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Obstetrics > Anteparum Haemorrhage > Flashcards

Anteparum Haemorrhage Flashcards

1
Q

What classes as an antepartum haemorrhage

A

Bleeding during pregnancy after 24 weeks from or into the genital tract.

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2
Q

Causes of antepartum haemorrhage

A

Placental abruption
Placenta praevia
Vasa praevia
Cancer (rare)
Localised trauma

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3
Q

What is placental abruption

A

Separation of the placenta from the uterine wall and decidua

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4
Q

Risk factors for placental abruption

A

Previous abruption
Pre-eclampsia
Bleeding early in pregnancy
Trauma
Multiple pregnancy
Fetal growth restriction
Multigravida
Increased maternal age
Smoking
Cocaine or amphetamine use
Low BMI

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5
Q

Presentation of placental abruption

A

Sudden onset severe abdominal pain which is continuous, vaginal bleeding, shock, CTG signs of fetal distress, ‘woody’ abdomen on palpation, suggesting large haemorrhage

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6
Q

What is a concealed abruption

A

Cervical os remains closed and any bleeding will be in the uterine cavity, so bleeding can be significantly underestimated.

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7
Q

Management of placental abruption

A

2 x grey cannula
Bloods
Crossmatch 4 units of blood
Fluid and blood resus
CTG monitoring
Close monitoring of mother

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8
Q

Assessing and treating placental abruption depends on what factors

A

Amount of placental separation, extent of bleeding, haemodynamic stability of mother and fetus

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9
Q

Treatment of placental abruption

A

Antenatal steroids for those between 24-34+6 weeks gestation.
anti-D prophylaxis and Kleihauer test.
Emergency C section may be required.
Active management of third stage of labour

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10
Q

Diagnosis of placental abruption

A

Clinical diagnosis, US used to rule out placenta praevia.

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11
Q

Guidelines to define the severity of antepartum haemorrhage

A

Spotting - spots of blood on underwear
Minor - less than 50ml loss
Major - 50-1000ml loss
Massive - 1000+ blood loss and signs of shock

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12
Q

What is placenta praevia

A

Placenta partially or fully within the lower uterine segment, placenta is over the internal cervical os

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13
Q

Risks of placenta praevia

A

Antepartum haemorrhage
Emergency caesarean
Emegency hysterectomy
Maternal anaemia and transfusions
Preterm birth and low birth weight
Stillbirth

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14
Q

Grade of placenta praevia

A

Grade 1 - placenta is in the lower uterus but not reaching internal cervical os
Grade 2 - placenta is reaching but not covering the internal cervical os
Grade 3 - placenta is partially covering the internal cervoical os
Grade 4 - placenta is completely covering the internal cervical os

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15
Q

Risk factors for placenta praevia

A

Previous caesarean
previous placenta praevia
older maternal age
maternal smoking
structural uterine abnormalities
assisted reproduction
Multiparity
Multiple pregnancy

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16
Q

Types of anterior placeta praevia

A

Acreta, increta and percreta

17
Q

Presentation of placenta praevia

A

Seen on 20 week scan
Asymptomatic mainly
Painless vaginal bleeding
Later in pregnancy around 36 weeks

18
Q

Management of placenta praevia

A

Repeat scans at 32 and 36 weeks gestation
Corticosteroids between 34-36 weeks
Planned pregnancy between 36-37 weeks

19
Q

Urgent management for haemorrhage from placenta praevia

A

Emergency caesarean, blood transfusions, intrauterine balloon tamponade
uterine artery occlusion, emegency hysterectomy

20
Q

What is a low lying placenta

A

Placenta is within 20mm of internal cervical os

21
Q

How is a low lying placenta managed

A

Similar to placenta praevia

22
Q

What is vasa praevia

A

When fetal vessels run unsupported in fetal membranes (surrounding amniotic cavity) and travel across the internal cervical os.

23
Q

Two instances where fetal vessels can be exposed, outside protection of umbilical cord or placenta

A

Velamentous umbilical cord.
An accessory lobe of the placenta

24
Q

What is a velamentous umbilical cord

A

Umbilical cord inserts into chorioamniotic membranes and fetal vessels travel unprotected through membranes before joining placenta.

25
Q

What is an accessory lobe of the placenta

A

Connected by fetal vessels which travel through the chorioamniotic membranes between placental lobes

26
Q

Types of vasa praevia

A

Type 1 - fetal vessels are exposed as velamentous ulbilical cord
Type 2 - fetal vessels are exposed as they travel to an accessory placental lobe

27
Q

Complications of vasa praevia

A

They can tear or rupture as they are unprotected (escpecially with cervical dilation) which can cause fetal bleeding, anaemia and death

28
Q

Risk factors of vasa praevia

A

Low lying placenta
IVF pregnancy
Multiple pregnancy

29
Q

Presentation of vasa praevia (4)

A

Can be present on US during pregnancy.
Can present with antepartum haemorrhage with bleeding during 2nd/3rd trimester.
Detected by vaginal exam during labour where pulsating vessels are seen in the membranes though dilated cervix.
Detected during labout wit fetal distress, dark red blood following rupture of membranes.

30
Q

Management of vasa praevia

A

Corticosteroids from 32 weeks gestation to mature fetal lungs and elective C section 34-36 weeks

31
Q

When is vasa praevia tested for

A

If there is stillbirth or unexplained fetal compromise during labour, placenta can be examined

32
Q

What is placenta accreta

A

When the placenta implants deeper, through and past the endometrium making it difficult to separate the placenta after delivery of the baby

33
Q

How does placenta accreta occur

A

May happen due to defect in the endometrium - imperfactions due to previous surgery, C section or curettage procedure.

34
Q

Three types of placenta accreta

A

Superficial placenta accreta - implants in surface of myometrium but not beyond
Placenta increta - placenta attaches deeply into the myometrium
Placenta percreta - placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

35
Q

Risk factors for placenta accreta

A

Previous placenta accrete
Previous endometrial curettage procedures
previous caesarean.
Multigravida
Increased maternal age
Low lying placenta or placenta praevia

36
Q

Presentation of placenta accreta

A

Does not typically cause any symptoms during pregnancy but can present with bleeding in third trimester

37
Q

Diagnosis of placenta accreta

A

Antenatal US scans, or diagnosed at birth when it becomes difficult to delver the placenta.

38
Q

Management of placenta accreta

A

MRI scan to assess depth and width of invasion.
Delivery planned between 35-37 weeks to reduce risk of spontaneous labour and delivery and PPH.

39
Q

Options for placenta during placenta accreta management

A

Hysterectomy, uterus preserving surgery, expectant management

Obstetrics (8 decks)

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