per 100,000 deliveries

37
Q

Percentage of abruptions in low risk pregnancies

A

70%

38
Q

Percentage of premature births associated with APH

A

20%

39
Q

Risks associated with unexplained APH

A 
Stillbirth
Preterm birth
PPROM
Oligohydramnios
Small gestational age
Fetal anomalies
40
Q

Role of tocolysis in APH

A

Contraindicated in abruption and “relatively contraindicated” in mild haemorrhage due to praevia.

41
Q

Blood tests required with APH

A

Minor: FBC, G&S
Major: FBC, UE/LFT, Clotting, 4 unit XMatch

42
Q

When to deliver APH?

A
  • If compromise, via CS at the time.
  • If no compromise and <37 weeks no evidence for preterm delivery.
  • If no compromise but >37 weeks then consider IOL.
43
Q

When should anti-D be given?

A

After any presentation with APH.

If recurrent, at least 6 weekly intervals.

44
Q

Cannula required for APH

A

Minor: 1 x 14 gauge
Major: 2 x 14 gauge

45
Q

Fluid therapy and blood product transfusion for massive APH

A

Until blood available:

  • up to 2 units Hartmann’s
  • up to 1-2 litres colloid
  • RBC (cross-matched if possible, if not uncrossmatched group-specific or O Neg)
  • 4 units of FFP (12-15ml/kg or total 1 litre) for every 4 units of RBC or if PT/APTT >1.5 x mean.
  • Platelets if platelet count < 75
  • Cryoprecipitate if fibrinogen <2
46
Q

How much FFP/cryo can be given with continuing massive haemorrhage and awaiting coagulation studies?

A

4 units FFP and 10 units of cryogenic.

47
Q

Target blood values during massive APH

A

Hb > 80
Platelets > 50
PT/APTT >< 1.5
Fibrinogen > 2

48
Q

Definition of anaemia in pregnancy

A

1st trimester: Hb < 110
2nd/3rd trimester: Hb <105
Postpartum: Hb <100

49
Q

What age should G&S samples be for provision of blood?

A

< 3 days old

50
Q

What compatibility of blood should be used?

A

ABO, RhD and Kell compatible red cell units. And negative for any clinically significant antibodies.
CMV negative blood and platelets during pregnancy (not necessary during delivery or postpartum)

51
Q

When is cell salvage recommended?

A

Anticipated blood loss great enough to induce anaemia or expected to exceed 20% of estimated blood volume.

52
Q

What anti-D is required after cell salvage?

A

Minimum of 1500 units followed by Kleihauer 30-40 minutes post transfusion.

53
Q

What compatibility of FFP/Cryo is required?

A

Ideally same group as recipient but ca have FFP of different ABO group if required provided doesn’t have high titre anti-A or anti-B.

54
Q

What anti-D is required after FFP/Cryo?

A

None!

55
Q

What anti-D is required after platelets?

A

250 units anti-D covers 5 adult therapeutic doses of platelets within 6 week period.

56
Q

Thrombosis risk associated with factor VIIa

A

2.5%

57
Q

How does TXA work?

A

Reversible binds plasminogen and prevents activation to plasmin. Reduces bleeding without increasing VTE risk.

58
Q

Definition of primary PPH

A

Loss of >500mL of blood from the genital tract within 24 hour of the birth of a baby.

59
Q

Categories of primary PPH

A

Minor: 500-1000mL
Major: >1000mL (Split into Moderate 1000-2000mL and Severe >2000mL)

60
Q

Definition of secondary PPH

A

Abnormal/excessive bleeding from birth canal between 24 hours and 12 weeks postnatal.

61
Q

Most common cause of PPH

A

Atony

62
Q

Benefits of active management of third stage

A

2/3 reduction in risk of major PPH

63
Q

Drugs for active management of third stage

A

Vaginal delivery: 10 units IM synt or syntometrine (5 units synt + 500 microgram ergometrine)
CS: 5 units IV syntocinon

64
Q

At what EBL are physiological signs of hypovolaemia usually seen?

A

Pulse and BP maintained whilst EBL <1000mL.
If BP slightly low (and increased HR and RR) then EBL 1000-1500mL
If systolic BP < 80mmHg, usually > 1500mL

65
Q

Management of PPH

A
  • Stimulate uterine contractions
  • Foley’s catheter
  • Synt 5 units IV
  • Ergometrine 0.5mg IM/IV
  • Synt infusion
  • Carboprost 250 microgram IM every 15 minutes for 8 doses (but f no improvement after 3 doses consider transfer to theatre)
  • Misoprostol 800 micro gram
  • Surgical options
66
Q

How long does misoprostol take to take effect?

A

1.5-2 hours

67
Q

Surgical options for management of PPH

A
  • Uterine balloon tamponade
  • B Lynch suture
  • Stepwise devascularisation
  • Interventional radiology embolisation
  • Hysterectomy

Laura MRCOG Part 2 (56 decks)

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