Bleeding in pregnancy

Question 1

Define what antepartum haemorrhage is

Answer 1

This is bleeding from or into the genital tract occurring from ≥ 24 weeks + 0 until the end of the 2nd stage of labour (i.e. birth of the baby)

Question 2

Bleeding in pregnancy can be split into 2 categories what are they?

Answer 2

1. Bleeding in early pregnancy (<24weeks)
2. And bleeding in late pregnancy (≥24weeks+0)

Question 3

What is the other name given to bleeding in late pregnancy ?

Answer 3

Antepartum haemorrhage

Question 4

Appreciate this:

Death from obsetric haemorrhage is very uncommon in the UK but globally it is very common consisting of up to 50% of maternal deaths each year

Question 5

List the functions of the placenta

Answer 5

• It is the sole source of nutrition for the fetus from 6weeks
• Gas transfer occurs here
• Metabolism/ waste disposal for the fetus
• Hormone production - HPL (human chorionic sommatotropin) & human growth hormone (HGH-V)
• It is protective acting as a filter
• Very vascular but is normal expelled harmlessly

Question 6

List the causes of antepartum haemorrhage

Answer 6

Dangerous ones:

• Placenta praevia
• Placental abruption
• Vasa praevia

Local causes:

• Cervical ectropion
• Polyps
• Cancer
• Infection e.g. cervicitis, STI

Other:

• Uterine rupture
• 40% of the time there is no apparent cause

Question 7

List the other main differentials for APH ?

Answer 7

1. Haemorrhoids = enlarged blood vessels (swellings) found inside/ around rectum & anus that can bleed
2. Cystitis = inflammation of the bladder
3. Heavy show; bloody show = the passage of small amount of blood/ blood-tinged mucus through the vagina near the end of pregnancy, it can occur just before labour or in the early stages of it

Question 8

Quantifying APH, define the following:

1. Spotting
2. Minor haemorrhage
3. Major haemorrhage
4. Massive haemorrhage

Answer 8

1. Spotting = staining, streaking or blood spotting noticed on underwear or sanitary protection
2. Minor haemorrhage = blood loss < 50ml that has settled
3. Major haemorrhage = blood loss of 50-1000ml, with no signs of clinical shock
4. Massive haemorrhage = blood loss > 1000ml &/or signs of clinical shock

Question 9

What are the clinical signs of shock?

Answer 9

• Low BP
• Altered mental state - reduced alterness, confusion, sleepiness
• Cold, moist skin, hands and eet may be blue or pale
• Weak or rapid pulse (or both)
• Rapid breathing (increased RR) & hyperventilation
• Decreased urine output

Question 10

Define what placental abruption is and how common it is

Answer 10

• This is separation of a normally implanted placenta - it may be separated partially or totally before birth of the fetus
• It accounts for 30% of APH

Question 11

How is placental abruption diagnosed ?

Answer 11

Clinically

Question 12

Describe the pathology of placental abruption

Answer 12

1. It occurs due to vasospasm followed by arteriole rupture
2. Blood then escapes into the amniotic sac or further under the placenta & into the myometrium, causing tissue contraction & interruption of placental circulation which causes hypoxia and inturn a Couvelaire uterus

Note couvelaire uterus = a pregnant uterus in which the placenta has detacted prematurely with leakage (extravasation) of blood into the uterus myometrium

Question 13

List the risk factors for placental abruption

Answer 13

• Unknown
• PET/HTN
• Trauma – blunt, forceful, domestic violence
• Smoking/Cocaine/Amphetamine
• Medical Thrombophilias/Renal diseases/Diabetes
• Poly-hydramnios, Multiple pregnancy, Preterm-PROM
• Abnormal placenta – The ‘Sick placenta’
• Previous abruption - recurrence 10%

Question 14

What are the symptoms of placental abruption

Answer 14

• Severe abdo pain which is continuous (unlike labour pain which is intermittent due to contractions)
• Bleeding (may be concealed)
• Backache
• Preterm labour
• May present with maternal collapse

Question 15

What are the signs of placental abruption ?

