Antepartum hemorrhage Flashcards Preview

Obstetrics and Gynaecology > Antepartum hemorrhage > Flashcards

Flashcards in Antepartum hemorrhage Deck (51):
1

Definition

Bleeding after 20 weeks, prior to labour

2

Definition

Bleeding after 20 weeks, prior to labour

3

Incidence

3-5%

4

Etiology

Uterine: placenta previa, placental abruption, vasa praevia, circumvallate placenta
Lower genital tract: cervical extropion, polyp, carcinoma, cervicitis, vaginitis
Unknown in 50%

5

Association of preterm infants and APH

20% preterm infants result of APH

6

History

Amount of bleeding
Onset
Pain
Contractions
Mucoid discharge
Triggering event-> intercourse (ectropion etc)
Last pap smear
STD history

7

Most important distinguishing feature between placental abruption and placenta praevia

Constant abdominal pain

8

Examination

Maternal well being:
Pulse, BP, T
Pallor
Abdominal tender, distension, ridigity
Speculum for cervical abnormalities
Digital examination- only when placenta praevia excluded, when contractions, to assess progress of cervix

Fetal well being:
Abdominal palpation for lie/presentation/engagement
CTG

9

Investigations

FBC
Group hold/screen, cross match
Rhesus-->?Anti-D
Urine
UEC
LFT
Coagulation profile
Kleihauer tests

10

What is the Kleihauer test and what does it indicate

Blood film->shows fetal RBCs in maternal circulation indicating placental abruption

11

Definition of placenta praevia

Placenta encroaches on lower segment

12

Define the lower segment of uterus

13

Etiology of placenta praevia

Multiparity
Multiples
Previous cesaerean
Smoking
+Age
Fetal anomalies

14

Grading of PP

1: At lower segment, not reaching os
2: Reaches os, does not cover
3: Covers os only when not dilated
4: Covers os even when dilated

15

Presentation of PP

Diagnosed on US
Painless bleeding
Pain->10% also have placental abruption
Postcoital bleeding
Spotting

16

Placenta previa and bleeding

ABCs
2 large IV cannula, IDC
Infusion NS
Bloods group/screen/xmatch, anti-Dif Rh negative
Avoid all vaginal examination
USS, gentle speculum
If anemia, no longer bleeding, 10.5
Continue until can do C section
Consent and book for C section
Be sure to always have group and hold up to date- risk of PPH
If

17

Placenta previa and bleeding

ABCs
2 large IV cannula
Infusion NS
Bloods group/screen/xmatch, anti-Dif Rh negative
Avoid all vaginal examination
USS, gentle speculum
If anemia, no longer bleeding, 10.5
Continue until can do C section
Be sure to always have group and hold up to date- risk of PPH

18

When might you consider an MRI

If suspect placenta accreta

19

Why is there +risk of post partum hemorrhage in PP

Lower segment does not contract as well and therefore less compression of the placental vessels

20

Recurrence rate of PP

4-8% in subsequent pregnancies

21

Incidence

3-5%

22

Etiology

Uterine: placenta previa, placental abruption, vasa praevia, circumvallate placenta
Lower genital tract: cervical extropion, polyp, carcinoma, cervicitis, vaginitis
Unknown in 50%

23

Complications of placental rupture-->maternal and fetal

Maternal:
Hypovolemia
AKI
ARD
PPH
DIC
Death
Sheehans

Fetal:
Mortality
Preterm
IUGR
Anemia
Congenital

24

History

Amount of bleeding
Onset
Pain
Contractions
Mucoid discharge
Triggering event-> intercourse (ectropion etc)
Last pap smear
STD history

25

Most important distinguishing feature between placental abruption and placenta praevia

Constant abdominal pain

26

Examination

Maternal well being:
Pulse, BP, T
Pallor
Abdominal tender, distension, ridigity
Speculum for cervical abnormalities
Digital examination- only when placenta praevia excluded, when contractions, to assess progress of cervix

