Bleeding in Late Pregnancy Flashcards by Aaron Duff

What is defined as bleeding in early pregnancy?

<24wks

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What is defined as bleeding in late pregnancy (antepartum haemorrhage)?

> =24wks

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What are some causes for antepartum haemorrhage?

Placenta previa
Placental abruption
Local- polyps, cancer, infection
Vasa previa- rare
Uterine rupture
Show
Idiopathic (40%)

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What is placental abruption?

Separation of a normally implanted placenta partially or totally before birth of the fetus

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What are RFs for placental abruption?

Pre-eclampsia/HT
Trauma
Smoking/Cocaine/Amphetamine
Medical- thrombophilias/renal/DM
Poly-hydramnios, multiple pregnancy, preterm-PROM
Abnormal placenta

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What is the rate of recurrence of abruption?

10%

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How can placental abruption be categorised?

Revealed

Concealed

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What life-threatening condition can occur when placental abruption causes bleeding into the uterine myometrium, pushing the uterus into the peritoneal cavity?

Couvelaire uterus

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What are the key clinical features of abruption?

Small or large volume of blood loss-signs may be inconsistent with revealed blood
Pain
Uterine tenderness/wooden hard
Uterine feels larger
Difficult to palpate fetal parts
CTG
Abnormally frequent contractions

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How is abruption diagnosed?

Clinically

US can aid

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What is placenta previa?

Placenta is partially or totally implanted in the lower uterine segment

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What is the incidence of placenta previa?

5% at anomaly scan

1:200 at term

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How can placenta previa be classified?

Lateral/marginal/incomplete centralis, complete centralis
Grade I-IV
Major/minor-distance from cervix by US

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What are the clinical features of placenta previa?

Painless, ‘causeless, recurrently 3T bleeding
Amount of blood variable
Uterus soft non tender
Malpresentations- breech/transverse/oblique
High head
Normal CTG

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How is placenta previa diagnosed?

20 week US- anomaly scan Then 32/34 week scan

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What should not be performed prior to exclusion of placenta previa?

Vaginal exam

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How should major degrees of placenta previa (=<2cm from os/covering os) be delivered?

C section

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How should minor degrees of placenta previa (>2cm from os) be delivered?

Consider vaginal delivery

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What is placenta accreta?

Placenta invades myometrium

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What is placenta percreta?

Placenta has reached serosa

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What is placenta accrete associated with?

Severe bleeding
PPH
May have hysterectomy

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What are some major RFs for placenta accrete?

Placenta previa

Previous C section (risk increases with no)

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What can be the cause of uterine rupture?

Study These Flashcards

Previous C section/uterine surgery

What can uterine rupture cause?

Study These Flashcards

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

What is vasa previa?

Velamentous insertion of cord/succenturate lobe | Fetal vessel wthin membranes

How can vasa previa be diagnosed?

Antenatally

What severe complication cause vasa praevia cause?

Fetal death

What are the clinical features of a local APH?

``` Small volume Painless Provoking factor Uterus soft, non tender No fetal distress Normally sited placenta ```

How is placenta previa managed?

``` Admit IV access-bloods Scan Anti D Steroids 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?

``` Admit IV access-bloods Resus/manage DIC Delivery viable baby- CS vs Vaginal Paeds Stillbirth- vaginal delivery Anti D 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?

Promote 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?

Wk 36 | 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?

Colposcopy

How should suspected infective causes of bleeding be managed?

Swabs/specific treatment

How should bleeding in PTL be managed?

Steroids +- tocolysis

How should vasa previa be managed?

C-section

How should rupture be managed?

Laparotomy | CS

How should delivery be carried out for suspected or confirmed placenta accrete?

C-section at 37 weeks to avoid unplanned pregnancy MDT involvement Cross match Cell salvage should be set up if available

How should antenatal admission with a PV bleed be managed?

Wide bore access FBC 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?

``` Maternal fatigue Feeding difficulties Prolonged hospital stay Delayed lactation Pituitary infarction Transfusion Haemorrhagic shock DIC Death ```

What is the incidence of PPH?

Up to 4% of all vaginal deliveries

How is PPH defined?

>500ml

How is PPH categorised?

``` Primary- within 24hrs Secondary- >24 hours/6/52 Minor <500ml Moderate 500-1500mk Major PPH >=1500ml ```

What are the likely aetiologies of PPH?

``` 4 T's Tone 70% Trauma 20% Tissue 10% Thrombin <1% ```

What are antenatal RFs for PPH?

``` Anaemia Prv C section Placenta previa, percreta, accrete Prv PPH or retained placenta Multiple pregnancy ```

What are intrapartum RFs for PPH?

Prolonged labour Operative vaginal delivery/C section Retained placenta

What is the initial management for PPH?

Uterine massage 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 Urinary catheter 500micrograms Ergometrine IV (avoid if CVD/HT) If vaginal/perineal/trauma- ensure prompt repair Help 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 Tissue sealants Factor VIIa Arterial embolisation

What is the surgical management of persistent PPH of >1500ml?

``` Undersuturing Brace sutures Uterine Artery Ligation Internal Iliac Artery Ligation Hysterectomy ```

Bleeding in Late Pregnancy Flashcards

(55 cards)