Answer 15

• Unwell distressed patient
• Uterine tenderness
• Woody hard uterus
• Vaginal bleeding (may be small or large volume as bleeding can be concealed so signs may be inconsistent with observed blood loss i.e. small blood loss but severe signs)
• Fetal parts difficult to identify
• Uterus large for dates (LFD) or normal
• May be in pre-term labour
• FH (fetal heart) bradycardia/absent (IUD)
• CTG shows irritable uterus - 1 contraction/min, FH: loss of variability, deccelerations seen

Question 16

What are the keys steps in management of a women presenting with placental abruption ?

Answer 16

1. Resuscitate the mother
2. Assessment/ diagnosis of the condition
3. Delivery
4. Management of complications

Question 17

What is done to resuscitate a mother with placental aburption ?

Answer 17

• ABCDE assessement
• 2 large bore cannulas
• FBC, clotting screen, LFT’s, Us & Es, Cross-matching, Kleinhauer test
• IV fluids
• Catheterise and monitor

Question 18

What is done to in the assessment of a mother with placental aburption ?

Answer 18

• Assess FH on CTG
• Perform U/S if no FH on CTG to evlaute the FH
• No reliable diagnostic test: U/S will fail to detect 3/4 of abruptions so diagnosis of abruption is primarily clinical

Question 19

What the delivery management of a women with palcental abruption ?

Answer 19

For moderate & severe abruption/APH:

• Women with APH & associated maternal &/or fetal compromise are required to be delivered immediately by C-section or artificial rupture of membranes & induction of labour

Minor aburption/APH:

• Expectant management only used for minor cases (all time for steroid cover)

Question 20

List the potential maternal complications of placental abruption

Answer 20

• Hypovolaemic shock
• Anaemia
• PPH
• Renal failure from renal tubular necrosis
• Coagulopathy (if DIC develops)
• Infection
• Thromboembolism
• Prolonged hosp stay
• Death (rare)

Question 21

List the potential fetal complications of placental abruption

Answer 21

• IUD (14%)
• SGA & IUGR
• Prematurity
• Hypoxia

Question 22

When are steroids given to pregnant women ?

Answer 22

• A single course of steroids is given to women between 24+0 and 34+6 weeks who are at risk fo preterm birth

Question 23

Following APH from aburption or unexplained origin, if the women is still pregnant and has not given birth what should be done ?

Answer 23

• Pregnnancy should be reclassified as high risk and Serial U/S for fetal growth should be performed

Question 24

What investigation should be avoided if placenta praevia is a possibility for the cause of APH?

Answer 24

Vaginal examination as it can cause catastrophic bleeding

Question 25

What is given to help prevent placental abruption ?

Answer 25

* Try to stop women smoking, using cocaine or amphetamines * Women with thrombophilia (anti-phos syndrome) given LMWH + low dose aspirin * Women at risk of abruption not those who have APS given low dose aspirin

Question 26

Define what placenta praevia is

Answer 26

This is where the placenta is partially or totally implanted in the lower uterine segment known as a 'low lying placenta'

Question 27

What percentage of APH does placenta praevia account for ?

Answer 27

20%

Question 28

What are the risk factors for developing placenta praevia ?

Answer 28

* Previous placenta praevia * Asian * Smoking * Previous termination * Multiparity * Advanced maternal age \>40 * Mutplie pregnancies * Assisted conception * Deficient endometrium due to - uterine scar, endometritis, manual removal of placenta, currettage, submucous fibroid

Question 29

State the classification of placenta praevia (I to IV)

Answer 29

* I - placenta reaches lower segment but not the internal os * II - placenta reaches internal os but doesn't cover it * III - placenta covers the internal os before dilation but not when dilated * IV - placenta completely covers the internal os

Question 30

State the classification of placenta praevia into major and minor

Answer 30

* Minor praevia = if the leading edge of the placenta is in the lower uterine segment but not covering the cervical os * Major praevia = if placenta lies over the internal cervical os

Question 31

What are the signs and symptoms of placenta praevia

Answer 31

* **Painless vaginal bleeding occurring \> 24weeks** * **Bleeding usually provoked by coitus** (sexual intercorse) * Bleeding can range from minor e.g. spotting to severe * **Patients condition is directly proportional to amount of observed bleeding** (unlike abruption) * **Uterus is soft & non-tender** * Presenting part is high * Malpresentation e.g. breech, transverse, oblique (if placenta is in an odd position so will the baby be) * CTG usually normal

Question 32

How is placenta praevia diagnosed ?

