Bleeding in Late Pregnancy # Flashcards
(91 cards)
1
Q
What defined bleeding in late pregnancy?
A
> 24 weeks
2
Q
What are good questions to ask about bleeding in pregnancy?
A
Amount Colour Is pain continuous or intermittent MEWS score Any trigger; esp coital Foetal movements
3
Q
What direct cause of pregnancies causes the most deaths in the 6 weeks postpartum?
A
VTE
4
Q
When does the placenta form, and when is it fully functional?
A
Forms 6 weeks
Functional at 12 weeks
5
Q
What are the functions of the placenta?
A
Gas transfer
Metabolism/ wast disposal
Hormone production (hPL)
Protective “filter”
6
Q
What is the definition of APH?
A
Bleeding from genital tract after 24 weeks gestation and before the end of the 2nd stage of labour
7
Q
What are the commonest causes of APH?
A
Abruption
Previa
8
Q
What can cause APH?
A
Placenta issues; praevia, abruption Uterine problem; rupture Indeterminate Vasa praevia Local; ectropion, polyp, infection, carcinoma
9
Q
DDx of APH?
A
Heavy show
Cystitis
Haemorrhoids
10
Q
What is the “show”?
A
Mucus plug comes away indicating start of labour
11
Q
How can APH be quantified?
A
Spotting; staining, streaking, wiping
Minor; <50ml
Major; 50-1000ml
Massive; >1000ml and/or shock
12
Q
What is a placental abruption?
A
Premature separation of a normally implanted placenta partially or totally before the birth of the foetus
13
Q
Is an abruption a clinical or investigative diagnosis?
A
Clinical
14
Q
How many pregnancies will an abruption complicate and what percentage of APH is due to ab abruption?
A
1% of pregnancies
40% of APH
15
Q
What is the pathology of an abruption?
A
Vasospasm followed by arteriole rupture into the decidua; blood escapes into the amniotic sac or further under the placenta and into the myometrium
16
Q
Why is an abruption painful?
A
Results in tonic contraction and interrupts placental circulation which results in hypoxia
17
Q
What is a couvelaire uterus?
A
Blue appearance to uterus due to bruising
18
Q
Risk factors for development of a placental abruption?
A
pre-eclampsia and maternal hypertension previous placental abruption prolonged rupture of membranes maternal age: pregnant women who are younger than 20 years or older than 35 years are at greater risk maternal trauma cigarette smoking cocaine or other amphetamine use thrombophilia chorioamnionitis short umbilical cord multiparity multifetal pregnancies
19
Q
What are the symptoms of a placental abruption?
A
Severe abdo pain; CONTINUOUS Backache with posterior placenta Bleeding (may be concealed if retroplacental) Preterm labour Maternal collapse
20
Q
Signs of a placental abruption on examination?
A
Uterus large for dates or normal
Uterine tenderness
Woody hard uterus
Can be in preterm labour with heavy show
21
Q
What condition will the foetus be in in placental abruption?
A
Foetal heart; bradycardia/ absent (IUD)
CTG; irritable uterus (1 contraction per min, FH abnormality, tachycardia, loss of variability, decelerations)
22
Q
Basic management of a placental abruption?
A
Resuscitate mother
Assess and deliver baby
Manage complications
Debrief the parents
23
Q
How should the mother be resuscitated in a placental abruption?
A
2 large bore IVs Bloods; FBC, clotting, LFT, U+Es, XM 4-6 units packed red cells Kleihauer IV fluids (careful with PET) Catheterise
24
Q
How should delivery be managed in a placental abruption?
A
Urgent delivery by c/s
ARM and induction of labour
Expectant/ conservative management (only for minor; allow steroid cover)
25
What are the maternal complications of a placental abruption?
```
Hypovolaemic shock
Anaemia
PPH
Renal failure from renal tubular necrosis
Coagulopathy (FFP, cryoprecipitate)
Infection
Prolonged hospital stay
Psychological sequelae; PTSD
Complications of blood transfusion
Thromboembolism
Mortality rate
```
26
Foetal complications of placental abruption?
Foetal death; IUD
Hypoxia
Prematurity; iatrogenic or spontaneous
SGA and FGR
27
Can abruptions be prevented in future pregnancies?
```
Recurrence is 10%
APS; LMWH and LDA
Drug misuse; referral to drug misuse agencies
Smoking cessation
Folic acid
Domestic violence
```
28
What is a placenta praevia?
Placental lies directly over internal os
29
When should the term low lying placenta be used in place of placenta praevia?
After 16-40, low lying placenta should be used when the placental edge is less than 20 mm from the internal os on transabdominal or transvaginal scanning (TVS)
30
Anatomically, what is the lower segment of the uterus?
