Bleeding in Late Pregnancy Flashcards
(85 cards)
1
Q
What is considered as bleeding in LATE pregnancy?
A
- UK >24 wks
2
Q
Define antepartum hemorrhage.
A
- bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
3
Q
What placental problem causes APH?
A
- placenta praevia
- placental abruption
4
Q
What are local causes of APH?
A
- Ectropion
- Polyp
- Infection
- Carcinoma
5
Q
What uterine problem may cause aph?
A
- uterine rupture
6
Q
Name another cause of APH; regarding the fetal blood vessels…
A
- Vasa praevia
7
Q
What is the DDX of APH?
A
- heavy show
- cystitis
- hemorrhoids
8
Q
What is heavy show?
A
- type of vaginal discharge containing mucus with bright red/ dark brown
- usually before labour !
9
Q
What is considered as MASSIVE APH?
A
> 1000ml
and/or shock
10
Q
WHat is considered as MINOR APH?
A
- <50ml
11
Q
What is placental abruption?
A
- separation of a NORMALLY implanted placenta (partially/totally) BEFORE fetal birth
12
Q
How common is placental abruption?
A
- only 1% of pregnancies
- —-but 40% of APH cases
13
Q
Why does placental abruption occur?
A
- vasospasm followed by arteriole rupture in to the decidua (blood escapes into AMNIOTIC sac or further UNDER the placenta and into myometrium)
—cause tonic contraction and interrupts placental circulation; causing fetal hypoxia ==> COUVELAIRE uterus (concealed placental abruption)
14
Q
What cause placental abruption?
A
- pre-eclampsia/HTN
- Trauma *blunt force—-domestic violence/MVA
- drug use
- polyhydramnios/ multiple preg./ preterm-PROM
- abnormal placenta
- previous abruption
- —–renal disease, thrombophilias/ DM
15
Q
How does placental abruption present as?
A
- CONTINUOUS severe abdominal pain
- –labour is meant to be INTERMITTENT pain
- BACKACHE (if posterior placenta)
- Bleeding (may be concealed) > couvelaire uterus, dx on laparotomy
- preterm labour
- —maternal collapse
16
Q
SIgns of placental abruption?
A
- unwell, distressed pt
- LFD/ normal
- uterine tenderness
- woody HARD uterus
- hard to identify fetal parts
- preterm labour (with heavy show)
- —fetal heart: Bradycardia/ absent (IUD)
- –CTG= irritable uterus (tachycardia/ loss of variability/ decelerations)
17
Q
How to manage placental abruption?
A
- resuscitate mom
- Rapid assessment and delivery
- communicate (Neonatal team/ midwife/ obstretician/ anaesthetists)
- manage complications
- debrief parents
18
Q
What investigations and actions are carried out for management of placental abruption?
A
- 2 large bore IV access, FBC, Clotting, LFT, U&Es, cross-matched 4-6 units red packed cells, Kleihauer
- IV fluids (care with Pre-eclampsia)
- catheterise! —hrly urine volumes
- CTG
- USS (fails to detect 3/4 cases of abruption)
19
Q
How is a delivery usually performed with placental abruption?
A
- urgent C-SECTION
- ARM (Artificial rupture of membranes) and IOL
- expectant management (only for MINOR)
20
Q
What is a couvelaire uterus?
A
- hematoma bruised uterus
- massive intravasation of blood into the uterine musculature (up till the uterine serosa)
21
Q
What are maternal complications of placental abruptio?
A
- hypovolemic shock
- anemia
- PPH (25%)
- renal failure from renal tubular necrosis
- infection
- prolonged hospital stay > psych
- thromboembolism
- mortality is rare
- coagulopathy (FFP/ cryoprecipitate)
- —blood transfusion problems
22
Q
Fetal complications from placental abruption
A
Fetal Death- Intrauterine death( 14%)
- hypoxia
- prematurity
- Small for gestational age and fetal growth restriction
23
Q
How to prevent placental abruption?
A
- stop smoking
- Low-dose aspirin
- LDA and LMWH for anti-phospholipid $
24
Q
What is placental praevia ?
A
- when placenta lies DIRECTLY over the internal os
- —-after 16wks the term of low-lying placenta should be used when the placental edge is LESS than 20 mmfrom the internal os —-seen on TVS `
25
What is the lower segment of the uterus? Why is it not the ideal spot for the placenta to be placed?
- part of the uterus BELOW the utero-vesical peritoneal pouch (superiorly) and internal os inferiorly
- the part of the uterus extending 7 cm from the top of the internal os
- thinner, less muscle fibres
- part of the uterus which does not contract in labour- just dilates
26
What % of APH is attributed to placenta Praevia?
- 20%
27
What is a huge risk factor for placenta praevia to develop?
- prior c-sections from previous pregnancy
28
What past uterine problems may result in placenta praevia?