Answer 32

**Transvaginal U/S** * Note check their anomaly scan at 20 weeks as this often picks it up * Followed up and then confirmed at 32-34 week scan

Question 33

What are the 3 keys steps in the management of a pregnant women bleeding from placenta praevia ?

Answer 33

1. Admit & resuscitate 2. Monitor FH 3. Delivery

Question 34

In a women bleeding from placenta praevia what resucitative measures are required ?

Answer 34

* 2 large bore cannulas * FBC, clotting screen, LFT's, Us & Es, Kleihauer test, X-match 4-6 units of RBC's * May need major haemorrhage protocol * IV fluids or transfusion * Anti-D if Rh -ve (basically same as for placental abruption)

Question 35

In a women bleeding from placenta praevia what FH monitoring is required ?

Answer 35

* CTG * U/S carried out if FH not detected on CTG (same as placental abruption)

Question 36

In a women bleeding from placenta praevia what are the management options for delivery ?

Answer 36

Conservative/expectant management: * Should be an inpatient for at least 24hrs until bleeding has stopped * Monitor FH with CTG after 28 weeks * Steroids course given if between weeks 24 to 34+6 * MgSO4 given if planning delivery between 24-32 weeks * Serial U/S also recommended * On pelvic rest, avoiding sexual intercourse If not stable then may need to do C-section

Question 37

What determines the mode of delivery in women with placenta praevia

Answer 37

* C-section (with consultant present) done if placenta is \< 2cm from the cervical os * Vaginal delivery done if placenta \> 2cm away from cervical os & no malpresentation Major bleeding may require preterm delivery C-section at 37 - 38 weeks if there has been prior bleeding in pregnancy or suspected/confirmed placenta accreta C-section at 38-39 weeks if there has not been bleeding in pregnancy

Question 38

What is the association of increasing the number of C-sections you have had done and placental abnormalities

Answer 38

The risk of placenta praevia & accreta both increase with the number of C-sections you have had done

Question 39

Read over abruption vs praevia: Abruption: * Shock out of keeping with visible blood loss * Pain constant * Tender, tense uterus * Normal lie & presentation of baby * FH - absent/distressed * Coagulation problems associated * Beware of PET, DIC, anuria Praevia: * Shock in proportion to visible blood loss * No pain * Uterus soft & non tender * Lie & presentation of baby may be abnormal * FH usually normal * Coagulation problems rare * Small bleeds before large

Question 40

Define what placenta accreta is

Answer 40

Planceta accreta is the general term for whe the plaenta invades & is inseperable from the uterine wall. There is 3 subtypes: 1. Placenta accreta = placenta attaches to the myometrium 2. Planceta increta = placenta invades into the myometrium 3. Placenta pancreta = placenta invades through the perimetrium (serosa)

Question 41

What are the 2 major risk factors for placenta accreta ?

Answer 41

1. It occurs in 5-10% of placenta praevias 2. Risk of it increases with increasing no. of C-sections

Question 42

When does placenta accerta become a problem?

Answer 42

It becomes a problem during delivery when the placenta does not completely separate from the uterus & is then followed by massive obstetric haemorrhage (\>3L expected)

Question 43

How is placenta accreta diagnosed ?

Answer 43

**1st line = U/S** +/- MRI Antenatal MRI can be used as well to assess depth of invasion etc

Question 44

What is the management of placenta accreta ?