Fetal well being:
Abdominal palpation for lie/presentation/engagement
CTG

27

Investigations

FBC
Group hold/screen, cross match
Rhesus-->?Anti-D
Urine
UEC
LFT
Coagulation profile
Kleihauer tests

28

What is the Kleihauer test and what does it indicate

Blood film->shows fetal RBCs in maternal circulation indicating placental abruption

29

Risk of recurrence of placental abruption in next pregnancy

8%

30

Define the lower segment of uterus

31

Etiology of placenta praevia

Multiparity
Multiples
Previous cesaerean
Smoking
+Age
Fetal anomalies

32

Grading of PP

1: At lower segment, not reaching os
2: Reaches os, does not cover
3: Covers os only when not dilated
4: Covers os even when dilated

33

Presentation of PP

Diagnosed on US
Painless bleeding
Pain->10% also have placental abruption
Postcoital bleeding
Spotting

34

Management of asymptomatic low lying placenta

Rescan at 34 weeks to determine location
If still grade 1/2 at 34 weeks, scan fortnightly
Unless bleeding, do not need to admit
If high presenting part/abnormal lie at 37 weeks, suggests placenta previa
Final scan at 36-37 weeks and acted upon
C-section done electively- major 37-38 weeks (usually when

35

Placenta previa and bleeding

ABCs
2 large IV cannula
Infusion NS
Bloods group/screen/xmatch, anti-Dif Rh negative
Avoid all vaginal examination
USS, gentle speculum
If anemia, no longer bleeding, 10.5
Continue until can do C section
Be sure to always have group and hold up to date- risk of PPH

36

When might you consider an MRI

If suspect placenta accreta

37

Why is there +risk of post partum hemorrhage in PP

Lower segment does not contract as well and therefore less compression of the placental vessels

38

Recurrence rate of PP

4-8% in subsequent pregnancies

39

Placental abruption definition and incidence

Premature separation of normally situated placenta, blood detaches
2% of pregnancies

40

Etiology/associations placental abruption

HTN
Trauma
Multiparity
+Serum AFP
Polyhydramnios, multiples
Cocaine
Previous abruption
+Age
Cigarrette
External cephalic version

41

Difference between concealed and revealed placental rupture

Concealed-->30%, blood remains behind placenta X escape cervix
Revealed -->70% escapes through cervix

42

Complications of placental rupture-->maternal and fetal

Maternal:
Hypovolemia
AKI
ARD
PPH
DIC
Death

Fetal:
Mortality
Preterm
IUGR
Anemia
Congenital

43

Presentation of placental rupture

Pain
Vaginal bleeding
Labour
Abdominal tenderness
Fetal distress
Hypovolemia
Ask about PET symptoms

44

How is the diagnosis of placental rupture made

Clinical diagnosis- do not need USS to confirm

45

Examination of placental rupture

General maternal well-being->BP, pusle, T, 02 sats
Abdominal examination->tonic contractions->hard, tender uterus
Must exclude HTN and proteinuria due to association with pre-eclampsia
Check for liver tenderness, hyperreflexia and clonus

46

Investigations in placental abruption

FBC, UEC, LFT, coags, Blood group and hold, Xmatch, Rh status (anti-RhD), urinalysis, Lkei
CTG, USS of limited valuue->if clinical diagnosis

47

Management of placental abruption

As for placenta praevia->dependant on severity of bleeding

48

Risk of recurrence of placental abruption in next pregnancy

8%

49

How is the blood loss in vasa previa different from the blood loss in PP and placental abruption

The blood lost from vasa previa is from the fetus->needs urgent delivery before the fetus exsanguinates

50

Management if coagulopathy

give 4 units FFP,
have 6 units PLTs ready
Usually resolves 4-6 hours
after delivery

51

Can an epidural be given in placental abruption

No, risk of coagulopathy