Bleeding in Late Pregnancy Flashcards by Hannah Farquhar

Define antepartum haemorrhage

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

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What are the key functions of the placenta?

gas transfer
metabolism/waste disposal
hormone production (HPL, hGhV)
protective filter

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What can cause antepartum haemorrhage?

Placental problem - praeiva/abruption 
Uterine problem - rupture 
Local causes - ectropion, polyps, infection, carcinoma 
Vasa praevia
Indeterminate

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State the differential diagnosis of antepartum haemorrhage

Heavy show, cystitis, haemorrhoids

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Describe the classifications of antepartum haemorrhage

Spotting - staining, streaking, wiping
Minor - <50ml settled
Major - 50-100ml no shock
Massive - >1000ml +/- shock

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Define placental abruption

Separation of a normally implanted placenta can occur partially or totally before birth of the foetus

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Describe the pathology behind placental abruption

Vasospasm followed by arteriole rupture into the decidua, blood escapes into the amniotic sac or further under the placenta and into the myometrium
Tonic contraction and interrupts placental circulation causing hypoxia

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What is meant by couvelaire uterus?

Haematoma bruised uterus, that does not contract

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State the risk factors for placental abruption

70% unknown, low risk pregnancies 
Pre-eclampsia 
Trauma 
Smoking/drugs
Medical conditions - renal, thyroid, diabetes, coagulopathy
Polyhydramios 
Abnormal placenta 
PROM 
Previous abruption

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What are the symptoms of placental abruption?

Severe continuous abdominal pain, backache if posterior placenta, bleeding, pre-term labour

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What are the signs of placental abruption?

Very unwell patient, uterus may be large, tender and woody hard

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What is meant by woody hard uterus?

Unable to identify fetal parts

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Describe the fetal signs of placental abruption

Fetal distress - bradycardia/absent heart beat/tachycardia

CTG - irritable uterus, loss of variability, decelerations, tachycardia

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What does a CTG of an irritable uterus show?

1 contraction/minute

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How do you resusciate a mother?

2 large bore IV access, bloods - FBC, clotting, LFT, U and E, crossmatch 4-6 units, Kleihaur
IV fluids, catheterise and urometer

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How is placental abruption managed?

Minor - expectant, allow steroid cover
Mild - induce labour by amniotomy
Major - C-section

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What are the maternal complications of placental abruption?

Hypovolaemic shock 
Anaemia
PPH 
Renal failure due to tubular necrosis 
DIC, coagulopathy 
Infection 
Complications of blood transfusion 
Thromboembolism

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What are the fetal complications of placental abruption?

IUD 
Hypoxia
Preterm (iatrogenic/spontaneous)
Small baby 
Fetal growth restriction

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How can placental abruption be prevented?

Anti-phospholipid Syndrome management 
Drug misuse 
Smoker 
Folic Acid 
Screen for domestic violence

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Define placenta praevia

Placenta lies directly over the internal os

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Define low lying placenta

After 16/40 when the placental edge is less than 20mm from the internal os on ultrasound

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What is special about the lower uterus?

Below the utero-vesical peritoneal pouch superiorly and the internal os inferiorly it contains less muscle fibres and does not contract instead passively dilates
7cm from the internal os

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State the risk factors for placental praevia

Previous c-section 
Previous TOP 
Advanced maternal age >40 
Multiparity/multiple pregnancy 
Assisted conception 
Smoking

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What can make a uterus deficient?

Presence of uterine scar, endometritis, manual removal of placenta, curettage, submucous fibroid

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How is placenta praevia screening for and diagnosed?

Midtrimester fetal anomaly scan includes placenta localisation - rescan at 32 and 36 weeks if persistent Transvaginal scan Assess cervical length <34 weeks if risk of preterm labour

State the symptoms of placenta praevia

Painless bleeding >24 weeks, may be triggered by coitus, can be minor and fetal movements usually present

What are the signs of placental praevia?

Uterus soft non tending with high presenting part commonly malpresenations with normal CTG

What must not be done in placenta praevia?

