Bleeding in Late Pregnancy Flashcards
(104 cards)
1
Q
What is bleeding in early pregnancy defined as?
A
Bleeding < 24 weeks
2
Q
What is antepartum haemorrhage defined as?
A
Bleeding >24 weeks
3
Q
What is the placenta made of?
A
Completely foetal tissue
4
Q
When is the placental the only source of nutrition from?
A
6 weeks
5
Q
What are the functions of the placenta?
A
- Gas transfer.
- Metabolism/waste disposal.
- Hormone production (HPL and hGh-V).
- Protective ‘filter.’
6
Q
The placenta is very ________
A
VASCULAR
7
Q
What is antepartum haemorrhage defined as?
A
- Bleeding from the genital tract after 24 weeks gestation and before the end of the 2nd stage of labour.
OR
*Bleeding from or into the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby.
8
Q
Antepartum means?
A
Occuring not long before childbirth
9
Q
List potential causes of APH.
A
- Placenta Praevia.
- Placental Abruption.
- Local causes - Cervical ectoprion, Polyps, Cervical cancer, Infection e.g. cervicitis - STI
- Vasa previa – rare.
- Uterine rupture.
- Indeterminate/Unexplained.
10
Q
What is the differential diagnosis of APH?
A
- Heavy show.
- Cystitis.
- Haemorrhoids.
11
Q
When asking a patient about ‘spotting’, what should you ask about?
A
Staining, streaking or blood spotting noted on underwear or sanitary protection
12
Q
What is minor haemorrhage defined as?
A
Blood loss less than 50ml that has settled.
13
Q
What is major haemorrhage defined as?
A
Blood loss of 50-1000ml, with no signs of clinical shock
14
Q
What is massive haemorrhage defined as?
A
Blood loss greater than 1000ml +/or signs of clinical shock.
15
Q
What is the term ‘abruptio-placentae’ latin for?
A
Breaking away (denoting a sudden accident).
16
Q
What is placental abruption?
A
Separation of a normally implanted placenta – partially or totally before birth of the foetus.
17
Q
What type of diagnosis is placental abruption?
A
Clinical diagnosis
18
Q
What % of pregnancies does placental abruption occur in?
A
1%
19
Q
What % of APH cases is placental abruption responsible for?
A
40%
20
Q
Outline the pathology of placental abruption.
A
Vasospasm followed by arteriole rupture into the decidua; blood escapes into the amniotic sac or further under the placenta and into myometrium.
Causes tonic contraction and interrupts placental circulation which causes hypoxia.
Results in Couvelaire uterus.
21
Q
WHAT ARE THE SYMPTOMS OF PLACENTAL ABRUPTION? (know this !!!)
A
- Severe abdominal pain which is continuous.
(different to labour pain which is intermittent, with contractions) - or Backache with posterior placenta.
- Bleeding (may be concealed).
- Preterm labour.
- May present with maternal collapse.
22
Q
How will a patient with placental abruption appear?
A
Unwell and distressed
23
Q
What will the size of the uterus be like in placental abruption?
A
Either LFD or normal.
24
Q
How will a uterus feel in placental abruption?
A
Tender and ‘woody’ hard
25
What will be difficult to identify in placental abruption?
Foetal parts
26
What might happen to a woman with placental abruption?
Preterm labour + heavy show
27
What might foetal HR be like in placental abruption?
Bradycardic/ absent (intrauterine death)
28
What will a CTG show in placental abruption?
```
Irritable uterus
(1contraction/minute)/ FH abnormality- tachycardia, loss of variability, decelerations)
```
29
What is the 1st step in the management of placental abruption?
RESUS OF MOTHER
30
What should be done in placental abruption, after the mother has been resuscitated?
- Assess and deliver the baby.
- Manage the complications.
- Debrief the parents
31
Outline the factors which should be considered/addressed out when thinking about maternal resuscitation in placental abruption.
* Communication (MW, Obstetrics, Anaesthetists, NNU, Theatre, Haematologist
* 2 Large bore IV access, FBC,clotting, LFT U& E ,Xmatch 4-6 units RBC ,Kleihauer (esp. if mother is Rh-ve)
* IV fluids (care with PET as don’t want to cause pulmonary oedema)
* Catheterise- hrly urine volumes
32
What should be used to assess foetal HR?
CTG
33
What should be done if there is no FH?
USS
34
Is USS useful?
Not very – will fail to detect 3/4 of cases of abruption.
35
What can be done in terms of delivery in placental abruption?
* urgent delivery by c-section.
* SRM and induction of labour.
* expectant management (only for minor cases; allow steroid cover).
36
What may the uterus be like in placental abruption?
Couvelaire uterus – haematoma bruised uterus.
37
List foetal complications that may occur during placental abruption.
