pvbleeding_latepreg

PV bleeding in late pregnancy - abruption, placenta praevia, etc

introduction

  • bleeding in the 2nd or 3rd trimesters of pregnancy requires:
    • resuscitation of the mother
    • assessment of fetal wellbeing
    • correction of coagulopathy if present
    • determination of cause of the bleeding
    • corticosteroids to promote fetal lung maturation should be administered to pregnancies at 23 to 34 weeks of gestation, given the increased risk of need for preterm delivery
  • nearly all patients after 20 weeks gestation require admission for observation
  • some patients need expeditious delivery or cesarian section

Mx in ED

  • 2x large bore iv access
  • bloods for FBE, U&E, cross match, coagulation studies
    • consider bedside clotting test
    • if disseminated intravascular coagulation (DIC) is suspected, activate the hospital’s massive transfusion protocol
  • assess extent of bleeding and resuscitate accordingly with blood transfusions if needed
    • do not perform VE is placenta praevia is a possibility
  • notify obstetrics team +/- anaesthetics ASAP
  • CTG to assess fetal well being
  • keep warm
  • aim for SaO2 > 95%
  • consider need for expeditious delivery (not if placenta praevia) or cesarian section
    • see below for placenta praevia indications for emergent cesarian section
    • if abruption:
      • severe abruption at any gestational age
      • non-severe abruption at gestation > 36wks
    • if possible, delay cesarian section if severe coagulopathy until it can be corrected

placental abruption

  • occurs in ~1% of pregnancies
  • usually painful bleeding with contractions
  • 14% occur before 32wks
  • 40-60% occur before 37wks

risk factors

  • smoking 2.5x risk
  • hypertension 5x risk
  • pre-eclampsia
  • severe trauma 6x risk
  • premature ROM - risk increases from time of ROM
  • chronic placental disease
  • uterine abnormailities
  • PH abruption 10x risk if one abruption, 20x risk if PH of two pregnancies with abruptions
  • cocaine use

placenta praevia

  • occurs in 1 in 250 births
  • bleeding is generally painless although 10-20% also develop contractions
  • 10% reach term without bleeding
  • only significant after 20 weeks gestation as the lower uterine segment has not formed prior to this
  • most resolve prior to delivery due to extension of the lower uterine segment
  • only 12% of low lying placentae on USS at 15-19wks are present at delivery as placenta praevia, compared to ~50% on scans at 24-27wks
  • do NOT perform VE is this is a possibility
  • the distance the placenta extends over the internal cervical os is the best predictor of placenta previa at delivery.
  • those who present < 30wks gestation with bleeding have higher risk of:
    • needing blood transfusions
    • preterm delivery
    • perinatal mortality
  • transabdominal USS gives a 25% false positive rate so careful TV scan should be done to confirm it

risk factors

  • PH placenta praevia
  • PH LUSCS
  • multiple gestation
  • multiparity
  • advanced maternal age

associated conditions

  • premature ROM
  • preterm labour
  • malpresentation
  • IUGR
  • vasa praevia
  • amniotic fluid embolism

Mx of patient with confirmed placenta praevia and bleeding

  • actively bleeding placenta previa is a potential obstetrical emergency
  • resuscitate the mother
    • 2x large bore iv access
    • cross match blood
    • if massive blood loss, check coagulation
  • monitor FHR
  • avoid tocolytics if actively bleeding
  • consider corticosteroids for fetal lung maturation if delivery can be delayed and fetus is premature
  • consider neuroprotective magnesium sulphate if 24-32wks gestation and delivery within 24hrs
  • cesarian section if either:
    • non-reassuring FH trace
    • life threatening refractory bleeding
    • significant bleeding after 34 weeks gestation

vasa praevia

  • rare cause of bleeding
pvbleeding_latepreg.txt · Last modified: 2013/07/31 10:13 by gary1