Part of uterus below the utero-vesical peritoneal pouch superiorly and the internal os inferiorly
Thinner and contains less muscle fibres than upper segment
31
Physiologically, what is the lower segment of the uterus?
Part of uterus which does not contract in labour but passively dilates
32
Metrically, what is the lower segment of the uterus?
Part of uterus which is about 7cm from the level of the internal os
33
What percentage of APH is due to praevia?
20%
34
What is a big RF for placenta praevia?
C/s - increased risk in future pregnancies
35
What are the risk factors for placenta praevia?
```
Previous c/s
Previous praevia
Smoking
ART
Previous termination
Multiparity
Maternal age >40
Multiple pregnancy
Deficient endometrium due to presence or history of; uterine scar, endometritis, manual removal of placenta, curettage, submucous fibroid
```
36
When is placenta praevia screened for?
20 week; midtrimester foetal anomaly scan should include placental localisation
37
When will you be rescanned if praevia is identified at the 20 week scan?
Rescan at 32 and 36 weeks if persistent praevia or LLP
TVUSS superior to transabdominal
Assess cervical length before 34 weeks for risk of preterm labour
38
What should be performed if placenta accreta is suspected?
MRI
39
What are the symptoms of placenta praevia?
Painless bleeding >24 weeks
Usually unprovoked by coitus can trigger
Bleeding can be minor or severe
40
What are the signs of placenta praevia on examination?
Uterus soft and non-tender
Presenting part is high
Malpresentations - breech/ transverse/ oblique
Foetal heart; CTG normal
41
Should you perform a digital vaginal examination in placenta praevia?
NO
| Speculum exam may be helpful
42
How is placenta praevia diagnosed?
Check anomaly scan
Confirm by TV USS
MRI to exclude accreta
43
What is the management for placenta praevia that is not bleeding?
Advise pt to attend immediately if; bleeding (incl spotting), contractions, pain
NO sex
Antenatal corticosteroids between 34 and 35+6 weeks in women at high risk of preterm birth
Consider tocolysis if symptomatic placenta praevia or a low lying for 48 hours antenatal corticosteroids
44
When should mag sulphate be given?
24-32 weeks if planning delivery
| Neuroprotection
45
How should delivery be planned in women who have placenta praevia but not bleeding?
34 - 36 weeks consider delivery if history of PV bleeding or other risk factors for preterm
Delivery timing tailored according to antenatal symptoms
Uncomplicated placenta praevia consider delivery between 36-37 weeks
46
What is the management of bleeding placenta praevia?
Admit for 24 hours until bleeding has ceased
Anti-D if rh neg
Antenatal corticosteroids between 24-36 weeks
TEDS; no fragmin unless prolonged stay
Prevent and treat anaemia
JW; ensure advanced directive
47
At what gestation can a CTG be used?
28 weeks
48
When should a c/s be chosen of VD in placenta praevia?
c/s; if placenta covers os or <2cm from cervical os
| Vaginal delivery if placenta >2cm from os and no malpresentation
49
What is the issue surrounding c/s in placenta praevia?
Skin and uterine incision vertical <28 weeks if transverse lie
Aim to avoid cutting though the placenta
50
What is placenta accreta?
A morbidly adherent placenta; abnormally adherent to the uterine wall
51
What is placenta accreta associated with?
Severe bleeding
PPH
Hysterectomy
52
What are major risk factors for the development of placenta accreta?
Placenta praevia
| Prior c/s
53
What is placenta increta?
Invading myometrium
54
What is placenta percreta?
Penetrating uterus to bladder
55
What is the MDT management of placenta accreta?
Prophylactic internal iliac balloon
Caesarean hysterectomy
Blood loss >3L expected
Conservative management - leave placenta in situ and give methotrexate
56
What is a uterine rupture?
Full thickness opening of uterus including serosa
| If serosa intact, it is dehiscence
57
What are risk factors for a uterine rupture?
Previous c/s or uterine surgery
Multiparity and use of prostaglandins/ syntocinon
Obstructed labour
58
Symptoms of uterine rupture?
Severe abdominal pain
Shoulder tip pain
Maternal collapse
PV bleeding
59
Signs of uterine rupture?
```
Intrapartum loss of contractions
Acute abdomen
Presenting part rises
Peritonism
IUD/ foetal distress
```
60
What is the management of uterine rupture?
```
Urgent ABCDE
2 large bore IV
FBC, clotting, LFT, U+Es, Kleihauer (if rh neg)
XM 4-6 units red packed cells
Initiate major haemorrhage protocol
IV fluids or transfuse
Anti-D
```
61
What is vasa praevia?
Unprotected foetal vessels transverse the membranes below the presenting part of the internal cervical os
62
How is vasa praevia diagnosed?
Ultrasound transabdominal and TV with doppler
| Clinically; ARM and sudden dark red bleeding with foetal bradycardia
63
What is type 1 vasa praevia?