* Fetal Death- IUD (14%)
* Hypoxia
* Prematurity
* Small for gestational age and fetal growth restriction
38
List maternal complications that may occur during placental abruption.
* Hypovolaemic shock
* Anaemia
* PPH (25%)
* Renal failure from renal tubular necrosis
* Coagulopathy (give FFP, cryoprecipitate)
* Infection
* Prolonged hospital stay Psychological sequelae
* Complications of blood transfusion
* Thromboembolism
* Mortality rare
39
What condition can placental abruption occur in?
APS - anti phospholipid syndrome
40
What can be given to women with APS to prevent placental abruption?
LMWH and Low Dose Aspirin.
41
In people at higher risk of placental abruption (not APS), what can be done to reduce risk?
* Smoking cessation
| * Low dose Aspirin
42
What is placenta praaevia?
Where the placenta is partially or totally implanted in the lower uterine segment
Placenta covers cervix so obstructs the birth canal
43
What is placenta praaevia known colloquially as?
'low lying placenta'
44
Anatomically, what is the lower segment of the uterus?
The part of the uterus below the utero-vesical peritoneal pouch superiorly, and the internal os inferiorly.
The thinner part of the uterus, containing less muscle fibres than the upper segment.
45
Physiologically, what is the lower segment of the uterus
The part of the uterus which does not contract in labour but passively dilates
46
Metrically, what is the lower segment of the uterus
The part of the uterus which is about 7cm from the level of the internal os.
47
What % of cases of APH does placenta praaevia account for?
20%
48
List some risk factors for placenta praaevia.
• Previous c/section (1 C/S OR 2.2 ; 2C/S OR 4.1; 3 C/S OR 22.4 )
• Previous placenta praevia
• Asian
• Smoking
• Previous termination of pregnancy
• Multiparity
• Advanced maternal age (>40 years)
• Multiple pregnancy
• Assisted conception
• Deficient endometrium due to presence or history of:
– uterine scar, endometritis ,manual removal of placenta ,curettage , submucous fibroid
49
How is placenta praevia classified?
By ultrasound imaging, according to what is relevant clinically
50
What are the 2 main types of placenta praevia?
Major praevia: if the placenta lies over the internal cervical os.
Minor or partial praevia: if the leading edge of the placenta is in the lower uterine segment, but not covering the cervical os.
51
What are the symptoms of placenta praevia?
* Painless bleeding at >24weeks.
* Usually unprovoked, but coitus can trigger bleeding.
* Bleeding can be minor (e.g. spotting) or severe).
52
What is the amount of bleeding in placenta praaevia proportional to?
The patients condition
53
How does the uterus in placenta praaevia feel?
Soft + non-tender
54
What is the presenting part in placenta praevia like?
High
55
What is presentation in placental praaevia like?
There is often malpresentation – breech/transverse/oblique
56
A CTG in placenta praaevia is abnormal
FALSE - normal
57
What must you NOT do to a patient until placenta praevia is excluded?
Vaginal exam
58
What type of exam may be useful in placenta praaevia?
Speculum
59
How is placenta praevia diagnosed?
Ultrasound – transvaginal USS for diagnosis
60
What needs to be excluded in placenta praevia? How?
Placenta accreta – with MRI
61
Outline the general principles of management of placental praevia.
* Resuscitation of mother: ABC.
* Assess baby.
* Investigations.
* Conservative management if stable.
- ---- inpatient for at least 24hrs until bleeding has ceased.
* Delivery plan at/near term.
62
When is anti D given?
If resus -ve mother
63
When should steroids be given in placenta praevia?
24-36+6 weeks
64
As well as steroids, what else should be given in placental praaevia?
MgSO4 – at 24-32weeks for neuro-protection if planning delivery
65
In placenta praevia, C section should be carried out if ...
If placenta is <2cm from cervical os (make sure a consultant is present).
66
In placenta praevia, vaginal delivery should be carried out if ...
If placenta is >2cm from os and no malpresentation
67
What is placenta accreta?
A morbidly adherent placenta; abnormally adherent to the uterine walls
68
If placenta accreta is invading the myometrium, what is this called
Placenta increta
69
If placenta accreta is invading the uterus to bladder, what is this called?
Placenta percreta
70
Outline the management of placenta accreta.
* Prophylactic internal iliac artery balloon.
* Caesarean hysterectomy.
* Blood loss >3l expected.
* Conservative mx (+ methotrexate (to get rid of placenta)).
71
What is uterine rupture?
Full thickness opening of the uterus
72
What are the risk factors for uterine rupture?
* Previous c-section/uterine surgery e.g. myomectomy.
* Multiparity and use of prostaglandins/syntocinon increase risk.
* Obstructed labour.
