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Bleeding in Late Pregnancy Flashcards

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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
what is the lower segment of the uterus
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
26
how is the lower segment of the uterus different from the upper
lower is thinner an contains less muscle fibres | lower doesn't contract in labour but instead passively dilates
27
what increases the risk of placenta praevia
``` 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 ```
28
what screening is done for placenta praevia
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
29
what are the symptoms of placenta praevia
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
30
what are the signs of placenta praevia
uterus is soft and non tender presenting part is high malpresentation- breech, transverse, oblique fetal heart CGT usually normal
31
what should you never do in suspected placenta praevia until it is excluded as a diagnosis
do not perform a digital vaginal or rectal exam | speculum exam may be useful
32
how is placenta praevia diagnosed
check anomaly scan confirm by TVUSS MRI to exclude placenta accreta
33
what is the general management for placenta praevia
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
what advise for non blleding patients with placenta praevia
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
when should you aim to delivery in placenta praevia
34+0 to 36+6 weeks 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+0 and 37+0 weeks
36
what extra steps need to be taken in a patient with placenta praevia who is bleeding
``` cross match 4-6 RNC may need major haemorrhage protocol IV fluids/ tranfuse anti D expedite delivery (CS) ```
37
what needs to be considered in delivery planning in placenta praevia
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
what is placenta accreta
a morbidly adherent placenta - abormally adherent to the uterine wall
39
what increases risk of placenta accreta
5-10% of placenta praevia | multiple CS
40
what is placenta accreta associated with
severe bleeding PPH considerable maternal morbidity (always consultant in delivery)
41
what are the types of placenta accreta
invading the myometrium: increta | penetrating uterus to bladder: percreta
42
what is the management of placenta accreta
prophylatic internal iliac artery balloon caesarean hysterectomy blood loss >3 litres to be expected conservative management (?+methotrexate)
43
what is a uterine rupture
full thickness opening of the uterus including the serosa
44
what is uterine dehiscence
opening of uterus but serosa is still intact
45
what are the risk factors for uterine rupture
previous C section/ uterine surgery mulitparity and use of prostaglandins (IOL)/ syntocinon obstructed labour previous rupture
46
what are the symptoms of uterine rupture
severe abdominal pain shoulder tip pain maternal collapse PV bleeding
47
what are the signs of uterine rupture
``` intra partum- loss of contractions acute abdomen presenting part rises loss of uterine contractions peritonism fetal distress, IUD ```
48
what is the management for uterine rupture
``` urgent resus and surgery 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) ```
49
what is vasa praevia
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
how is vasa praevia diagnosed
TAUSS and TVUSS with doppler clinically: when artificial rupture of membranes causes sudden dark bleeding and fetal bradycardia/ death
51
what are the types of vasa praevia
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
what are the risk factors for vasa praevia
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
what is the management for vaso praevia
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
what are the cervical causes of antepartum haemorrhage
ectropion polyp carcinoma
55
what are the vaginal causes of APH
trauma
56
how many APH's have an unexplained cause
1/3rd
57
what is a post partum haemorrhage
blood loss = to or exceeding 500ml after the birth of the baby - primary within 24hrs of delivery - secondary >24hrs- 6 weeks post delivery
58
what are the classifications of PPH
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
what should you always remember when quantifying PPH
visual blood loss may be underestimated total blood volume depends on maternal body weight: 100mls/kg volume in pregnancy
60
what are the causes of PPH
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
how do you prevent PPH
identify antenatal and intrapartum risk factors | active management of the 3rd stage of labour
62
what are the antenatal risk factors for PPH
``` anaemia previous CS placenta praevia, percreta, accreta previous PPH previous retained placenta multiple pregnancy polyhydramnios obesity fetal macrosomia (caution with JW, advanced directive) ```
63
what are the intrapartum risk factors for PPH
prolonged labour operative vaginal delivery CS retained placenta
64
how is the third stage of labour actively managed
syntocinon/ syntometrine (IM/IV)
65
how do you identify the cause of a PPH
``` Hx exam uterine tone vaginal tears placenta and membranes ```
66
what is the initial management for a PPH
``` 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&E, LFT, Lactate Cross-match 6 units red packed cells May need Major Haemorrhage protocol stop bleeding fluid replacement ```
67
what measures should be taken in a minor PPH (500-1000ml no shock)
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
how do you stop the bleeding in PPH
``` 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
what are the non surgical mechanisms for stopping bleeding in PPH
Packs & Balloons – Rusch Balloon, Bakri Balloon Tissue Sealants Interventional Radiology : Arterial Embolisation
70
what are the surgical mechanisms for stopping bleeding in PPH
``` Undersuturing Brace Sutures – B-Lynch Suture Uterine Artery Ligation Internal Iliac Artery Ligation Hysterectomy ```
71
how is fluid replaced 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
72
what should you consider in secondary PPH
Retained products of conception (RPOC)- exclude with USS | Infection likely to play a role
73
what should you always remember to do in APH
kelinauer anti D steroids
74
what do most women respond to in PPH
uterotonic agents

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