Bleeding in late pregnancy

Question 1

What is the term of bleeding n late pregnancy

Answer 1

Antepartum haemorrhage

Question 2

What is the definition of late pregnancy bleedin

Answer 2

After 24 weeks (in UK)

Question 3

What are the main causes for bleeding in late pregnancy

Answer 3

Placenta previa
Placental abruption
Local -polps, infction, cancer
Vasa previa -RARE
Uterine rupture
Show
40 percent no apparent cause

Question 4

What is placental abruption

Answer 4

A separation of a normally implanted placental either partially or totally before birth of the fetus

Question 5

What is the main risk factor for placental abruption

Answer 5

Pre-eclampsia/Hypertension

Question 6

What other risk factors are there for placental abruption

Answer 6

Trauma
Smoking and drugs
Medical - thrombophilia, renal, diabetes
Poly-hydramnios, multiple pregnancies
Abnormal placenta

Question 7

What is the recurrenc rate if abrutopn

Answer 7

10 percent

Question 8

What are the clinical features of placental abruption

Answer 8

Small or large volume blood loss
PAINFUL
Uterine tenderness/wooden hard
Uterus feels larger
Difficult to feel fetal parts

Question 9

What is the difference between revealed/concealed placental abruption

Answer 9

Revealed - blood come out of genital tract

Concealed- blood pools behind placenta

Question 10

What is couvelair uterus

Answer 10

A lifethreatening complication of placental abruption whereby there is bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity.

Question 11

Name other complications of placental abruption

Answer 11

PPH
DIC
Death- maternal or fetus

Question 12

What is placenta previa

Answer 12

Placental partially or totally implabted in the lower uterin segment

Question 13

How common is placenta previa

Answer 13

5 percent of women at anomaly scan

1:200 at term

Question 14

What are the classifications of placenta previa

Answer 14

Lateral - 1
Marginal- 2
Incomplete centralis - 3
Complete centralis -4

3 and 4 are over cervix
Major/minor - distance from cervix on ultrasound

Question 15

What are the clinical features of placenta previa

Answer 15

Painless, ‘causeless’, recurrent 3rd trimesteric bleeding
Amount of blood variable
Uterus soft non tender
Malpresentations – Breech/Transverse/Oblique
High head
CTG usually normal

Question 16

How is PP diagnosed

Answer 16

ULTRASOUND
Check anomaly scan!

20 week scan and 32/34 week scan should be done to decide type/extent of placent previa

Question 17

What should no be performed in PP

Answer 17

vaginal examination

ALWAYS EXCLUDE PP beforehand

Question 18

When would you consider a vaginal delievery in PP

Answer 18

If minor degree of PP ie more than 2cm from Os

Question 19

When must a C section be done in PP

Answer 19

if placental less than 2cm from Os or covering Os

Question 20

What is placenta accreta

Answer 20

Placenta invades myometrium

Question 21

What is placenta percreta

Answer 21

Placenta has reached serosa

Question 22

What is the risk factors for placenta accreta

Answer 22

Placenta previa

Prior C section

Question 23

what is vasa previa

Answer 23

is an obstetric complication in which fetal blood vessels cross or run near the internal orifice of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue

Question 24

When should you deliver in PP

Answer 24

Major bleeding may require preterm delivery
Caesarean Section at 37 - 38 weeks if there has been prior bleeding in pregnancy or suspected/confirmed placenta accreta
Caesarean Section at 38-39 weeks if there has not been bleeding in pregnancy

Question 25

What type of delivery should be done in PA

Answer 25

C section | Vaginal if stillbirth

Question 26

When should you admit a pregnant woman t hospital

Answer 26

Any history of acute bleeding 23 – 32 weeks –Min stay of 24 hours clear of bleeding Recurrent bleeding after 28 weeks –Min stay of 72 hours –Consider need to be admitted until delivery Any bleeding after 32 weeks –Min stay of 72 hours –Consider need to be admitted until delivery Major placenta praevia after 36 weeks with no bleeding –Consider the social circumstances –Consider other obstetric factors –Consider need for admission until delivery –Consultant decision

Question 27

Why are steroids given

Answer 27

Promote fetal lung surfactant production | ↓ neonatal respiratory distress syndrome (RDS) by up to 50% if administered 24-48h before delivery

Question 28

When are steroids given in AP and PP

Answer 28

Administer up to 36 weeks. Only significant effects up to 34 weeks. Proven benefit up to 1 week

Question 29

Which steroid is preferred

Answer 29

Betamethasone 12mg IM x 2 injections 12 hours apart | rather than dexmehtasone

Question 30

When should you cross match a women with PV bleeding in pregnancy

Answer 30

cross match 2-4 units with a ny bleedin more than 1 tsp

Question 31

what is kleihauer test

Answer 31

a blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother's bloodstream.[1] It is usually performed on Rh-negative mothers to determine the required dose of Rho(D) immune globulin (RhIg) to inhibit formation of Rh antibodies in the mother and prevent Rh disease in future Rh-positive children.[2]

Question 32

Should you give enoxaparin for DVT prophylaxis

Answer 32

NO - TEDS, mobilization and hydration only

Question 33

What is the definition of PPH

Answer 33

loss of more than 500 ml of blood Primary - in first 24 hrs Secondary- more than 24hrs -6 weeks

Question 34

What would a moderate or major PPH be

Answer 34

between 500ml - 1500ml | Major more than 1500ml

Question 35

What are the four Ts of PPH

Answer 35

Tone - most common Trauma Tissue Thrombin

Question 36

What are the complications of PPH

Answer 36

Maternal fatigue, feeding difficulties, prolonged hospital stay, delayed lactation, pituitary infarction, transfusion, haemorrhagic shock, DIC, death

Question 37

What are the risk factors for PPH antenatally

Answer 37

``` anaemia –previous caesarean section –placenta praevia, percreta, accreta –previous PPH or retained placenta –Multiple pregnancy ```

Question 38

What are the intrapartum risk factors of PPH

Answer 38

–prolonged labour –operative vaginal delivery / caesarean section –retained placenta

Question 39

What three intial things should be done to manage PPH

Answer 39

Uterine massage 5 units iv Syntocinon stat 40 units Syntocinon in 500ml

Question 40

How sould persistant PPH be managed

Answer 40

Confirm placenta and membranes complete Urinary Catheter 500 micrograms Ergometrine IV (Avoid if Cardiac Disease / Hypertension) ? Vaginal / perineal trauma - ensure prompt repair