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Reproduction > Bleeding in Late Pregnancy > Flashcards

Bleeding in Late Pregnancy Flashcards

1
Q

What is bleeding in early and late pregnancy

A

early <24 weeks (threatened miscarriage, not viable)

late > 24 weeks

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2
Q

what about fetus do you want to ask in bleeding in late pregnancy

A

changes in fetal movements

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3
Q

what is the most common indirect cause of maternal death

A

cardiac disease

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4
Q

what is the most common cause of direct maternal death

A

VTE

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5
Q

when does the placenta provide nutrients to the fetus

A

from week 6

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6
Q

what are the functions of the placenta and when is it fully functional

A

fully functional at 12 weeks

  • gas transfer
  • metabolism/ waste disposal
  • hormone production (human placental lactogen)
  • protective (filters toxins ingested by mother)
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7
Q

define an antepartum haemorrhage

A

bleeding from the genital tract after 24+0 weeks gestation and before the end of the second stage of labour (birth of baby)

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8
Q

what is the most common causes of antepartum haemorrhage

A

placental abruption and praevia

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9
Q

what can causes antepartum haemorrhage

A 
placental praevia 
placenta abruption 
uterine rupture 
vasa praevia 
local causes: ectropion (when cervical glandular epithelium is present on vaginal aspect of cervix), polyp, infection, carcinoma
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10
Q

what are the differentials for an antepartum haemorrhage

A

heavy show
cystitis
haemorrhoids

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11
Q

how do you quantify an antepartum haemorrhage

A

spotting- staining, streaking, wiping
minor- <50 mls, settled
major- 50-1000ml, no shock
massive- >1000ml and/or shock

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12
Q

how is placental abruption diagnosed

A

clinically, cannot be confirmed by any Ix

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13
Q

what is placental abruption

A

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

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14
Q

what causes placental abruption

A

vasospasm followed by arteriole rupture into to decidua- blood escapes into the amniotic sac or further under the placenta and into myometrium
this causes tonic contraction and interrupts placental circulation = hypoxia (painful continuous contraction)
resutls in couvelaire uterus (has blueish appearance)

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15
Q

what are the risk factors for placental abruption

A

pre-eclampsia/ HPTx
trauma: blunt, forceful- domestic violence, RTA
smoking, cocaine, amphetamine
medical thrombophilias, renal diseases, diabetes
polyhydramnios, multiple pregnancy, preterm labour ROM
abnormal placenta
previous abruption

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16
Q

what are the symptoms of placental abruption

A 
severe abdominal pain that is continuous 
(back ache with posterior placenta)
bleeding- may be concealed 
preterm labour 
may present with maternal collapse
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17
Q

what are the signs of placental abruption

A

unwell distressed patient
signs may be inconsistent with revealed blood
uterus large for dates/ normal
uterine tenderness
woody, hard uterus
fetal parts may be difficult to identify (due to hard uterus)
may be in pre term labour (with heavy show)

fetal heart- bradycardia/ absent (IUD), CTG shows irritable uterus (1 contraction per minute, feta tachycardia, loss of variability, decelerations)

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18
Q

what is the management of placental abruption

A

resuscitate the mother - primary concern:

  • 2 large bore IV access, FBC, clotting, LFT, U&Es, cross match 4-6 units RBS, kleihauer
  • IV fluid (take care with PET)
  • catheterise (measure hourly output with utometer)

assess and deliver the baby:
-assess fetal heart with CTG (USS if nor HB)
-delivery urgent, via CS, artificial rupture of membranes + IOL
-conservative delivery if haemorrhage minor
manage the complications
debrief the parents

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19
Q

what is the kleihauer test

A

determines whether there has been a fetal maternal haemorrhage and if so how large

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20
Q

what are the maternal complications of placental abruption

A 
hypovolaemic shock 
anaemia
PPH 
renal failure (from renal tubular necrosis) 
coagulopathy (FFP, cryoprecipitate) 
infection 
prolonged hospital stay 
psychological sequelae
complications of blood transfusion 
thromboembolism 
(mortality rare)
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21
Q

what are the possible fetal complications of placental abruption

A

fetal death
hypoxia (brain injury)
prematurity (iatrogenic/ spontaneous)
small for dates/ IUGR

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22
Q

how can you prevent placental abruption

A 
in APS- give LMWH and LDA
smoking cessation 
LDA
refer to drug misuse help services 
folic acid 
multiagency prevention for domestic violence
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23
Q

what is a placenta praevia

A

when the placenta lies directly over the internal os

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24
Q

what is a low lying placenta

A

when the placental edge is less than 20mm from the internal os on TA/TVUSS after 16 weeks gestation

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25
Q

what is the lower segment of the uterus

A

the part of the uterus below the utero-vesicle peritoneal pouch superiorly and internal os inferiorly
the part of the uterus that is 7cm from the level of the internal os