- deficient endometrium due to hx of:
| - uterine scar/ endometritis/ manual removal of placenta/ curettage/ submucous fibroid
29
What are other risk factors of placenta praevia apart from C-section?
```
Previous placenta praevia
Smoking
Assisted reproductive technology
Previous termination of pregnancy
Multiparity
(>40 years)
Multiple pregnancy
```
30
How and when to screen for placental praevia?
by TVS and Transabdominal scan
- mid-trimester fetal anomaly scan should include placental location!
- ---if present RE-SCAN at 32 and 36 wks
----assess cervical length before 34 wks for risk of Preterm labour
31
Why do a MRI scan after the screening for placental location?
- if placenta accreta is suspected
32
What are the symptoms of PP?
- painLESS bleeding >24wks
- coitus may trigger; otherwise unprovoked
- minor or severe bleeding
- pt's condition proportional to amount bled
33
What are the signs of P.P?
- soft, non-tender uterus
- HIGH presenting part
- malpresentation (breech/transverse/oblique)
- normal CTG
34
Do you perform a Vaginal examination on a pt with placenta previa?
- DO NOT PERFORM VE until PP is EXCLUDED !!!
| - ----speculum examination may be useful
35
How to confirm dx of P.P?
- Anomaly scan (mid-trimester)
- confirm by TV USG
- MRI to exclude placenta accreta
36
How to manage P.P?
- ABC on mom
- Assess bby
- Investig.
- conservative management; if stable
- prevent and rx anemia
- delivery plan near term
37
When to admit a PP pt?
- if PV bleeding
- distant from hospital/ transport problems
- jenovah's witness ( do VTE score)
38
If a P.P mom has been having PV bleeding; when is it recommended for delivery?
34wks-36 wks+6
| ---same if any other risk factors are present for PRE-TERM delivery
39
If uncomplicated p.p when is best for delivery?
36-37 wks
40
How management procedures are done for P.P pt with bleeding hx?
- admit and resuscitate
- communicate
- 2 Large bore IV access,
- FBC, clotting , LFT, U& E , Kleihauer ( if Rh Neg)
- Cross match 4-6 units Red packed cells
- May need Major Haemorrhage protocol
- IV fluids or transfuse
- Anti D ( if Rh Neg)
41
What is done for fetal management in a pp pt with bleeding hx?
- MONITOR fetal well being (CTG after 28 weeks)
- STEROIDs (24-34+6 weeks)
- MgSO4 (neuroprotection 24-32wks) ----if planning delivery
- conservative management if stable
42
When do you advise a P.P pt to attend the ANC immediately?
- if bleeding, spotting, contrxns or pain (even vague supra-pubic period like aches)
- with no penetrative sex..?
43
When is tocolysis given to P.P pt?
- if symptomatic P.P or low-lying placenta
| - for 48hrs for antenatal corticosteroids
44
How does the location and presentation of the placenta, in Placenta previa, change the manner in which the baby is delivered?
- C-section (if placenta covers OS or <2cm from os)
| - Vaginal delivery (if >2cm from os and NO malpresentation)
45
What actions should the senior operator and anesthetists gain consent for?
- CONSENT to include hysterectomy AND RISK general anesthesia
46
How are the surgical incisions diff. with transverse lie?
- skin and uterine incisions done VERTICALLY
| - ---AVOID cutting placenta
47
Define placenta accreta.
| Seen in which other placental abnormality?
- morbidly ADHERENT placenta
| 5-10% of Placenta Praevia
48
What is placenta accreta a.w?
- severe bleeding
- PPH
- considerable maternal morbidity
49
MAjor risk factors of P.A?
- placenta previa
| - prior C-section
50
What is P.Accreta?
- invading myometrium : INCRETA
| - penetrating uterus to bladder= Percreta
51
What is done to manage P.A?
- Prophylactic internal iliac artery balloon
- Caesarean hysterectomy
- Blood loss >3Litres expected
- Conservative Management (?plus Methotrexate)
52
What is uterine rupture?
- the full thickness of the uterus opens up
53
Risk factors of uterine rupture?
- previous C-section (1 IN 500)
- previous uterine surgery
- multiparity
- IOL: w/ use of prostaglandins/syntocinon (1 IN 250) increases risk
- obstructed labour
54
Symptoms of uterine rupture?
Severe abdominal pain
Shoulder-tip pain
Maternal collapse
PV bleeding
55
What are the signs of Uterine rupture? -
```
Intra-partum - loss of contractions
Acute abdomen
Presenting Part rises
Loss of uterine contractions
Peritonism
Fetal distress / Intrauterine death
```
56
How to manage uterine rupture?
- RESUSCITATION and surgical management.
- comms
- 2 Large bore IV access,
FBC, clotting , LFT, U& E , Kleihauer ( if Rh Neg)
Cross match 4-6 units Red packed cells
May need Major Haemorrhage protocol
IV fluids or transfuse
Anti D ( if Rh Neg)
57
What is Vasa Previa?
