Bleeding in Late Pregnancy

Question 1

what bleeding counts as early pregnancy

Answer 1

<24 weeks

Question 2

what bleeding is late pregnancy

Answer 2

> 24 weeks

bc this is when the baby is viable

Question 3

what is antepartum haemorrhage

Answer 3

bleeding from the genital tract after 24 weeks gestation and before the second stage of labour

Question 4

causes of antepartum haemorrhage

Answer 4

placental problems (praaevia, abruption)

Uterine problems (rupture)

Local causes (ectropion, polyp. infection, carcinoma)

Vasa praaevia

Unknown

Question 5

what are some differentials for antepartum haemorrhage

Answer 5

heavy show
cystitis
haemorrhoids

Question 6

what is a minor APH

Answer 6

<50ml settled

Question 7

what is a major APH

Answer 7

50-1000ml

no shock

Question 8

what is a massive APH

Answer 8

> 1000ml and/or shock

Question 9

what is placental abruption

Answer 9

premature breaking away of a normal placenta from the uterus partially or totally before birth

is a CLINICAL diagnosis - no investigations done

Question 10

cause placental abruption

Answer 10

vasospasm then arteriole rupture into the decider

blood escapes into the amniotic sac or further under the placenta into myometrium

causes myometrium contraction and interrupts placental circulation causing hypoxia

Question 11

what is couvelaire uterus

Answer 11

placental abruption causes bleeding that penetrates the myometrium and goes into the peritoneal cavity

medical emergency

Question 12

risk factors for placental abruption

Answer 12

unknown 
pre-eclampsia/hypertension 
trauma
smoking/cocaine/amphetamine 
thrombiphilias/ renal disease/ diabetes
polyhydraminos 
multiple pregnancy 
preterm baby
abnormal placenta 
previous abruption

Question 13

symptoms of placental abruption

Answer 13

continuous severe abdominal pain 
backache with posterior placenta
bleeding 
preterm labour 
maternal collapse

Question 14

signs of placental abruption

Answer 14

unwell distressed patient 
Large for dates or normal uterus 
uterine tenderness 
woody hard uterus 
fetal parts difficult to identify 
may be in preterm labour

fetal Bradycardia/absent HR

CTG shows irritable uterus

Question 15

management of placental abruption

Answer 15

resuscitate mother
assess and deliver the baby (urgent CS or IOL)
manage the complications
debrief parents

Question 16

how do you resuscitate the mother in placental abruption

Answer 16

2 large bore IV access
bloods: FBC, clotting, LFT U&Es, cross match, kleihauer (RH-)
IV fluids
catheterise

Question 17

complications of placental abruption

Answer 17

Hypovolaemic shock 
Anaemia 
PPH 
Renal failure from renal tubular necrosis 
Coagulopathy 
infection 
complications of blood transfusion 
thromboembolism 
prolonged hospital stay 
psychological sequelae 
fetal heath 
fetal hypoxia 
prematurity 
small for gestational age, FGR

Question 18

what is placenta praevia

Answer 18

placenta is low lying directly over the internal os

Question 19

what is a low lying placenta

Answer 19

at 16/40 weeks when the placenta is less than 20 mm from the internal os on trans abdominal or transvaginal scanning

Question 20

risk factors for placenta praaevia

Answer 20

previous CS
previous TOP 
advanced maternal age 
multiparty 
multiple pregnancy

Question 21

when is placenta praaevia screened for

Answer 21

mid trimester fetal anomaly scan includes placental localisation

rescan at 32 and 36 weeks is persistent placenta praevia or low lying placenta

Question 22

symptoms of placenta praaevia

Answer 22

Painless bleeding >24 weeks

can be triggered by sex but usually unprovoked

fetal movements present

Question 23

signs of placenta praaevia

Answer 23

uterus soft and non tender

presenting part high

malpresentation (breech, transverse, oblique)

normal CTG

do not perform a digital vaginal exam until excluded PP (speculum examination instead)

Question 24

how do you diagnose placental praaevia

Answer 24

Check anomaly scan
Confirm with transvaginal US
MRI to exclude placenta accrete (placenta invades into the myometrium)

