Flashcards in Bleeding in Late Pregnancy Deck (55):
What is defined as bleeding in early pregnancy?
What is defined as bleeding in late pregnancy (antepartum haemorrhage)?
What are some causes for antepartum haemorrhage?
Local- polyps, cancer, infection
Vasa previa- rare
What is placental abruption?
Separation of a normally implanted placenta partially or totally before birth of the fetus
What are RFs for placental abruption?
Poly-hydramnios, multiple pregnancy, preterm-PROM
What is the rate of recurrence of abruption?
How can placental abruption be categorised?
What life-threatening condition can occur when placental abruption causes bleeding into the uterine myometrium, pushing the uterus into the peritoneal cavity?
What are the key clinical features of abruption?
Small or large volume of blood loss-signs may be inconsistent with revealed blood
Uterine tenderness/wooden hard
Uterine feels larger
Difficult to palpate fetal parts
Abnormally frequent contractions
How is abruption diagnosed?
US can aid
What is placenta previa?
Placenta is partially or totally implanted in the lower uterine segment
What is the incidence of placenta previa?
5% at anomaly scan
1:200 at term
How can placenta previa be classified?
Lateral/marginal/incomplete centralis, complete centralis
Major/minor-distance from cervix by US
What are the clinical features of placenta previa?
Painless, 'causeless, recurrently 3T bleeding
Amount of blood variable
Uterus soft non tender
How is placenta previa diagnosed?
20 week US- anomaly scan Then 32/34 week scan
What should not be performed prior to exclusion of placenta previa?
How should major degrees of placenta previa (=<2cm from os/covering os) be delivered?
How should minor degrees of placenta previa (>2cm from os) be delivered?
Consider vaginal delivery
What is placenta accreta?
Placenta invades myometrium
What is placenta percreta?
Placenta has reached serosa
What is placenta accrete associated with?
May have hysterectomy
What are some major RFs for placenta accrete?
Previous C section (risk increases with no)
What can be the cause of uterine rupture?
Previous C section/uterine surgery
What can uterine rupture cause?
Small or large volume blood loss
Intra-partum loss of contractions
Fetal head high
What is vasa previa?
Velamentous insertion of cord/succenturate lobe
Fetal vessel wthin membranes
How can vasa previa be diagnosed?
What severe complication cause vasa praevia cause?
What are the clinical features of a local APH?
Uterus soft, non tender
No fetal distress
Normally sited placenta
How is placenta previa managed?
Delivery- <2cm C-section at 38-39wks, delivery soon if significant bleeding
When should C-section be carried out at 37-38 weeks in placenta previa?
If there has been prior bleeding in pregnancy or suspected/confirmed placenta accreta
How should placental abruption be managed?
Delivery viable baby- CS vs Vaginal
Stillbirth- vaginal delivery
Steroids if expectant management
What is the antenatal admission criteria?
Any Hx of acute bleeding 23-32 wks
Recurrent bleeding after 28 wks
Any bleeding after 32 wks
Major placenta previa after 36 wks with no bleeding
What do steroids do to fetal lung surfactant production?
What effect do steroids have on neonatal respiratory distress syndrome?
Reduce by up to 50% if administered 24-48hrs before delivery
Until what week should steroids be administered?
Only significant effect up to 34 weeks, proven benefit up to 1 week of treatment
What choice of steroid is preferred in antenatal use?
Betamethasone over dexamethasone
What is 1 full course of betamethasone antenatally?
12mg IM x2 injections 12 hours apart
How should suspected cervical causes of bleeding be managed?
How should suspected infective causes of bleeding be managed?
How should bleeding in PTL be managed?
Steroids +- tocolysis
How should vasa previa be managed?
How should rupture be managed?
How should delivery be carried out for suspected or confirmed placenta accrete?
C-section at 37 weeks to avoid unplanned pregnancy
Cell salvage should be set up if available
How should antenatal admission with a PV bleed be managed?
Wide bore access
Cross match 2-4 units with any bleeding more than 1 tsp.
Kleihauer test- administer anti-D as per protocol if Rh-
Do not give enoxaparin thromboprophylaxis if indicated- TEDS, mobilisation and hydration only
What are some complications of PPH?
Prolonged hospital stay
What is the incidence of PPH?
Up to 4% of all vaginal deliveries
How is PPH defined?
How is PPH categorised?
Primary- within 24hrs
Secondary- >24 hours/6/52
Major PPH >=1500ml
What are the likely aetiologies of PPH?
What are antenatal RFs for PPH?
Prv C section
Placenta previa, percreta, accrete
Prv PPH or retained placenta
What are intrapartum RFs for PPH?
Operative vaginal delivery/C section
What is the initial management for PPH?
5 units IV Syntocinon stat
40 units Syntocinon in 500ml Hartmanns- 125ml/h
What is the management for persistent PPH?
Confirm placenta and membranes complete
500micrograms Ergometrine IV (avoid if CVD/HT)
If vaginal/perineal/trauma- ensure prompt repair
Maternity Operating Theatre for EUA
PGF2α 250micrograms IM (up to x8)
D/W haematology BTS- blood products required
What is the non-surgical management of persistent PPH of >1500ml?
Packs and balloons