Answer 44

* Prophylactic internal iliac artery balloon occlusion done * Then it is generally recommended a planned cesarean hysterectomy is done after weeks 36-37 if possible * Conservative management should not be done if women is already bleeding

Question 45

Define what uterine rupture is

Answer 45

Defined as a full thickness opening of the uterus

Question 46

What are the risk factors for uterine rupture?

Answer 46

* Previous C-section/uterine surgery * Multiparity & use of syntocin * Obstructed labour * Usually occurs in labour

Question 47

What are the signs and symptoms of uterine rupture ?

Answer 47

* Severe abdo pain * Shoulder-tip pain * Maternal collapse * PV bleeding (vaginal) * Intrapartum loss of contractions * Fetal distress/ IUD * Puritanism - vomiting, pain or abdo tenderness & shock

Question 48

What is the management of uterine rupture ?

Answer 48

Urgent resuscitation & surgical management

Question 49

What is the resuscitation management of uterine rupture ?

Answer 49

* 2 large bore cannulas * FBC, clotting screen, LFT's, Us and Es, Kleihauer test, X-match 4-6 units of RBC's * May need major haemorrhage protocol * IV fluids or transfusions * Anti-D if Rh -ve Same as all other resus management

Question 50

What is the surgical management of uterine rupture ?

Answer 50

Laparotomy (if uterus rupture small repair, if large hysterectomy may be done) & deliver the baby via C-section

Question 51

Define what vasa praevia is

Answer 51

Defined as fetal vessels coursing through the membranes over the internal cervical os, unprotected by placental tissue or umbilical cord

Question 52

What are the risk factors for vasa praevia ?

Answer 52

* Placental anomalies such as bilobed placenta where fetal vessels run through the membranes joining the separate lobes together * Placenta praevia * Multiple pregnancy * IVF

Question 53

How does vasa praevia often present ?

Answer 53

* Presents with fresh vaginal bleeding at the time of membrane rupture + FH abnormalities - deccelerations, bradycardia, sinusoidal tract or fetal demise * Note blood volume may be very small as fetal blood volume 200ml at term ==\> small amounts of blood can have serious consequences

Question 54

What is the fetal mortality rate of vasa praevia ?

Answer 54

60%

Question 55

How is vasa praevia diagnosed ?

Answer 55

It may be diagnosed on antenatal U/S + doppler

Question 56

What is the management of vasa praevia ?

Answer 56

C-section is fetal compromise/ demise present

Question 57

When taking a history about APH what should you ask about ?

Answer 57

* Bleeding - quantify * Pain - SCORATES * Contractions - freq and strength * Fetal movements - change from normal ? * Post-coital - pain or bleeding ? * Smear history * Antenatal scan history - U/S

Question 58

Go over the antenatal admission criteria for APH

Answer 58

Any history of acute bleeding 23 – 32 weeks: * Min stay of 24 hours clear of bleeding Recurrent bleeding after 28 weeks: * Min stay of 72 hours * Consider need to be admitted until delivery Any bleeding after 32 weeks: * Min stay of 72 hours * Consider need to be admitted until delivery Major placenta praevia after 36 weeks with no bleeding: * Consider the social circumstances * Consider other obstetric factors * Consider need for admission until delivery * Consultant decision

Question 59

Should steroids be given to a women who presents with APH ?

Answer 59

Single course is given if presents between 24 to 36+6 weeks (greatest effect between 24 to 34+6 but still given up until 37 weeks essentially)

Question 60

Should antenatal care be adapted for women with APH ?

Answer 60

Yes any from abruption, praevia or unclassified are reclassified as high risk and have consultant led care with serial U/S for fetal growth measurements

Question 61

Go over the principles of labour & delivery

Answer 61

* If fetal death diagnosed then vaginal delivery * If fetal compromise then C-section * Women with APH & associated maternal &/or fetal compromise are to be delivery immediately

Question 62

What is the purpose of steroids prior to delivery in preterm babies ?

Answer 62

* It promotes fetal lung surfactant production * It ↓ neonatal RDSby up to 50% if administered 24-48h before delivery * Betamethasone preferred to Dexamethasone * 1 course = 12mg Betamethasone IM X2 injections 12 hours apart