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HMS303 Reproductive, Ageing & Development > Ante Partum Hemorrhage / Late pregnancy bleeding > Flashcards

Ante Partum Hemorrhage / Late pregnancy bleeding Flashcards

(47 cards)

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1
Q

Source of bleeding during pregnancy is virtually never ________.

A

fetal

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2
Q

Common origins/sites of bleeding

A
  • disruption of blood vessels in the decidua (pregnancy endometrium)
  • lesions in cervix or vagina
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3
Q

Define Antepartum hemorrhage

A

Vaginal bleeding that occurs after 20wks gestation & unrelated to labor & delivery

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4
Q

Major causes of Antepartum Hemorrhage

A
  • Placenta praevia (20%)
  • Placenta abruption (30%)
  • Uterine rupture (rare)
  • Vasa praevia (rare)
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5
Q

Minor causes of Antepartum Hemorrhage

A
  • Cervical = polyps, infection (cervicitis), carcinoma.
  • Vaginal = infection (vaginitis), vaginal warts, vaginal cancer, trauma.
  • Uterine pathology = leiomyoma (fibroids), polyps.
  • Trauma
  • Bloody show = passage of operculum (mucous plug)
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6
Q

Define Placenta Praevia

A

Implantation of the placenta in the lower segment of the uterus so that it partially or totally covers the internal os of the cervix.

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7
Q

Prevalence of Placenta Praevia

A

Approx. 4 per 1000 births but varies worldwide.

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8
Q

Placenta Praevia is higher at 20 weeks than at birth because of?

A

Because the placenta migrates upwards as gestation advances.

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9
Q

Major risk factors - Placenta Praevia

A
  • Previous placenta praevia (4 - 8% recurrence)
  • Previous caesarian delivery (increase risk 47 - 60%)
  • Multiple gestations (40% higher risk compared to single)
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10
Q

Other risk factors - Placenta Praevia

A
  • Previous uterine surgical procedures
  • Increasing parity
  • Increasing maternal age
  • Infertility treatment
  • Previous pregnancy termination
  • Maternal smoking
  • Male fetus
  • Maternal cocaine use
  • Prior uterine artery embolization
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11
Q

Placental bleeding is a major sequelae. What does this mean?

A

Means it results from a prior disease, injury or trauma to the body.

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12
Q

Partial detachment of placenta are due to shearing forces from:

A
  • changes in cervix & lower uterine segment
  • vaginal examination (digital examination) = iatrogenic
  • coitus (sex)
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13
Q

Where does the bleeding occur in placenta praevia?

A

Bleeding primarily maternal blood in the intervillous space

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14
Q

Ultrasound examination of placenta praevia

A
  • asymptomatic (incidental) finding
  • 16-20wks
  • gestational age, fetal anatomy & cervical length
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15
Q

90% placenta praevia on ultrasound before 20 weeks resolves before delivery. Why is this?

A
  • This is because the lower segment lengthens (5mm at 20wks to 50mm at term) & relocates lower edge of placenta away from os.
  • Placenta trophotropism = with less vascular lower segment, the placenta tends to migrate upwards to more vascular decidua.
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16
Q

Placenta trophotropism

A

Process by which the placenta migrates upwards from a less vascular lower segment to a more vascular decidua.

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17
Q

The more the placenta extends over the _____ _____, the more likely it is to ________ until ______.

A

internal os, persist, delivery

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18
Q

Bleeding in placenta praevia

A
  • Painless (90%):
    1/3 initial onset <30wks
    1/3 initial onset between 30wks-36wks
    1/3 initial onset >36wks
  • Unpredictable & may occur at any time without warning
  • May range from slight intermittent bleeding to heavy profuse bleeding
  • Uterine contractions & pain may occur (10 - 20%)
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19
Q

Classification of placenta praevia (3)

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A
  1. Marginal - placenta is positioned at the edge of the cervix.
  2. Partial - placenta partially covers the internal os.
  3. Total - complete coverage of the internal os by the placenta.
20
Q

Diagnosis of Placenta Praevia

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A
  • Clinical suspicion
  • vaginal bleeding (painless) after 20wks of gestation
  • persistent abnormal fetal lie = transverse, oblique
  • Ultrasonography - gold standard
21
Q

Goal of managing Placenta Praevia

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A

To keep pregnancy intrauterine until risk of continuing pregnancy outweighs risk of preterm delivery.

(prolonging pregnancy to get as close as to the due date without complications)

22
Q

What examination is not performed in a patient with Placenta Praevia, & why?

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A

Vaginal exam - bc it may exacerbate bleeding when the placenta is disturbed, therefore an ultrasound scan (excludes placenta praevia) is always done before considering a vaginal exam.