- unprotected fetal vessels traverse the membranes BELOW the presenting part over the internal cervical os
> may rupture during labor or amniotomy
58
How to dx Vasa Praevia?
- Ultrasound transabdominal
| - TVS with doppler
59
What occurs if you were to Artificially rupture the membrane of a vasa praevia mother?
- sudden dark red bleeding
- fetal bradycardia and death
- ----mortality is 60%
60
What are the diff. types of Vasa Praevia?
Type 1: vessel is connected to a velamentous umbilical cord
2: vessel connects the placenta with an accessory lobe
61
Risk factors of V.Previa?
- bilobed placenta; fetal vessels run through the membranes; joining the seprate lobes together
- hx of low-lying placenta in 2nd trimester
- multiple preg
- IVF (1 in 300)
62
How to manage V.PREVIA?
- Antenatal dx
- steroids from 32 weeks
- inpatient management if risk of pre-term (32-34wks)
- --deliver by elective c-section before labour
- placenta for histology
63
What course of action if ruptured Vasa praevia was dx during labour?
- emergency C-section
- neonatal resuscitation
- use of blood transfusion if needed
64
Name other causes of APH.
- cervical: Ectropion/ polyp/carcinoma
- vaginal causes
- unexplained
65
Why is it significant to know if a pt is a Jenovah's Witness?
- they don't accept any blood transfusions
66
What is post-partum hemorrhage?
-blood loss equal to >500ml AFTER delivery of bby
67
What is the diff. between Primary and secondary PPH?
Iary: within 24hr of delivery
IIary: >24hr- 6 wks post partum
68
When is considered to be MAJOR PPH?
- >1000ml is lost
| - signs of CVS collpase/ on going bleeding
69
How to calculate blood volume in pregnancy?
- 100 ml/ kg
70
What are the 4 Ts in the causes of PPH?
Tone 70%
Trauma 20%
Tissue 10%
Thrombin <1%
71
PPH risk factors...
```
anaemia
previous caesarean section
placenta praevia, percreta, accreta
previous PPH
Previous retained placenta
Multiple pregnancy
Polyhydramnios
Obesity
Fetal macrosomia
```
72
How to prevent PPH?
- identify Intra-partum risk factors: PROLONGED labour/ operative vaginal delivery/ C-section/ retained placenta
- --actively manage third stage !!!----Syncotonin/syntometrine (IM/IV)
73
Initial management of PPH?
- call for help
| - SIMULTANEOUS management is key: ASSESS/ STOP bleeding/ FLUID replacement
74
Management of Minor PPH....
IV access (one 14-gauge cannula)
Group & Save, FBC,coagulation screen, including fibrinogen
Observations: pulse, respiratory rate and blood pressure recording every 15 minutes
IV warmed crystalloid infusion
75
What is the 1st line of action in stopping the bleeding; most cases respond to?
- uterine massage (bimanual compression)
- expel clots
- 5 units IV Syntocinon stat 40 units
- Syntocinon in 500ml Hartmann's - 125 ml/h
- Foleys C`atheter
76
What is hartmann's solution?
sodium lactate
77
Another course of action to stop PPH?
- confirm placenta and membranes complete
- urinary catheter
- 500 micrograms Ergometrine IV (Avoid if Cardiac Disease / Hypertension)
- ---prompt repair of vaginal/ perineal trauma
78
What other meds can be given to stop the bleeding?
```
Carboprost /Haemabate ( PGF2α) 250mcg IM every 15min ( Max 8 doses)
Misoprostol 800mcg PR
Tranexamic acid 0.5g-1g IV
EUA in theatre if persistent bleeding
CALL CONSULTANT
```
79
Once in the OT room for examination under anaesthesia. What is she checked for?
- Vaginal/cervical trauma
- retained prods of conception
- rupture
- inversion allows advance techn.
80
Surgical methods to stop bleeding?
```
Undersuturing
Brace Sutures – B-Lynch Suture
Uterine Artery Ligation
Internal Iliac Artery Ligation
Hysterectomy
```
81
Non-surgical methods to stop bleeding?
- Packs & Balloons – Rusch Balloon, Bakri Balloon
- Tissue Sealants
- Interventional Radiology : Arterial Embolisation
82
How to replace fluid in PPH?
2 Large bore IV access
Rapid fluid resuscitation- Crystalloid Hartmann’s , 0.9% N/Saline
- Blood Transfusion early
- Consider O Neg if life threatening haemorrhage
- If DIC/coagulopathy – FFP, Cryoprecipitate, platelets
- Use Blood warmer
- Cell saver
83
Management of Secondary PPH?
- exclude retained products of conception with USS
| - ---infection likely to play role
84
WHat occur post-delivery?
Thromboprophylaxis
Debrief couple
Manage anaemia – IV Iron/ oral
Datix & Risk Management
85
Main 3 managment methods with APH?
- Kleihauer, Anti-D, Steroids!
