Bleeding in Late Pregnancy Flashcards Preview

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Flashcards in Bleeding in Late Pregnancy Deck (55):
1

What is defined as bleeding in early pregnancy?

<24wks

2

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

>=24wks

3

What are some causes for antepartum haemorrhage?

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

4

What is placental abruption?

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

5

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

6

What is the rate of recurrence of abruption?

10%

7

How can placental abruption be categorised?

Revealed
Concealed

8

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

Couvelaire uterus

9

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

10

How is abruption diagnosed?

Clinically
US can aid

11

What is placenta previa?

Placenta is partially or totally implanted in the lower uterine segment

12

What is the incidence of placenta previa?

5% at anomaly scan
1:200 at term

13

How can placenta previa be classified?

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

14

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

15

How is placenta previa diagnosed?

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

16

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

Vaginal exam

17

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

C section

18

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

Consider vaginal delivery

19

What is placenta accreta?

Placenta invades myometrium

20

What is placenta percreta?

Placenta has reached serosa

21

What is placenta accrete associated with?

Severe bleeding
PPH
May have hysterectomy

22

What are some major RFs for placenta accrete?

Placenta previa
Previous C section (risk increases with no)

23

What can be the cause of uterine rupture?

Previous C section/uterine surgery

24

What can uterine rupture cause?

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

25

What is vasa previa?

Velamentous insertion of cord/succenturate lobe
Fetal vessel wthin membranes

26

How can vasa previa be diagnosed?

Antenatally

27

What severe complication cause vasa praevia cause?

Fetal death

28

What are the clinical features of a local APH?

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

29

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

30

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

31

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

32

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

33

What do steroids do to fetal lung surfactant production?

Promote production

34

What effect do steroids have on neonatal respiratory distress syndrome?

Reduce by up to 50% if administered 24-48hrs before delivery

35

Until what week should steroids be administered?

Wk 36
Only significant effect up to 34 weeks, proven benefit up to 1 week of treatment

36

What choice of steroid is preferred in antenatal use?

Betamethasone over dexamethasone

37

What is 1 full course of betamethasone antenatally?

12mg IM x2 injections 12 hours apart

38

How should suspected cervical causes of bleeding be managed?

Colposcopy

39

How should suspected infective causes of bleeding be managed?

Swabs/specific treatment

40

How should bleeding in PTL be managed?

Steroids +- tocolysis

41

How should vasa previa be managed?

C-section

42

How should rupture be managed?

Laparotomy
CS

43

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

44

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

45

What are some complications of PPH?

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

46

What is the incidence of PPH?

Up to 4% of all vaginal deliveries

47

How is PPH defined?

>500ml

48

How is PPH categorised?

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

49

What are the likely aetiologies of PPH?

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

50

What are antenatal RFs for PPH?

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

51

What are intrapartum RFs for PPH?

Prolonged labour
Operative vaginal delivery/C section
Retained placenta

52

What is the initial management for PPH?

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

53

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

54

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

Packs and balloons
Tissue sealants
Factor VIIa
Arterial embolisation

55

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

Undersuturing
Brace sutures
Uterine Artery Ligation
Internal Iliac Artery Ligation
Hysterectomy