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Year 3 Clinical > Bleeding in Late Pregnancy, Antepartum and Post-Partum Haemorrhage > Flashcards

Bleeding in Late Pregnancy, Antepartum and Post-Partum Haemorrhage Flashcards

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1
Q

Define bleeding in early pregnancy?

A

<24 weeks

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2
Q

Define bleeding in late pregnancy?

A 
Antepartum haemorrhage (APH):
• UK ≥24 weeks
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3
Q

Obstetric haemorrhage as a cause of maternal death?

A

Globally, it is a major cause of death; in the UK, deaths due to it are uncommon, although it is an important cause maternal morbidity

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4
Q

What is the placenta?

A

Entirely foetal tissue; it is the sole source of nutrition for the foetus, from 6 weeks onwards

It is a very vascular organ but it is expelled harmlessly

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5
Q

Functions of the placenta?

A
  1. Gas transfer
  2. Metabolism / waste disposal
  3. Hormone production:
    • Human Placental Lactogen (HPL)
    • Human Growth Hormone-Variant (hGh-V)
  4. Protective filter
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6
Q

Define antepartum haemorrhage (APH)?

A

Bleeding from the genital tract after 24 weeks gestation and before the end of the 2nd stage of labour

Bleeding from or into the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby

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7
Q

Causes of APH?

A

Placenta praevia - never do vaginal examination until this is excluded

Placental apruption

Local causes:
• Cervical ectropion
• Polyps
• Cervical cancer
• Infection, e.g: cervicitis

Vasa previa (rare)

Uterine rupture

Indeterminate / unexplained

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8
Q

Differential diagnosis of APH?

A

Heavy show

Cystitis

Haemorrhoids (common during pregnancy)

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9
Q

How to quantify APH during the history?

A

Spotting, staining, streaking, etc, noted on underwear or sanitary protection

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10
Q

Amounts of APH?

A

Minor haemorrhage - blood loss <50 ml that has settled

Major haemorrhage - blood loss of 50-1000 ml, with no signs of clinical shock

Massive haemorrhage - blood loss >1000 ml and/or signs of clinical shock

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11
Q

What is placental abruption?

A

Separation of a NORMALLY implanted placenta before birth of the foetus; this separation can be either:
• Partial
• Total - IUFD may occur

Usually occurs in the 2nd half of pregnancy

ADD IMAGE

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12
Q

Occurrence of placental abruption?

A

Occurs in 1% of pregnancies but comprises 40% of APH cases

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13
Q

Pathogenesis of placental 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

This causes tonic contraction and interrupts placental circulation, leading to hypoxia

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14
Q

Risk factors for placental abruption?

A

Idiopathic

Pre-eclampsia / hypertension

Trauma:
• Blunt
• Forceful

Domestic violence, RTA

Smoking, cocaine, amphetamines

Medical thrombophilias, renal diseases, DM

Polyhydramnios, multiple pregnancy, preterm PROM (premature rupture of membranes)

Abnormal placenta (AKA the ‘sick’ placenta)

Previous abruption (recurrent rate of 10%)

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15
Q

Symptoms of placental abruption?

A

SUDDEN-onset, CONTINUOUS, severe abdominal pain (can be differentiate from the intermittent pain of labour, which is also accompanied by contractions)

NOTE - if the patient has a posterior placenta, this can present as backache

Bleeding (may be concealed)

Enlarged uterus, disproportionate to the gestational age

Preterm labour

May present with maternal collapse

NOTE - signs may be inconsistent with the amount of revealed blood

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16
Q

Maternal signs of placental abruption?

A

Unwell, distressed patient

Uterus can be normal of large for dates (LFD); it is also tender and feels WOODY HARD, making foetal parts difficult to identify

Patient may be in preterm labour (with heavy show)

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17
Q

Foetal signs of placental abruption?

A

Foetal heart rate - bradycardia OR absent (with IUFD)

CTG is used to assess the foetal heart; if no foetal heart can be found, use USS (fails to detect 3/4 of placental abruption cases)

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18
Q

Mx of placental abruption?

A

Resuscitate mother:
• 2 large IV access (grey and orange cannulas)
• IV fluids administered (caution with PET)

Check FBC, clotting screen, LFTs, U&Es, cross-match blood (4-6 units required)

If the mother is Rh -ve, must perform Kleihauer test

Catheterise the patient and assess hourly urine volumes

Assess and deliver the baby and then manage any complications

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19
Q

What is the Kleihauer test?

A

Measures the amount of fetal hemoglobin transferred from the foetal to maternal bloodstream

It must be performed in all Rh -ve mothers and is used to determine the required dose of anti-D antibodies required to inhibit formation of Rh Abs in the mother, in order to prevent Rh disease in future Rh +ve children

NOTE - with APH, never forget Kleihauer, anti-D and steroids

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20
Q

Options for delivery of the baby with placental abruption?

A

URGENT DELIVERY by C/S

Artificial rupture of membrane (ARM) and induction of labour (IOL)

Expectant Mx (only used for minor placental abruptions; it allows for steroid cover, to stimulate foetal lung maturation)

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21
Q

Maternal complications of placental abruption?