Digital examination

How is placenta praevia managed?

``` ABCDE Assess baby Resus - admit for at least 24 hours TED stockings No sex Delivery plan and magnesium sulphate ```

If a woman has placenta praevia and is bleeding describe the management

``` Resus Major haemorrhage protocol IV fluids and transfuse Anti-D Monitor fetal heart on CTG Steroids 24-36weeks Magnesium sulphate Deliver if active bleeding ```

Describe delivery options in placenta praevia

C-section; if placenta covers os or <2cm from cervical os Vaginal if placenta >2cm from os and no malpresentation

What do you need to consent for in C section?

General anaesthetic Hysterectomy Cell salvage Vertical incision

Define placenta accreta

Morbidly adherent placenta - abnormally adherent to the uterine wall

What are the risk factors for placenta accreta?

Previous c section, placenta praevia

Name the two grades of placenta accreta

Invading myometrium - increta | Penetrating uterus to bladder - percreta

How is placenta accreta managed?

Prophylactic internal iliac artery balloon Caesarean hysterectomy Blood loss >3l expected Conservative management and methotrexate - deliver baby and abode placenta by cutting upper segment of uterus

What is meant by uterine rupture?

Full thickness opening of uterus including the serosa

What is a rupture called when the serosa is intact?

Dehinscence

State the risk factors for uterine rupture

Previous c-section/uterine surgery, multiparity, use of prostaglandins/syntocinon, obstructed labour

What are the symptoms of uterine rupture?

Severe abdominal pain, shoulder tip pain, maternal collapse, PV bleeding

What are the signs of uterine rupture?

``` Intra-partum loss of contractions Acute abdomen Presenting part rises Peritonism Fetal distress/IUD ```

How is uterine rupture managed?

Resus and surgery

Define vasa praevia

Unprotected fetal vessels transversing the membrane below the presenting part over the internal os - will rupture during labour/amniotomy

How is vasa praevia diagnosed?

Ultrasound TA or TV with doppler | Clinically - sudden dark red bleeding and fetal distress

Name the two types of vasa praevia

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

What are the risk factors for vasa praevia?

Placental anomalies History of low lying placenta in second trimester Multiple pregnancy IVF

How is vasa praevia managed?

Steroids Elective C-section 34-36 weeks if detected APH - emergency c-section

Define post partum haemorrhage

Blood loss >500ml after the birth of the baby

What are the two types of PPH?

Primary - within 24 hours of birth | Secondary - >24 hours to 6 weeks post delivery

What are the two classifications of PPH?

Minor - 500ml-1000ml without shock | Major - >1000ml or signs of CV collapse/on-going bleeding

State the four Ts of PPH

Tone Trauma Tissue Thrombin

What are the antenatal risk of PPH?

Anaemia, C-section, placenta problems, previous PPH, multiple pregnancy, obesity, polyhydramios, fetal macrosomia

What are the intrapartum risk of PPH?

Prolonged labour, operative delivery, C-section, retained placenta

What is given in stage 3 to prevent PPH?

Syntocinon and syntometrine IM/IV

State the three key steps in managing PPH

- Assess - Stop Bleeding - Fluid Replacement

Describe the assess part of PPH management

Vital signs - pulse, BP, cap refill, stats every 15 mins Oxygen high flow 6l/min Determine cause Blood samples - FBC, clotting, fibrinogen, U/E, LFT, lactate, cross match 6 units

How is fluid replacement in PPH carried out?

2 large bore IV access - rapid fluid resuscitation with crystalloid, hartmann's or 0.9% saline Blood transfusion and warming DIC/coagulopathy Cell saver

What is tried first to stop the PPH bleeding?

``` Uterine massage/bimanual compression Expel clots IV stat - 5 units syntocinon Infusion 40 units syntocinon in 500ml Hartmann's Foleys Catheter with hourly volumes ```

If step one fails what is done next?

``` Ergometrine Carboprost/haemabate Misoprostol Tranexamic Acid Examination under anaesthetic ```

Name three non-surgical techniques to stop PPH

Packs and balloons (Bakri or Rusch) Tissue sealants Interventional radiology (arterial embolisation)

Name the surgical techniques to stop PPH

Understuturing, brace sutures, uterine artery ligation, internal iliac artery ligation, hysterectomy

What is required post delivery and PPH?

Thromboprophylaxis, debrief couple, manage anaemia

Bleeding in Late Pregnancy Flashcards

(62 cards)