73
What are the symptoms of uterine rupture?
* Severe abdominal pain.
* Shoulder tip pain.
* Maternal collapse.
* PV bleeding.
74
What are the signs of uterine rupture?
* Intra-partum – loss of contractions.
* Acute abdomen.
* Presenting part rises.
* Loss of uterine contractions.
* Peritonism.
* Foetal distress/IUD.
75
Outline the management of uterine rupture.
* Urgent Resuscitation & Surgical management
* Communication (MW, Obstetrics, Anaesthetists, NNU, Theatre, Haematologist)
* 2 Large bore IV access (grey or orange cannula)
* FBC, clotting, LFT, U& E , Kleihauer (if Rh Neg)
* Xmatch 4-6 units RBC
* May need Major Haemorrhage protocol
* IV fluids or transfuse
* Anti D (if Rh Neg)
76
What is vasa praevia?
Unprotected fetal vessels traverses the fetal membranes over the internal cervical os.
77
How is vasa praevia identified?
USS with doppler
78
What is the danger with vasa praevia?
ARM, sudden bleeding and fetal bradycardia/death
79
What is the mortality with vasa praevia?
60%
80
What are the risk factors for vasa praevia?
* Placental anomalies such as a bilobed placenta or succenturiate lobes where the foetal vessels run through the membranes joining the separate lobes together.
* A history of low-lying placenta in the second trimester.
* Multiple pregnancy
* In vitro fertilisation (incidence of 1 in 300)
81
List cervical causes of APH (antepartum haemorrhage)
* Ectropion.
* Polyp.
* Carcinoma.
82
What is PPH defined as?
Blood loss equal to or exceeding 500ml after the birth of the baby
83
When is PPH defined as 'primary'?
Within 24 hours of delivery
84
When is PPH defined as 'secondary'?
>24h - 6/52 post-delivery
85
How much blood loss is normal during labour?
100mls per kg
86
What is blood loss during labour proportional to?
Maternal weight
87
During labour, what volume of blood loss is defined as 'minor'?
500-1000 mls with no clinical signs of shock
88
During labour, what volume of blood loss is defined as 'major'?
> 1000 mls with clinical signs of shock or ongoing bleeding
89
What can the causes of PPH be remembered as? What are they?
4 T's
* Tone 70%
* Trauma 20%
* Tissue 10%
* Thrombin <1%
90
Can you prevent PPH?
YES !!
91
What are the risk factors for PPH?
* Anaemia
* Previous c section
* Placenta praevia/accrete
* Previous PPH
* Previous retained placenta
* Multiple pregnancy
* Polyhydramnios
* Obesity
* Foetal macrosomnia
92
To help in preventing PPH, intrapartum risk factors should be identified. What are these?
* Prolonged labour.
* Operative vaginal delivery.
* Caesarean section.
* Retained placenta.
93
How should 3rd stage of labour be managed to help prevent PPH?
Give the mother Syntocinon/syntometrine IM/IV
94
Outline the management of minor PPH (<1000 mls - clinical shock).
* IV access – one 14 gauge cannula
* Gravidity + parity
* FBC + coagulation screen + fibrinogen
* Obs – pulse, resp rate, BP recording every 15 mins
* IV warmed crystalloid infusion
95
How can the bleeding in PPH be stopped?
* Uterine massage- bimanual compression
| * Expel clots
96
What should be done after the bleeding is stopped in PPH?
* 5 units IV Syntocinon stat 40 units
* Syntocinon in 500ml Hartmanns - 125 ml/h
* 500mcg Ergometrine IV
* Foleys Catheter
97
Do most cases of PPH respond to treatment?
YES
98
List 3 non-surgical methods of stopping bleeding in PPH.
* Packs + balloons – (rusch balloon/bakri balloon)
* Tissue sealants
* Arterial embolization
99
List 4 surgical methods of stopping bleeding in PPH.
* Undersuturing
* Brace sutures – b lynch suture
* Uterine artery ligation
* Hyserectomy
100
What blood type should be considered in life threatening haemorrhage?
O - ve (this blood type covers all bases)
101
Outline the main features of fluid replacement in PPH.
* 2 Large bore IV access
* Rapid fluid resuscitation - crystalloid Hartmann’s, 0.9% N/Saline
* Blood transfusion early
* Consider O -ve blood if life threatening haemorrhage
* If DIC/coagulopathy – FFP, cryoprecipitate, platelets
* Use Blood warmer
* Cell saver
102
What is secondary PPH defined as?
Bleeding >24hrs-6 weeks postnatally
103
What MUST be excluded in a female with secondary PPH?
RPOC (retained products of conception) with USS
104
What 2 things must you remember for APH?
Kleihauer
+
Anti-D & Steroids