A

Mortality is rare

Hypovolaemic shock

Anaemia

PPH (25%)

Renal failure from renal tubular necrosis

Coagulopathy

Thromboembolism

Infection

Complications of blood transfusion

Prolonged hospital stay and psychological sequelae

Couvelaire uterus - rare, but potentially life-threatening, where placental abruption causes bleeding that penetrates into the uterine myometrium and into the peritoneal cavity

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22
Q

Foetal complications of placental abruption?

A

IUD (foetal death)

Hypoxia

Prematurity

SGA (small for gestation age) and IUGR

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23
Q

Prevention of placental abruption?

A

If patient has anti-phospholipid syndrome, administer LMWH and LDA (low dose aspirin)

Smoking cessation

NOTE - there is no sure method to prevent placental abruption

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24
Q

Define placenta praevia?

A

AKA low-lying placenta

Placenta is partially or totally implanted in the lower uterine segment; often the placenta covers the cervix, preventing a normal birth

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25
What is the lower segment of the uterus?
Anatomically, it is the part of the uterus between the utero-vesical pouch (superiorly) and the internal os (inferiorly); it is thinner and contains less muscle than the upper segment of the uterus Metrically, it is the part of the uterus that is ~7 cm from the level of the internal os Physiologically, it is the part of the uterus that does not contract in labour and instead passively dilates
26
Occurrence of placenta praevia?
Comprises 20% of APH
27
Risk factors for placenta praevia?
PREVIOUS C/S (the more a patient has had, the higher the risk) Previous placenta praevia Asian ethnicity Smoking Previous TOP Multiparity Advanced maternal age (>40 years of age) Multiple pregnancy Assisted conception ``` Deficient endometrium due to the presence or history of: • Uterine scar • Endometritis • Manual removal of the placenta • Curettage • Submucous fibroid ```
28
How is placenta praevia classified?
By USS imaging, according to what is relevant clinically NOTE - placental abruption is a clinical diagnosis
29
Types of placenta praevia?
Major praevia - if the placenta lies over the internal cervical os Minor (partial) praevia - leading edge of the placenta is in the lower uterine segment but not covering the cervical os
30
Symptoms of placenta praevia?
PAINLESS bleeding >24 weeks gestation; it is usually unprovoked but coitus can trigger it Bleeding can be minor spotting or severe NOTE - unlike in placental abruption, the patient's condition is directly proportional to the amount of observed bleeding
31
Signs of placenta praevia?
Uterus is soft and non-tender (it is woody hard in placental abruption) Presenting part is high Malpresentations are common (breech, transverse, oblique) CTG usually normal
32
Caution when examining a patient with vaginal bleeding?
DO NOT perform a vaginal examination (digital) until placenta praevia is excluded However, a speculum examination may be normal
33
Diagnosis of placenta praevia?
TRANSVAGINAL USS for diagnosis Check the patient's anomaly scan (all pregnant women have this) MRI (to exclude placenta accreta)
34
Mx of placenta praevia?
Resuscitation of the mother (ABC): • 2 large bore IV access • IV fluids or transfusion Assessment of the baby ``` Investigations: • FBC, clotting screen • LFTs, U&Es • Kleihauer (if the mother is Rh -ve) and anti-D if required • Cross-match 4-6 units RBC ``` Monitor FH, using a CTG after 28 weeks If the patient is stable, conservative Mx, although they remain as an inpatient for at least 24 hours, until bleeding has ceased; they should avoid penetrative sexual intercourse If the patient is at/near term, plan delivery
35
If delivery is planned for placenta praevia, what must be administered?
If 24-34+6 weeks, administer steroids If 24-32 weeks, magnesium sulphate is given to provide neuroprotection
36
Methods of delivery for a woman with placenta praevia?
If the placetna is <2cm from the cervical os, do C/S If the placenta is >2cm from the os and there is no malpresentation, aim for vaginal delivery
37
What is placenta accreta?
Morbidly adherent placenta, i.e: the placenta is abnormally adherent to the uterine wall; it is a cause of considerable maternal morbidity It there is invasion into the myometrium, this is increta If it penetrates the uterus to bladder, this is percreta It is assoc. with severe bleeding (>3L), PPH and the patient may end up requiring a hysterectomy
38
Occurrence of placenta accreta?
Rare but occurs in 5-10% of placenta praevia
39
Risk factors for placenta accreta?
Increasing risk with multiple C/S Placenta praevia
40
Mx of placenta accreta?
Prophylactic internal iliac artery balloon Caesarian hysterectomy (these patient do not have an LSCS; they have a midline incision) Conservative Mx?