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26
Q

how is the lower segment of the uterus different from the upper

A

lower is thinner an contains less muscle fibres

lower doesn’t contract in labour but instead passively dilates

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27
Q

what increases the risk of placenta praevia

A 
previous CS
previous placenta praevia 
smoking
ART
maternal smoking 
previous TOP
multiparity 
advanced maternal age (>40)
multiple pregnancy 
deficient endometrium due to: uterine scar, endometritis, manual removal of placenta, curettage, submucous fibroid
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28
Q

what screening is done for placenta praevia

A

mid trimester fetal anomaly scan should include placental localisation
rescan at 32 and 36 weeks if persistent placenta praevia or LLP
(Transvaginal better than TA)
assess cervical length before 34 weeks for risk of preterm labour
MRI if placenta accreta suspected

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29
Q

what are the symptoms of placenta praevia

A

painless bleeding >24 weeks
(usually unprovoked but coitus can trigger it)
bleeding can be minor (spotting) or severe
patient condition is directly proportional to the amount of observed bleeding (unlike abruption which can be concealed)
fetal movements generally present

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30
Q

what are the signs of placenta praevia

A

uterus is soft and non tender
presenting part is high
malpresentation- breech, transverse, oblique
fetal heart CGT usually normal

31
Q

what should you never do in suspected placenta praevia until it is excluded as a diagnosis

A

do not perform a digital vaginal or rectal exam

speculum exam may be useful

32
Q

how is placenta praevia diagnosed

A

check anomaly scan
confirm by TVUSS
MRI to exclude placenta accreta

33
Q

what is the general management for placenta praevia

A

resus mother- ABC
assess baby
conservative management if stable
admit if PV bleeding, distant from hopsital, transport problems, jehovahs witness (all should be inpatient for at least 24 hours until bleeding has ceased)
prevent and treat anaemia
delivery plan at/near term
anti D if rhesus -ve
antinatal steroids between 24+0 and 25+6 weejs
TEDs- no fragmin unless prolonged stay
ensure advanced directive with jehovahs witnesses
MgSO4 (neuroprotection 24-32 weeks if planning delivery)

34
Q

what advise for non blleding patients with placenta praevia

A

advise to attend immediately if:

  • bleeding (inc spotting)
  • contractions
  • pain (inc vague suprapubic period like aches)
no sex 
antenatal steroids (34+0 and 35+6 weeks or <34+0 weeks in high risk of preterm birth)
consider tocolysis (delaying birth) if symptomatic 
MgSo4 neuroprotection (24-32 weeks- if planning delivery)
35
Q

when should you aim to delivery in placenta praevia

A

34+0to 36+6weeks consider delivery if history of PV bleeding or other risk factors for preterm delivery.
Delivery timing tailored according to antenatal symptoms
Uncomplicated placenta praevia consider delivery between 36+0and 37+0weeks

36
Q

what extra steps need to be taken in a patient with placenta praevia who is bleeding

A 
cross match 4-6 RNC
may need major haemorrhage protocol 
IV fluids/ tranfuse
anti D 
expedite delivery (CS)
37
Q

what needs to be considered in delivery planning in placenta praevia

A

if placenta covers os or <2cm from cervical os = CS
vaginal delivery if placenta >2cm from os and no malpresentation
if bleeding need quick delivery = CS

if doing CS:
Senior operator & Anaesthetist
Consent to include hysterectomy and risk of General Anaesthesia
Cell salvage
Skin and uterine incisions vertical <28weeks if transverse lie
Aim to avoid cutting through the placenta

38
Q

what is placenta accreta

A

a morbidly adherent placenta - abormally adherent to the uterine wall

39
Q

what increases risk of placenta accreta

A

5-10% of placenta praevia

multiple CS

40
Q

what is placenta accreta associated with

A

severe bleeding
PPH
considerable maternal morbidity (always consultant in delivery)

41
Q

what are the types of placenta accreta

A

invading the myometrium: increta

penetrating uterus to bladder: percreta

42
Q

what is the management of placenta accreta

A

prophylatic internal iliac artery balloon
caesarean hysterectomy
blood loss >3 litres to be expected
conservative management (?+methotrexate)

43
Q

what is a uterine rupture

A

full thickness opening of the uterus including the serosa

44
Q

what is uterine dehiscence

A

opening of uterus but serosa is still intact

45
Q

what are the risk factors for uterine rupture

A

previous C section/ uterine surgery
mulitparity and use of prostaglandins (IOL)/ syntocinon
obstructed labour
previous rupture

46
Q

what are the symptoms of uterine rupture

A

severe abdominal pain
shoulder tip pain
maternal collapse
PV bleeding

47
Q

what are the signs of uterine rupture

A 
intra partum- loss of contractions 
acute abdomen 
presenting part rises 
loss of uterine contractions 
peritonism 
fetal distress, IUD
48
Q

what is the management for uterine rupture

A 
urgent resus and surgery 
2 Large bore IV access,
FBC, clotting , LFT, U&amp; 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)
49
Q

what is vasa praevia

A

when unprotected fetal vessels traverse the membranes below the presenting part over the internal cervical os
these will rupture during labour or at amniotomy

50
Q

how is vasa praevia diagnosed

A

TAUSS and TVUSS with doppler
clinically:
when artificial rupture of membranes causes sudden dark bleeding and fetal bradycardia/ death

