Bleeding In Late Pregnancy

Question 1

What is bleeding in late pregnancy called?

Answer 1

Antepartum haemorrhage

Question 2

What is the definition of bleeding in early pregnancy?

Answer 2

before 24 weeks

Question 3

What is the placenta?

Answer 3

Entirely fetal tissue
Sole source of nutrition from 6 weeks
Gas transfer
Metabolism / waste disposal
Hormone production (HPL & hGh-V)
Protective filter
Very vascular

Question 4

What is the aetiology of an APH?

Answer 4

Placenta previa
Placental abruption
Local causes - Polyps, cancer, infection
Uterine rupture
Show

Question 5

What are risk factors for placental abruption?

Answer 5

Pre-eclampsia/Hypertension
Trauma
Smoking/Cocaine/Amphetamine
Medical - Thrombophilias, Renal disease, diabetes
Poly-hydramnios, Multiple pregnancy, preterm-PROM
Abnormal placenta

Question 6

What is Couvelaire uterus?

Answer 6

AKA uteroplacental apoplexy

Loosening of the placenta

Question 7

What are clinical features of a placental abruption?

Answer 7

Small/Large blood loss
Painful
Uterine tenderness/Wooden hard
Uterus feels bigger
Difficulty to feel fetal parts
CTG

Question 8

What is Placenta Previa?

Answer 8

Placenta is partially or totally implanted in the lower uterine segment

Question 9

What is the incidence of placenta previa?

Answer 9

5% at anomaly scan

1:200 at term

Question 10

What are the classifications of placenta previa?

Answer 10

Lateral/Marginal/Incomplete/Centralis/Complete centralis
Grade I-IV
Major/Minor - distance from cervix by ultrasound

Question 11

How is placenta previa diagnosed?

Answer 11

By Ultrasound
Painless ‘causeless’ recurrent 3rd trimester bleeding
Variable blood amount
Uterus is soft not tender
High head
CTG usually normal
Malpresentations - Breech/Transverse/Oblique

Question 12

What should not be done until placenta previa is EXCLUDED?

Answer 12

Vaginal examination

Question 13

When is the diagnosis of placenta previa made?

Answer 13

20 week scan then 32/34 week scan

Question 14

What type of delivery is used in major degrees of placenta previa?

Question 15

What type of delivery is used in minor degrees of placenta previa

Answer 15

> 2cm from OS = Consider vaginal delivery

Question 16

What is Placenta Accreta?

Answer 16

When placenta invades myometrium

Question 17

What has the placenta reached in Percreta?

Answer 17

The serosa

Question 18

What is Placenta accreta associated with?

Answer 18

Severe bleeding

PPH and may end up having a hysterectomy

Question 19

What are major risk factors for placenta accreta?

Answer 19

Placenta previa and prior caesarean delivery

Question 20

Describe a Uterine Rupture?

Answer 20

Small/large blood volume
Intra-partum-loss of contractions
Previous CS/Uterine surgery
Obstructed labour
Peritonism
Fetal head high
Fetal distress/IUD
Haematuria

Question 21

What is Vasa Praevia?

Answer 21

Valementous insertion of cord/Succenturate lobe
Fetal vessels within membranes
Can be diagnosed ante-natally
Fetal blood (200ml at term)
Fetal death

Question 22

What is the management of Placenta previa?

Answer 22

Admit
IV access, blood tests/Cross match
Scan
Anti-D
Steroids
Delivery

Question 23

How do you time delivery with placenta praevia?

Answer 23

May be preterm
CS at 37-38 weeks if been prior bleeding/ placenta accreta
CS at 38-39 weeks if not been bleeding in pregnancy

Question 24

How do manage a Placental Abruption?

Answer 24

Admit
IV access, bloods and cross match
Resuscitate/Manage DIC
Deliver viable baby-CS versus vaginal
Stillbirth - vaginal delivery
Anti-D
Steroids if expectant management

Question 25

What is the Antenatal admission criteria for any history of acute bleeding (23-32 weeks)

Answer 25

Min. stay of 24 hours clear of bleeding

Question 26

What is the Antenatal admission criteria for recurrent bleeding after 28 weeks?

Answer 26

Min stay of 72 hours | Consider need to be admitted until delivery

Question 27

What is the Antenatal admission criteria for any bleeding after 32 weeks?

Answer 27

Min stay of 72 hours | Consider need to be admitted until delivery

Question 28

What is the Antenatal admission criteria for major placneta praevia after 36 weeks with no bleeding?

Answer 28

Consider the social circumstances Consider other obstetric factors Consider need for admission until delivery Consultant decision

Question 29

What antenatal benefit do steroids have?

Answer 29

Promote fetal lung surfactant production Decrease respiratory distress syndrome by up to 50% if given 24-48 hours before delivery Given up to 36 weeks

Question 30

What dose of steroids are given ante-natally?

Answer 30

Betamethasone preferred to Dexamethasone | 1 course = 12mg Betamethasone IM X2 injections, 12 hours apart

Question 31

What other checks should be carried out?

Answer 31

``` Cervical - Colposcopy Infection - Swabs/Specific treatment PTL- Steroids +/- tocolysis Vasa praevia - CS Rupture - Laparotomy / CS Unknown - Conservative ```

Question 32

Describe the delivery for suspected/Confirmed placenta accreta?

Answer 32

Ninewells delivery CS at 37 weeks Surgical plan clearly documented (including planned hysterectomy) Cross match 6 units of blood Cell salvage set up Prior to surgery, consider inserting arterial line

Question 33

What should be done regarding an antenatal admission with a pv bleed?

Answer 33

``` Secure wide bore venous access Check FBC Take blood group and save Cross match 2-4 units Check Kleihauer test + give anti-D ```

Question 34

What should not be given in an antenatal admission with a pvbleed and what should be done?

Answer 34

NO - Enoxaparin thromboprophylaxis YES - TEDS, Mobilisation, Hydration

Question 35

What are antenatal risk factors for PPH?

Answer 35

``` Anaemia Previous CS Placenta praevia, placenta accreta Previous PPH or retained placenta Multiple pregnancy ```

Question 36

What are intrapartum risk factors for PPH?

Answer 36

Prolonged labour Operative vaginal delivery / CS Retained placenta

Question 37

What is the initial management for PPH?

Answer 37

Uterine massage 5 units IV Syntocinon stat 40 units Syntocinon in 500ml Hartmanns - 125ml/h

Question 38

What is the management for persistent PPH?

Answer 38

``` Confirm placenta and membranes complete Urinary catheter 500 micrograms Ergometrine IV (Avoid if cardiac disease/Hypertension Promptly repair and vaginal or perineal trauma ```

Question 39

What are the non-surgical treatments of a PPH over 1500ml?

Answer 39

Packs & Balloons Tissue sealants Factor VIIa Arterial embolisation

Question 40

What is the surgical management of a PPH over 1500ml

Answer 40

``` Undersuturing Brace sutures Uterine artery ligation Internal iliac artery ligation hysterectomy ```