41
Define uterine rupture?
Full-thickness opening of the uterus
42
Occurrence of uterine rupture?
Occurs in 1/500 labours with 1 previous C/S This incidence increases if the patient previously had an IOL
43
Risk factors for uterine rupture?
Previous C/S Uterine surgery, e.g: hysterectomy Multiparity Use of prostaglandins / syntocin Obstructed labour
44
Symptoms of uterine rupture?
Severe abdominal pain and shoulder-tip pain Maternal collapse PV bleeding
45
Signs of uterine rupture?
If intrapartum, there is a loss of uterine contractions Acute abdomen presentation and peritonism PP rises Foetal distress / IUD
46
Mx of uterine rupture?
Maternal resuscitation (ABC): • 2 large bore IV access • IV fluids or transfusion ``` Investigations: • FBC, clotting screen • LFTs, U&Es • Kleihauer (if the mother is Rh-ve) and administer anti-D, if necessary • Cross-match 4-6 units RBC ``` SURGICAL MANAGEMENT
47
What is vasa praevia?
Unprotected foetal vessels transverse the foetal membranes over the internal cervical os Mortality of 60%
48
Presentation of vasa praevia?
Usually occurs with artificial rupture of membranes (ARM) Presents with sudden bleeding and foetal bradycardia (foetal distress) / IUD
49
Risk factors for vasa praevia?
Placental anomalies: • Bilobed placenta - placenta separated into two near equal-sized lobes • Succenturiate lobes - smaller accessory placental lobe that is separate to the main disc of the placenta; there can be >1 In both cases, the foetal vessels run through the membranes joining History of low-lying placenta in the 2nd trimester Multiple pregnancy In-vitro fertilisation (IVF)
50
Ix for vasa praevia?
USS with doppler
51
Other causes of APH?
Cervical causes: • Ectropion • Polyp • Carcinoma Vaginal causes Unexplained (1/3rd of APH cases) - pregnancies complicated by unexplained APH are also at increased risk of adverse maternal and perinatal outcomes
52
Define post-partum haemorrhage (PPH)?
Blood loss ≥500ml after the birth of the baby 2 categories: • Primary PPH - within 24 hours of delivery • Secondary PPH - between >24 hours and 6 weeks post-delivery (infection is likely to play a role here)
53
Classifications of PPH?
Minor PPH - 500-1000 ml without clinical shock Major PPH - >1000ml lost OR signs of CV collapse OR ongoing bleeding NOTE - visual blood loss may be underestimated and the total blood volume depends on the maternal body weight On average, in pregnancy, blood volume is 100 mls/kg
54
Causes of PPH?
``` 4 Ts: • Tone (70% of cases) • Trauma (20% of cases) • Tissue (10%) • Thrombin (<1%) ```
55
Risk factors for PPH?
Anaemia Previous C/S Placenta praevia, percreta, accreta Previous PPH Previous retained placenta Multiple pregnancy Polyhydramnios Obesity Foetal macrosomia
56
Intrapartum risk factors for PPH?
Prolonged labour Operative vaginal delivery C/S Retained placenta
57
Prevention of PPH?
Identification of risk factors ACTIVE MX OF THE 3RD STAGE OF LABOUR: • Syntocinon / syntometrine (IM/IV)
58
Initial Mx of PPH?
Assess Stop the bleeding Fluid replacement
59
Assessment of a patient with PPH?
Vital signs are observed (pulse, RR, BP, CRT, sats) every 15 minutes Give oxygen Determine cause of the bleeding (4 Ts) Blood samples required (FBC, clotting screen, fibrinogen, U&Es, LFTs, lactate) Cross-match 6 units of red packed cells
60
Measures for minor PPH (500-1000 mls) without clinical shock
IV access IV warmed crystalloid infusion FBC, coagulation screen (inc. fibrinogen) and G&S Observations of pulse, RR and BP every 15 minutes
61
Methods of stopping bleeding in PPH?
Uterine massage (bimanual compression) Expel clots 5 units IV syntocinon stat 40 units Syntocinon in 500ml Hartmanns (125 ml/hr) Insertion of Foleys catheter (drain urine) 500 mcg Ergometrine IV (avoid if the patient has cardiac disease / hypertension) Check for and repair any vaginal, perineal or cervical trauma Carboprost / Haemabate 250 mcg every 15 minutes Misoprostol 800 mcg PR Tranexamic acid 0.5-1g IV NOTE - most cases of PPH respond to the utero-tonic agents above
62
If bleeding persists despite efforts to stop it, what should be done?
EUA (examination under anaesthesia) Non-surgical techniques: • Packs & balloons • Tissue sealants • Interventional radiology (arterial embolisation) ``` Surgical techniques: • Under-suturing • Brace sutures • Uterine artery ligation • Internal iliac artery ligation • Hysterectomy ```
63
Fluid replacement for PPH?
2 large bore IV access Rapid fluid resuscitation is with: • Crystalloid Hartmann's • 0.9% saline Early blood transfusion (consider O- if life threatening haemorrhage) If DIC / coagulopathy: • FFP • Cryoprecipitate • Platelets
64
Ix for secondary PPH?
Use USS to exclude retained products of conception (RPOC)
65
Post-delivery Mx of PPH?
Thromboprophylaxis Manage anaemia with Fe (oral/IV)

Year 3 Clinical (100 decks)

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