51
Q

what are the types of vasa praevia

A

type 1- when vessel is connected to a velamentous umbilical cord
type 2- when it connects the placenta with a succenturiate or accessory lobe

52
Q

what are the risk factors for vasa praevia

A

placental anomalies such as bi lobed placenta or succenturiate lobes (where fetal vessels run through the membranes joining the separate lobes together)
Hx of low lying placenta in the second trimester
multiple pregnancy
in vitro fertilisation

53
Q

what is the management for vaso praevia

A

Antenatal diagnosis-
Steroids from 32 weeks
Consider inpatient management if risks of preterm birth (32-34 weeks)
Deliver by elective c/section before labour (34-36 weeks)

if APH caused by vasa praevia:
emergency CS
neonate resus (inc blood transfusion if required)
placenta for histology

54
Q

what are the cervical causes of antepartum haemorrhage

A

ectropion
polyp
carcinoma

55
Q

what are the vaginal causes of APH

A

trauma

56
Q

how many APH’s have an unexplained cause

A

1/3rd

57
Q

what is a post partum haemorrhage

A

blood loss = to or exceeding 500ml after the birth of the baby

  • primary within 24hrs of delivery
  • secondary >24hrs- 6 weeks post delivery
58
Q

what are the classifications of PPH

A

primary - within 24hrs of birth
secondary- >24hrs- 6 weeks post partum

minor- 500ml-1000ml (without clinical shock)
major- >1000mls or signs of cardiovascular collapse/ ongoing bleeding

59
Q

what should you always remember when quantifying PPH

A

visual blood loss may be underestimated
total blood volume depends on maternal body weight:
100mls/kg volume in pregnancy

60
Q

what are the causes of PPH

A

the 4 T’s
tone- 70% caused by uterine atony
trauma- 20% (CS, instrumental delivery, episiotomy)
tissue- 10% (any placenta/ products of conception left in uterus)
thrombin- <1%

61
Q

how do you prevent PPH

A

identify antenatal and intrapartum risk factors

active management of the 3rd stage of labour

62
Q

what are the antenatal risk factors for PPH

A 
anaemia 
previous CS
placenta praevia, percreta, accreta 
previous PPH 
previous retained placenta 
multiple pregnancy 
polyhydramnios
obesity 
fetal macrosomia 
(caution with JW, advanced directive)
63
Q

what are the intrapartum risk factors for PPH

A

prolonged labour
operative vaginal delivery
CS
retained placenta

64
Q

how is the third stage of labour actively managed

A

syntocinon/ syntometrine (IM/IV)

65
Q

how do you identify the cause of a PPH

A 
Hx
exam 
uterine tone 
vaginal tears 
placenta and membranes
66
Q

what is the initial management for a PPH

A 
call for help 
assess;
Vital Signs: Pulse, BP, Capillary refill time, Saturations every 15min
Give Oxygen
Determine Cause of bleeding- 4Ts
Blood Samples: FBC, clotting, fibrinogen, U&amp;E, LFT, Lactate
Cross-match 6 units red packed cells
May need Major Haemorrhage protocol
stop bleeding
fluid replacement
67
Q

what measures should be taken in a minor PPH (500-1000ml no shock)

A

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

68
Q

how do you stop the bleeding in PPH

A 
Uterine massage- bimanual compression
Expel clots 
5 units IV Syntocinon stat 40 units 
Syntocinon in 500ml Hartmann's - 125 ml/h
Foleys Catheter

if still bleeding

Confirm placenta and membranes complete (nothing left inside)
Urinary Catheter
500 micrograms Ergometrine IV (Avoid if Cardiac Disease / Hypertension) (these are oxytocics)
? Vaginal / perineal trauma - ensure prompt repair
? cervical trauma

still bleeding

Carboprost /Haemabate ( PGF2α) 250mcg IM every 15min ( Max 8 doses) (prostaglandin)
Misoprostol 800mcg PR (these are oxytocics)
Tranexamic acid 0.5g-1g IV
EUA in theatre if persistent bleeding
CALL CONSULTANT

Transfer to Maternity Operating Theatre for EUA
 ? Vaginal / cervical trauma. 
? Retained Products Of Conception
 ? Rupture 
? Inversion Allows advanced techniques
69
Q

what are the non surgical mechanisms for stopping bleeding in PPH

A

Packs & Balloons – Rusch Balloon, Bakri Balloon
Tissue Sealants
Interventional Radiology : Arterial Embolisation

70
Q

what are the surgical mechanisms for stopping bleeding in PPH

A 
Undersuturing 
Brace Sutures – B-Lynch Suture
Uterine Artery Ligation 
Internal Iliac Artery Ligation 
Hysterectomy
71
Q

how is fluid replaced in PPH

A

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

72
Q

what should you consider in secondary PPH

A

Retained products of conception (RPOC)- exclude with USS

Infection likely to play a role

73
Q

what should you always remember to do in APH

A

kelinauer
anti D
steroids

74
Q

what do most women respond to in PPH

A

uterotonic agents

Reproduction (51 decks)

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