Haemorrhage

Question 1

What is an antepartum haemorrhage?

Answer 1

Bleeding from the vagina >24/40

Question 2

What condition is an APH associated with?

Answer 2

Cerebral palsy

Question 3

What are the 2 main causes of an APH?

Answer 3

1. Placenta praevia

2. Abruption

Question 4

What are some other causes of an APH?

Answer 4

• Cervicitis
• Cervical polyp
• Cervical cancer
• Vaginal trauma

Question 5

What are the 2 classifications of placenta praevia?

Answer 5

Major = <2cm from or covering cervical os
Minor = >2cm from cervical os

Question 6

What are some possible causes of placenta praevia?

Answer 6

• Previous CS (scarring)
• Multiparity
• Multiple pregnancy
• Placental abnormalities
• Uterine tumours
• Smoking and drugs

Question 7

What are the signs of placenta praevia?

Answer 7

• No pain
• Hard abdomen
• Pv bleeding
• Maternal shock
• Foetal distress
• Malpresentation/ unstable lie

Question 8

What should never be done in a case of placenta praevia/ abruption?

Answer 8

Vaginal examination

Question 9

What is vasa praevia?

Answer 9

• Foetal blood vessels within the membranes cover the cervical os
• Associated with velamentous insertion of the cord

Question 10

What are the signs of placental abruption?

Answer 10

• Pv bleeding
• Abdominal pain
• Irritable/ hypertonic uterus
• Backache
• Foetal distress
• Maternal shock

Question 11

What are the 3 classifications of uterine rupture?

Answer 11

1. Complete - involves whole uterine wall and pelvic peritoneum
2. Incomplete - involves myometrium only
3. Scar Dehiscence

Question 12

What are some possible causes of uterine rupture?

Answer 12

• Previous CS
• Hyperstimulation
• Prolonged labour
• Shoulder dystocia
• Difficult 3rd stage
• Placental abruption

Question 13

What are some signs of uterine rupture?

Answer 13

• Foetal distress/ no FH
• Maternal collapse
• Abdominal pain
• Tachycardia
• Pv bleeding
• Haematuria
• Cessation of contractions
• Shoulder tip pain

Question 14

What are the 3 categories of PPH?

Answer 14

Minor = 500-1000ml
Major = >1000ml
Severe = >2000ml

Question 15

What are the 2 types of PPH?

Answer 15

Primary = within 24 hours of delivery
Secondary = 24 hours - 6 weeks after delivery

Question 16

What is the main clinical sign of a significant haemorrhage?

Answer 16

Tachycardia/ Bradycardia

Hypotension as a late sign

Question 17

What are the 4 possible causes of PPH?

Answer 17

Tone
Tissue
Thrombin
Trauma

Question 18

What is the management for a PPH caused by tone?

Answer 18

• Rub up a contraction
• Medication
• Bi-manual compression

Question 19

What must always be checked during a PPH?

Answer 19

Placenta for completeness

Question 20

What are the usual drugs used for PPH?

Answer 20

• Syntocinon 10iu IM
• Syntometrine 5iu IM
• 40iu Syntocinon in 500ml N. Saline IV

Question 21

What are the 3 additional drugs that can be used for PPH?

Answer 21

• Carboprost 250mcg IM (every 15 mins max 8 doses)
• Tranexamic acid 1g IV
• Misoprostol 1mg PR

Question 22

What is the additional management for a severe PPH?

Answer 22

• Balloon tamponade
• B-lynch suture
• Iliac artery ligation
• Hysterectomy

Question 23

If the uterus inverts, what should be done immediately?

Answer 23

Manually replace the uterus if possible

Question 24

What are the 3 abnormal placental implantations?

Answer 24

• Accreta (adheres to endometrium)
• Increta (invades myometrium)
• Percreta (through myometrium into serosa)

Question 25

What are the 2 treatment options for abnormal placental implantation?

Answer 25

1. Conservative (leave in situ and give abx) | 2. Surgical (manual removal/ hysterectomy)

Question 26

What are 3 examples of conditions affecting thrombin?

Answer 26

- Idiopathic thrombocytopenia - Von Willibrand's disease - Thrombophilia

Question 27

What bloods must be taken for an APH/PPH?

Answer 27

FBC, G+S, Us+Es, LFTs, clotting, X match 4 units

Question 28

What is the basic management for a haemorrhage?

Answer 28

- Oxygen 15L - Lie patient in left lateral (APH)/ flat (PPH) - Keep patient warm - Catheterise - Fluids (2L Hartmann's solution) - Weigh all swabs for EBL

Question 29

What is the process of blood clotting called?

Answer 29

Haemostasis

Question 30

What are the 3 mechanisms of clotting?

Answer 30

1. Vasoconstriction 2. Aggregation of platelets 3. Coagulation

Question 31

What is DIC?

Answer 31

An acquired disorder of haemostasis (in obstetric patients, is ALWAYS secondary to another condition)

Question 32

What are some possible complications of DIC?

Answer 32

- Renal failure - Jaundice - Cyanosis + difficulty breathing - Brain damage - Sheehan's syndrome - Hypovolaemia

Question 33

What is Sheehan's syndrome?

Answer 33

Necrosis of the pituitary gland

Question 34

What are some signs of DIC?

Answer 34

- Low platelet count - Blood not clotting on bed - Woman continues to bleed when rubbing up a contraction - Thin, pale blood

Question 35

Which drug must NOT be given IV and why?

Answer 35

Carboprost - causes tissue damage and sudden drop in BP

Question 36

What is Von Willibrand's disease?

Answer 36

Thromin disorder in pregnancy characterised by deficiency of clotting factor V111

Question 37

What is thrombophilia?

Answer 37

Sticky blood (blood likes to clot)

Question 38

What is the thrombophilia disorder most commonly seen in obstetrics?

Answer 38

Factor V Leiden

Question 39

Why are pregnancy women more at risk of a DVT?

Answer 39

1. Reduced blood flow 2. Hypercoagulability 3. Abnormalities to vessel walls

Question 40

What are the signs of a DVT?

Answer 40

- Pain - Unilateral swelling - Redness - Unusual lumps

Question 41

How is a DVT treated?

Answer 41

- Low molecular weight heparin - Pain relief - Fluids - TEDs

Question 42

What are the symptoms of a PE?

Answer 42

- Chest pain - SOB - Cough with blood

Question 43

What is idiopathic thrombocytopenia?

Answer 43

An immune disorder characterised by an unusually low level of platelets, often resulting in bruising and bleeding

Question 44

What is the management in ANDU for a woman with a pv bleed?

Answer 44

- Ask about pain and movements - Note colour and amount - Take bloods (inc. X match) - SHO speculum

Question 45

What are the signs and symptoms of uterine inversion?

Answer 45

- Lower abdo/ back pain - Haemorrhage - Fundus feels dimpled - Uterine protrusion through cervix/ seen at introitus - Shock