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what is the definition of antepartum haemorrhage?
bleeding from the genital tract after 24 weeks gestation
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name 3 common causes of APH
- 1. undetermined origin
- 2. placental abruption
- 3. placenta praevia
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name 3 rare causes of APH
- 1. incidental genital tract pathology
- 2. uterine rupture (mainly in CS/scared uterus)
- 3. vasa praevia
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what is placenta praevia?
placenta implanted in the lower segment of the uterus
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why can low lying placentas appear to 'move' upwards as a pregnancy continues?
- due to formation of the lower segment of the uterus in the third trimesters
- myometrium where the placenta implants moves away from the internal cervical os
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what proportion of placenta which are low lying at 20 weeks are praevia at term?
1/10
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what is the classification of placenta praevia?
- marginal: placenta in lower segment, NOT over os
- major: placenta completely or partially COVERING OS
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name 4 risk factors for placenta praevia
- twins
- age
- scarred uterus - previous CS
- women of high parity
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what are the complications of placenta praevia?
- 1. OBSTRUCTION : placenta in the lower segment obstructs engagement of the head
- 2. so need for C-SECTION
- 3. low placenta may cause lie to be TRANSVERSE
- 4. HAEMORRHAGE: severe, continue during and after delivery as lower segment is less able to contract and constrict maternal blood supply (remember lower uterus 90% connective tissue; 10% muscle)
- 5. PLACENTA ACCRETA: prevent placental separation
- 6. PLACENTA PERCRETA: accrete and percreta may provoke MASSIVE HAEMORRHAGE AT DELIVERY
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what is placenta accrete?
placenta implants in a previous c-section scar, may be so deep as to PREVENT PLACENTAL SEPARATION
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what is placenta percreta?
placenta penetrates through uterine wall into surrounding structures eg bladder
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if there is massive haemorrhage due to placenta accrete or percreta, what may need to be done?
hysterectomy
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what is a typical history of placenta praevia?
- intermittent painless bleeds
- which increase in frequency and intensity over weeks
- bleeding can be catastrophic
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what may you find OE of placenta praevia?
- 1. breech presentation
- 2. transverse lie
- 3. fetal head is not engaged, and is high
- 4. vaginal examination can provoke massive bleeding and is never performed in a woman who is bleeding vaginally unless praevia has been excluded
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what are 3 ways that placenta praevia can present?
- 1. finding on USS
- 2. vaginal bleeding
- 3. abnormal lie: breech or transverse
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how is the diagnosis of placenta praevia made?
ultrasound
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which other investigations should be done in placenta praevia?
- to assess maternal and fetal well being
- 1. CTG
- 2. FBC
- 3. clotting study
- 4. cross match
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what is the first step in any patient with placenta praevia and bleeding?
- admission!
- until delivery because of risk of massive haemorrhage
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what is the management before delivery of a pt with placenta praevia
- 1. admit
- 2. blood cross matched and available
- 3. if Rh D-ve, give antiD
- 4. iv access maintained
- 5. give steroids if gestation is < 34 weeks
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if a patient has placenta praevia but is asymptomatic, what is their initial management before delivery?
delay admission until 37 weeks, as long as they can get to hospital easily
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how do you delivery a baby in a lady with placenta praevia?
elective c-section at 39 weeks by the most senior person available
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what are the complications at delivery in placenta praevia?
- blood loss
- PPH as lower segment of uterus does not contract well after delivery and that is where placenta is so bad!
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when in placenta praevia can vaginal delivery be contemplated?
- if the degree of praevia is marginal and fetal head is past the lower edge on ultrasound
- only do VE in theatre with full facilities for immediate C-section
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what is the treatment of placenta accrete?
- compression of the inside of the scar after removal of the placenta with an inflatable balloon
- or hysterectomy
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what is placental abruption?
when part or all of placenta separates before delivery of fetus
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what % of pregnancies does abruption occur?
1%
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when you get part of placenta separating, what happens?
- 1. maternal bleeding behind it
- 2. further separation and acute fetal distress
- 3. blood tracks down between the membranes and myometrium to come our and be revealed as APH
- 4. blood may enter liquor
- 5. blood may simply enter myometrium and there is no visible haemorrhage
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what % of abruption is there no visible haemorrhage?
20%
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name 5 complications of abruption
- 1. fetal death is common
- 2. haemorrhage to need blood transfusion
- 3. DIC
- 4. renal failure
- 5. ultimately maternal death
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what are the risk factors for placental abruption? split into 4 categories
- 1. fetal: IUGR, multiple pregnancy
- 2. maternal current: pre-eclampsia
- 3. maternal past: previous abruption, high parity
- 4. social: smoking, cocaine usage
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what has abruption been associated with?
- trauma
- ECV
- sudden reduction in uterine volume: eg ROM in polyhydramnios
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what is the bleeding in abruption like compared to praevia?
- PAINFUL: due to blood behind placenta and in myometrium
- CONSTANT - with exacerbations
- DARK
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how does the degree of vaginal bleeding reflect the severity of the abruption?
it DOES NOT reflect severity of abruption because some blood may not escape from the uterus
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if you get pain alone but are suspecting abruption, what is that called? and what are signs OE of that?
- concealed
- tachycardia out of proportion to vaginal loss
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if you get vaginal bleeding in abruption, what is that called?
revealed
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name 2 major symptoms of placental abruption
- abdominal pain
- vaginal bleeding
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what are the signs OE of placental abruption?
- tachycardia
- low BP
- tender, woody hard uterus (often contracting)
- fetal distress or absent heart sounds
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how is a diagnosis of abruption made?
- clinical grounds
- Ix help to assess severity and plan resuscitation and delivery
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how is fetal wellbeing established?
CTG
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what are the signs of abruption on CTG
frequent uterine activity
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what 3 tests are done to establish maternal well being in suspected abruption
- FBC
- clotting screen
- cross match
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what role does USS have in suspected abruption?
- rule out praevia.
- otherwise not much help
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what are the classical signs of abruption
- PV bleed - may or may not if concealed
- pain
- uterine tenderness - woody hard
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what is the immediate management of abruption?
- admit
- iv fluids
- steroids if gestation < 34 weeks
- blood transfusion may be needed
- opiate analgesia
- antiD to Rh -ve women
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how do you deliver a baby in suspected abruption? what does it depend on?
- first stabilise mother
- depends on FETAL DISTRESS
- if fetal distress, urgent delivery by c-section needed
- if no fettle distress but gestation is 37+ do IOL with amniotomy
- if the fetes is dead, coagulopathy is likely. blood products are given and labour is induced
- if no fettle distress and PRETERM pregnancy, and degree of abruption is MINOR then give steroids if <34 weeks and monitor closely on antenatal ward. if symptoms settle, discharge but now high risk pregnancy and need fettle growth USS
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what is a major risk to the mother after the baby is born?
post partum haemorrhage
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what is vasa praevia?
when a fettle blood vessel runs in the membranes in front of the presenting part eg head or bum if breech
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when do you get vasa praevia?
- when umbilical cord is attached to the MEMBRANES rather than the placenta
- = velamentous insertion
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when happens when you got ROM in vasa praevia?
massive fettle bleeding
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what is typical presentation of vasa praevia?
- painLESS
- moderate vaginal bleeding at amniotomy or SROM
- fetal distress
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in uterine rupture what kind of bleeding predominates?
- intra-abdominal loss
- rather than PV
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