Vessel is connected to a velamentous umbilical cord
64
What is type 2 vasa praevia?
Connected the placenta with a succenturiate or accessory lobe
65
Risk factors for vasa praevia?
Placental anomalies such a bi-lobed placenta or succenturiate lobes where the foetal vessels run through the membranes joining the separate lobes
Hx of praevia
Multiple pregnancy
IVF
66
What is the management of vasa praevia if diagnosed antenatally?
Antenatal diagnosis; steroids from 32 weeks, consider inpatient management if risks of preterm birth (32-34 weeks)
Deliver by c/s before labour (34-36 weeks)
67
What is the management of vasa praevia if diagnosed whilst in labour?
Emergency c/s and neonatal resuscitation
Use of blood transfusion if required
Placenta for histology
68
Aside from abruption, praevia, accreta and vasa praevia, what can cause APH?
Cervical; ectropion, polyp, carcinoma
Vaginal
Unexplained
69
What is the definition of PPH?
Blood loss equal to or exceeding 500ml after birth of the baby
70
What is primary and secondary PPH?
Primary; within 24 hours
| Secondary; after 24 hours to 6/52 post delivery
71
What is minor PPH?
500-1000 ml blood loss
72
What is major PPH?
>1000 ml of signs of CV collapse or ongoing bleeding
73
What are the 4 T's of PPH?
Tone - uterine atony
Trauma - c/s, forceps, episiotomy
Tissue - retained tissue
Thrombin
74
What are antenatal risk factors for PPH?
```
Anaemia
Previous c/s
Placenta praevia, percreta, accreta
Previous PPh
Previous retained placenta
Multiple pregnancy
Polyhydraminos
Obesity
Foetal macrosoia
```
75
What are intrapartum risk factors for PPH?
Prolonged labour
Operative vaginal delivery
C/S
Retained placenta
76
What can be done to prevent PPH?
Active management of 3rd stage; syntocinon IM/IV
77
What should be examined when determining the aetiology of PPH?
```
History
Exam
Uterine tone
Vaginal tears
Placenta and membranes; assess if there is likely to be any retained tissue
```
78
Initial management of PPH?
Call for help
Assess
Stop bleeding
Fluid replacement
79
Management for minor PPH?
IV access
G+S, FBC, coag screen incl fibrinogen
Obs; pulse, RR, BP every 15 mins
IV warmed crystalloid infusion
80
How is a major PPH assessed?
```
Vital signs; pulse, BP, cap refil, sats
O2
Determine cause; 4Ts
Blood; FBC, clotting, fibrinogen, U+Es, LFTs, lactate
XC 6 units
Activate major haemorrhage protocol
```
81
How can bleeding be stopped in PPH?
```
Uterine massage; bimanual compression
Expel clots
5 units IV syntocinon stat
Infuse 40 units in 500ml hartmann's at 125 ml/hr (if PET; 40 units at 40 ml/hr)
Foley catheter
MOST respond
```
82
What should be done if pt has not responded to initial management for stopping bleeding in PPH?
```
Confirm placenta and membranes complete
Urinary catheter
500 micograms ergometrine IV
THEN
Carboprost/ haemabate 250 mcg IM every 15 mins
Misoprostol 800 mcg PR
Tranexamic acid 0.5g-1g IV
EUA in theatre if persistent bleeding
```
83
What is the mode of carboprost?
Prostaglandin F2 alpha
84
In what subset of patients is ergometrine contraindicated?
Cardiac disease
| Hypertension; PET
85
What is assessed in EUA in PPH?
Vaginal/ cervical trauma
Retained products of conception
Rupture
Inversion
86
Non-surgical managements of stopping prolonged bleeding in PPH?
Packs and balloons; rusch, bakri
Tissue sealants
IR; arterial embolisation
87
What are the surgical management of stopping prolonged bleeding in PPH?
```
Under Suturing
Brace sutures; B-lynch
Uterine artery ligation
Internal iliac artery ligation
Hysterectomy
```
88
How should fluid be replaced in PPH?
```
2 large bore IV
Rapid fluid resuscitation; crystalloid
Blood transfusion early
If DIC/ coagulopathy; FFP, cryoprecipitate, platelets
Use blood warmer
Cell saver
```
89
What investigation should be done for secondary PPH?
Exclude retained products of conception with USS
| Likely to be infecion
90
What is the management of patients post PPH?
Thromboprophylaxis
Debrief couple
Manage anaemia; IV rion
Datix and risk management
91
What is kleihauer?
A test to determine if there has been and the size of foeto-maternal haemorrhage (FMH)
FMH estimation is is performed to ensure that pregnant women who have undergone potentially sensitising events are given adequate quantities of anti-D.
Will be positive if more than 4ml of foetal blood in maternal circulation