23
Q

Management of Placenta Praevia
- Stabilize & monitor mother

Study These Flashcards
A
  • Admit patient
  • Insert a large bore IV cannula = for FBC, Blood group, Rhesus, Crossmatch (blood transfusion)
  • Ultrasound to confirm diagnosis
24
Q

Management of Placenta Praevia (4)
- Less than 37wks & minimal bleeding

Study These Flashcards
A
  • Expectant management
  • Limited physical activity, no vaginal douching or sexual intercourse
  • Consider corticosteroids for fetal lung maturity (helps mature the development of the lungs)
  • Deliver when fetus is mature or hemorrhage threatening fetal or maternal wellbeing.
25
Management of Placenta Praevia - Greater than 37wks
Deliver = mode of delivery is to be determined by degree of placenta praevia: - complete placenta praevia = caesarian section - low lying placenta = may consider trial of vaginal delivery.
26
Placenta Abruption (abruptio placentae)
Partial or complete placental detachment from the uterine wall after 20wks of gestation.
27
Placenta Abruption - complicates approx. _______ per _____ births.
2-10 per 1000 births
28
Pathophysiology of Placenta Abruption
Rupture of placental vessels in the decidua basalis (basal layer) → accumulating blood splits the decidua from its placental attachment → leads to the development of potentially life-threatening complications = severe bleeding, maternal DIC (disseminated intravascular coagulation), fetal compromise.
29
Placenta Abruption - Risk factors
- previous abruption - hypertension/preeclampsia - multiparity - increased age - smoking/alcohol use - cocaine use - polyhydramnios - premature rupture of membranes - external trauma - uterine anomalies (bicornuate uterus/ uterine synaechae/ leiomyomata)
30
Clinical Features of Placenta Abruption
- pain = sudden onset, constant, localized to uterus & lower back. - painful vaginal bleeding (80%) - external/revealed = presents with vaginal bleeding - internal/concealed (20%) = may or may not present with vaginal bleeding. - uterine tenderness/ uterine contractions/ hypertonus (uterus doesn't relax between contractions) - shock/anemia = out of proportion to external blood loss - fetal distress/ fetal demise/ bloody amniotic fluid - couvelaire uterus = extravasation of blood into the uterine musculature and beneath the uterine peritoneum.
31
Placenta Abruption - 2 main types
1. Revealed - bleeding tracks down from the site of placental separation & drains through the cervix - results in vaginal bleeding 2. Concealed - bleeding remains within the uterus, and typically forms a clot retroplacentally (behind). - bleeding is not visible but can be severe enough to cause systemic shock.
32
Management of Placenta Abruption - Maternal stabilization
- large bore IV with fluids = FBC, Group, Crossmatch, Coagulation profile. - monitoring of vital signs, urine output, blood loss.
33
Management of Placenta Abruption - Fetal monitoring
Cardiotocogram (CTG)
34
Management of Placenta Abruption - Abruption without fetal/maternal compromise (mild)
<37 wks - close monitoring - deliver when fetus is mature or signs of fetal/maternal compromise >37 wks - deliver
35
Complications of Placenta Abruption - Maternal
- hypovolemic shock - DIC = disseminated intravascular coagulation - blood transfusion - hysterectomy (removal of uterus) - renal failure - in hospital death
36
Complications of Placenta Abruption - Fetal
- non-reassuring status - growth restriction - death
37
Complications of Placenta Abruption - Newborn
- pre-term birth - small for gestational age - death
38
Vasa Previa
Rare condition where one of the branches of the fetal umbilical vessels lies in the membranes & across the cervical os.
39
If vasa praevia is undiagnosed...
50% perinatal mortality, increasing to 75% if membranes rupture.
40
If vasa praevia is diagnosed antenatally using ultrasound without labour or symptoms...
97% survival
41
Management of Vasa Praevia
- Planned c-section delivery at 37wks - Emergency c-section if bleeding earlier
42
Rupture of uterus can occur?
*During pregnancy - before or after the onset of labor. * Spontaneously - previous caesarian scar (classical c/section more than lower segment c/section) - uterine anomaly - intact uterus (rare) - as a side effect of uterotonic agents (oxytocin) *Acquired - trauma (car accidents, physical violence) - obstetrics procedures (e.g. forceps rotation, external cephalic version)
43
Rupture of the uterus may lead to ____ of both ____ & ____.
death, mother, fetus
44
Clinical features - Rupture of uterus
- high index of suspicion - vaginal bleeding - absence of contractions in a woman who was contracting regularly - abdominal distension - fetal distress & possibly death - maternal reduction in level of consciousness & shock
45
Management - Rupture of the uterus
- Obstetrics emergency - Multidisciplinary team effort - ABC - Stabilize woman & transfer for urgent laparotomy - uterine repair vs hysterectomy.
46
Complications of Rupture of the uterus - Fetal
- hypoxia - acidosis - NICU admission - death
47
Complications of Rupture of the uterus - Maternal
- severe blood loss - blood transfusion - surgical risk with possible hysterectomy - death

HMS303 Reproductive, Ageing & Development (9 decks)

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