Question 25

how do you manage placenta praevia

Answer 25

``` Resuscitate mother (ABCDE) Asses baby's condition Investigations Steroids Anti D if Rh- Conservative management if stable Steroids between 24 and 35+6 weeks delivery plan at/near term ```

Question 26

how do you manage a placenta praevia which isn't bleeding

Answer 26

advise patient to attend immediately if any bleeding - including spotting contractions or pain advice no sexual intercourse

Question 27

how do you manage a significant bleed from placenta praevia

Answer 27

Admit and resuscitate 2 large bore IV access FBC, clotting, LFTs, U+Es, kleihauer, cross match major haemorrhage protocol IV fluids or blood transfusion Anti D if RH - asses fetal well being, monitor fetal heart, give steroids and magnesium sulphate (24-32 weeks if planning delivery) expectant management if stable expedite delivery if active bleeding

Question 28

how do you delivery the baby in placenta praevia

Answer 28

C/Section if placenta covers os or <2cm from cervical os Vaginal if placenta is >2cm from os and no malpresentation

Question 29

what is placenta accreta

Answer 29

morbidly adherent placenta (placenta starts to invade the uterine wall)

Question 30

what is placenta increta

Answer 30

when the placenta invades the myometrium

Question 31

what is placenta percreta

Answer 31

when the placenta penetrates the uterus through to the bladder

Question 32

how do you manage placenta accreta

Answer 32

prophylactic internal iliac artery balloon caesarian hysterectomy blood loss >3L expected conservative management

Question 33

what is a uterine rupture

Answer 33

full thickness opening of uterus including the serosa if the serosa is intact it is called uterine dehiscence

Question 34

what are some risk factors for uterine rupture

Answer 34

previous C/Section or uterine surgery multiparty and use of prostaglandins (eg. syniocin in IOL) obstructed labour

Question 35

symptoms of uterine rupture

Answer 35

severe abdominal pain shoulder-tip pain maternal collapse PV bleeding

Question 36

signs of uterine rupture

Answer 36

Intra-partum loss of contractions Acute abdomen peritonism fetal distress/ IU death

Question 37

management of uterine rupture

Answer 37

urgent resuscitation and surgical management 2 large bore IV access FBC, clotting, LFT, U+Es, Kleihauer cross match major haemorrhage protocol IV fluids/blood transfusion Anti D send to theatre

Question 38

what is vasa praevia

Answer 38

unprotected free fetal vessels transverse the membranes below the presenting part of the internal cervical os will rupture during labour or amniotomy

Question 39

How do you diagnose vasa praevia

Answer 39

ultrasound (trans abdominal and transvaginal with doppler)

Question 40

risk factors for vasa praevia

Answer 40

placental anomalies low lying placenta multiple pregnancy IVF

Question 41

how do you manage vasa praevia

Answer 41

antenatal diagnosis steroids from 32 weeks delivery by elective CS before labour if there's an antepartum haemorrhage from vasa praevia - emergency c section

Question 42

what are some other causes of bleeding in late pregnancy

Answer 42

``` ectropion polyp carcinoma vaginal causes unexplained ```

Question 43

what is a post part haemorrhage

Answer 43

blood loss >500ml after the brith of the baby primary - within 24 hours secondary - >24 hours

Question 44

what is a minor PPH

Answer 44

500ml-1000ml without clinical shock

Question 45

what is a major PPH

Answer 45

>1000ml or signs of shock or ongoing bleeding

Question 46

4Ts - causes of post partum haemorrhage

Answer 46

Tone (uterine atony) Trauma Tissue (retained placental/membrane tissue) Thrombin (bleeding disorders)

Question 47

risk factors for PPH

Answer 47

``` anaemia previous CS Placental praevia, percreta, accreta previous PPH previous retained placenta multiple pregnancy Polyhydramnios obesity fetal Macrosomia ```

Question 48

how do you prevent PPH

Answer 48

Active management of third stage | syntocinon/syntometrine IM/IV

Question 49

management of PPH

Answer 49

Asses Stop bleeding Fluid replacement

Question 50

how do you stop the bleeding in PPH

Answer 50

``` Uterine passage - bimanual compression Expel clots 5 units IV syntocinin urinary catheter ergometrine IV prompt repair of trauma Carboprost/haemabate Misoprostol Tranexemic acid ``` examination under anaesthetic in theatre if persistent bleeding

Question 51

what is done in theatre to stop PPH

Answer 51

packs and balloons tissue sealants interventional radiology ``` undersuturing brace sutures uterine artery ligation internal iliac artery ligation hysterectomy ```

Question 52

management for a secondary PPH (>24hr - 6 weeks postnatally)

Answer 52

exclude retained products of conception with US often caused by infection

Question 53

how do you manage PPH post delivery

Answer 53

thrombophylaxis debrief couple manage anaemia