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Flashcards in Bleeding in pregnancy Deck (47)
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What is the definition of antepartum haemorrhage?

bleeding from the genital tract after 20 weeks gestation and before the onset of labour


What is the incidence of antepartum haemorrhage?

affects 2-5% of pregnancy


What are 5 main impacts/risks with antenatal haemorrhage?

- maternal stress
- severe bleeding
- disseminated intravascular coagulation
- fetal neurological damage due to hypoxia
- FDIU/stillbirth/neonatal death


What are the 4 main causes of bleeding in late pregnancy?

- unclassified (47%)
- vasa praevia (0.5%)
- placenta praevia (31%)
- placental abruption (22%)


What are 8 key causes of unclassified or incidental bleeding in pregnancy?

- heavy show/onset of labour
- cervical ectropion
- cervicitis (infection)
- vulvovaginal varicosities
- polyps
- trauma
- haemoturia
- carcinoma


What is Vasa Praevia?

- where blood vessels in the placenta or umbilical cord are trapped betweent the fetus and the cervix
- rare - 0.5% of APH


What is Placenta Praevia?

- where the placenta is partially or wholly implanted in the lower uterine segment
- placenta may begin to separate causing mild to severe usually painless bleeding
- 31% of APH


What is the incidence of placenta praevia?

0.3-0.6% of all pregnancies


What are the 4 main risk factors for placenta praevia?

risk increases with:
- parity
- age
- smoking
- previous C/S


What is the recurrence rate for placenta praevia?



What are 10 complications that may be associated with placenta praevia?

- severe blood loss and maternal shock
- anaesthetic and surgical complications
- invasive placenta
- septicemia (infection more likely closer to os)
- thrombosis
- PPH (no oblique muscle fibres in lower segment, decreased action of living ligatures)
- hysterectomy
- renal failure
- maternal death
- fetal hypoxia


What are the four grades of placenta previa?

1 Edge of placenta in lower segment
2 Entire placenta in lower segment
3 Placenta reaches cervical os
4 Placenta covers cervical os


What signs and symptoms may indicate bleeding is due to placenta praevia?

- bright red fresh PV bleeding
- uterus not tender or tense, painless as low placental location allows loss to escape, no retroplacental clot
- potentially unstable fetal lie and high head
- reduced fetal movements due to hypoxia


How is placenta praevia diagnosed?

- confirmed and graded by ultrasound


What is conservative management for placenta praevia?

- appropriate for slight bleeding with well mother/baby
- admission
- strict bed rest
- serial CTG and US
- preparation for birth


What is active management of severe haemorrhage caused by placenta praevia and placental abruption?

- immediate preparation for emergency C/S - support, communication
- IV access 16G cannula
- FBE, group & hold, clotting
- IV infusion/blood transfusion to stabilise
- fetal monitoring


What is placental abruption?

premature separation of a normally located placenta >20 weeks gestation


what is the incidence of placental abruption?

0.5-2% of pregnancies


List 8 risk factors for placental abruption?

- severe preeclampsia
- sudden reduction in uterine size (amnio reduction)
- direct trauma (car accident, violence)
- high parity
- previous C/S
- previous abruption
- smoking
- cocaine use


What is revealed haemorrhage?

- where placenta partially separates around the margin causing bleeding from placental bed which separates membranes from the uterine wall and drains PV
- results in DARK, non clotting PV loss


What is concealed haemorrhage?

- where placenta separates but is unable to escape, so is retained behind placenta and forced into surrounding myometrium
- no PV loss
- signs and symptoms of hypovolaemic shock
- uterine enlargement
- extreme pain


What 8 complications may be associated with placental abruption?

- disseminated intravascular coagulopathy (DIC)
- post partum haemorrhage
- renal failure (hypovolaemia)
- pituitary necrosis (hypotension)
- postnatal anaemia
- 10 times risk in subsequent pregnancies
- perinatal mortality (significant cause of T3 stillbirths)
- maternal mortality & morbidity


Why are signs of shock not always associated with bleeding in pregnancy?

- increased blood volume so signs may not present until 25-30% blood loss
- after fetal circulation has been affected


What assessments are vital where a woman presents with bleeding in pregnancy?

- history (maternal history, gestation, associated with any other event?)
- bleeding (amount, intermittent/continuous)
- ? previous US for placental position
- maternal wellbeing (vital signs, signs of shock)
- fetal wellbeing (fetal movements, ? CTG depending on gestation)
- GENTLE palpation of abdomen (soft/hard, painful, uterine activity, ? lie, presentation, engagement)
- ? medical staff perform speculum (vaginal examination contraindicated)


What management is likely to be necessary if APH but mother and baby are both NOT compromised at 20-24/40, 24-36/40, >36/40?

- unlikely to be placenta praevia
- admission
- bed rest
- monitoring (USS + CTG)
- paed consultation
- ? abruption/placenta praevia
- ? corticosteroids
- Anti-D if Rh -ve
- paed consultation
- ? abruption/placenta praevia
- admission
- bed rest
- monitoring (maternal and fetal)
- ? C/S


What management is likely to be necessary if APH with maternal or fetal compromise?

- management depends on condition of mother/baby, degree of haemorrhage, gestation
- ? non-reassuring CTG
- ? signs of maternal compromise

- Call for help (medical staff, senior midwives, anaesthetist, paed, other midwives, hospital coordinater, CODE)
- Analgesia to counteract shock (100-150mg Pethidine or 15mg Morphine)
- IV access (X2 16G cannula)
- collect blood (FBR, group & hold, coagulation profile, Kleihauer test for fetomaternal haemorrhage)
- IV fluids (volume expanders/plasma expanders/blood transfusion)
- oxygen
- catheter (measure output, protein?, manage fluid balance)
- corticosteroids if


When managing APH where there is maternal or fetal compromise what other issues are vital to consider?

- partner/family
- communication
- psychological care
- prognosis for baby
- transition to parenthood
- impact on future pregnancies


What is disseminated intravascular coagulation (DIC)?

- pathological process where clotting pathways are activated and cause widespread formation of small clots
- uses up available platelets and clotting factors leading to bleeding


What are the 3 main steps in coagulation?

- prothrombin activator is formed
- converts prothrombin to thrombin
- thrombin causes fibrinogen to form a fibrin mesh which traps blood cells and forms a clot


Pregnancy is said to be a hypercoagulable state, what does this mean?

- levels of clotting factors (factor VII, X and fibrinogen) increase in first trimester
- platelets tend to drop in late pregnancy but after birth platelet aggregation increases and thrombin generation increases to prevent excessive bleeding.