Antepartum Hemorrhage and Placenta Previa Quiz

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Questions and Answers

What are the types of morbidly adherent placenta associated with placenta previa?

The types are placenta accreta, placenta increta, and placenta percreta.

Describe the typical presentation of bleeding associated with placenta previa.

Bleeding is usually painless and bright red, with 1/3 of cases occurring before 30 weeks, the next 1/3 between 30-36 weeks, and the final 1/3 after 36 weeks.

What is the likelihood of a low-lying placenta resolving by 37 weeks of pregnancy?

90% of low-lying placentas will resolve by 37 weeks.

What routine assessments should be performed for patients with placenta previa diagnosed before 24 weeks?

Patients should have a follow-up ultrasound at 28, 32, and 34 weeks to reassess the position of the placenta. Signup and view all the answers

What are common examinations performed when evaluating a patient with suspected placenta previa?

Examinations typically reveal a soft abdomen and uterus, easy detection of fetal parts, presence of fetal heart sounds, and a high not engaged presenting part. Signup and view all the answers

Define antepartum hemorrhage and mention the timeframe associated with it.

Antepartum hemorrhage is defined as bleeding from the genital tract after the 24th completed week of gestation and before the onset of labor. Signup and view all the answers

List the types of antepartum hemorrhage and how they can be differentiated.

Types of APH include placenta praevia, abruption placenta, and local causes in the vagina and cervix. Differentiation is based on ultrasound and examination of the bleeding source. Signup and view all the answers

What should be performed before conducting a digital examination in a patient with APH?

An ultrasound scan should be conducted to identify the location of the placenta before a digital examination. Signup and view all the answers

Describe the location and characteristics of the placenta in placenta praevia.

In placenta praevia, the placenta is implanted wholly or partially on the lower segment of the uterus, which does not contract during labor. Signup and view all the answers

Identify the risk factors for developing placenta praevia.

Risk factors for placenta praevia include multiparity, previous cesarean sections, advanced maternal age, and IVF pregnancies. Signup and view all the answers

What is the classification of placenta praevia and describe Grade II?

Grade II placenta praevia is when the placenta reaches the internal os but does not cover it. Signup and view all the answers

How does hypo-volaemic shock present in obstetric patients?

Hypo-volaemic shock in obstetric patients presents with signs such as hypotension, tachycardia, and decreased urine output. Signup and view all the answers

What is the significance of vasa previa and its incidence?

Vasa previa is a condition where fetal blood vessels cross or run near the internal cervical os; its incidence is about 1%. Signup and view all the answers

What initial steps should be taken if a patient presents with bleeding due to placenta previa?

Insert a broad-bore IV cannula and start an infusion with crystalloid solution. Signup and view all the answers

How should the hemodynamic state of a mother with abruptio placenta be assessed?

By evaluating vital signs and stabilizing the mother as necessary. Signup and view all the answers

What is the goal hematocrit level for a patient with severe anemia or continuous uterine bleeding?

The goal hematocrit is at least 30%. Signup and view all the answers

What are the indications for delivery in cases of bleeding due to placenta previa?

Non-reassuring fetal heart rate, life-threatening maternal hemorrhage, or gestational age ≥ 34 weeks with fetal lung maturity. Signup and view all the answers

What should be monitored continuously between 24 and 36 weeks in patients with bleeding?

Continuous fetal heart monitoring is required. Signup and view all the answers

What measures are included in conservative expectant management for a patient with bleeding?

Hospitalization, hydration, blood transfusion, and bed rest. Signup and view all the answers

What actions should a patient be instructed to take after steroid administration if there are no uterine contractions or bleeding?

Consider home therapy and return to the hospital if contractions or bleeding occur. Signup and view all the answers

How often should fetal growth, amniotic fluid index, and placental localization be assessed by ultrasound in stable patients?

Every 2 weeks. Signup and view all the answers

What is the recommended procedure for patients with grades three and four placenta previa between 37 and 38 weeks’ gestation?

A cesarean section (C/S) should be performed. Signup and view all the answers

In cases of placenta accrete, what proportion of patients typically require a cesarean hysterectomy?

Two-thirds (2/3) of patients require a cesarean hysterectomy. Signup and view all the answers

What should be done if a presenting part is located below the lower edge of the placenta in cases of grade 1 or grade 2 anterior previa?

A trial of labor may be given for vaginal delivery. Signup and view all the answers

What is a major cause of maternal death associated with placenta previa?

Postpartum hemorrhage (PPH) is a major cause of maternal death. Signup and view all the answers

Define abruptio placenta and its significance.

Abruptio placenta is the premature separation of the normally situated placenta after 24 weeks of gestation, which can be life-threatening. Signup and view all the answers

What factors are associated with an increased risk of abruptio placenta?

Hypertension, multiparity, folate deficiency, and trauma are associated risk factors. Signup and view all the answers

What type of hemorrhage can be observed with abruptio placenta?

Both concealed and revealed hemorrhage can occur with abruptio placenta. Signup and view all the answers

What is the risk associated with epidural analgesia in patients with coagulopathy?

Epidural analgesia is contraindicated due to the risk of coagulopathy. Signup and view all the answers

What should be done if there are small areas of premature separation in the placenta?

They should be monitored as several small abruptions may precede a larger one. Signup and view all the answers

What steps should be taken if a coagulopathy develops in a patient?

Administer four units of fresh frozen plasma and prepare six units of platelets. Signup and view all the answers

What factors may help reduce the risk of Abruptio Placenta?

Counseling against smoking and cocaine abuse, and controlling maternal blood pressure with antihypertensive drugs. Signup and view all the answers

List four differences between placenta praevia and placental abruption.

<ol> <li>Presentation: painless vs. painful; 2) Blood pressure association: not increased vs. increased; 3) Tenderness: soft abdomen vs. tender abdomen; 4) Coagulopathy: late vs. early.</li> </ol> Signup and view all the answers

What symptoms may indicate cervical conditions other than normal pregnancy bleeding?

Irregular bleeding and discharge, which can be seen in cervicitis, cervical polyps, cervical erosion, or cervical ectropion. Signup and view all the answers

What is the recommended treatment for cervical cancer detected before 24 weeks of pregnancy?

Perform a hysterectomy and immediate Wertheim hysterectomy followed by radiation according to the stage. Signup and view all the answers

What can cause scanty bleeding at the time of membranes rupture?

Rupture of vasa praevia due to velamentous insertion of cord vessels crossing the cervical os. Signup and view all the answers

Name two rare conditions that can lead to bleeding during pregnancy.

Idiopathic thrombocytopenia and von Willebrand's disease. Signup and view all the answers

Study Notes

Antepartum Hemorrhage (APH)

Defined as vaginal bleeding after 24 weeks of gestation and before labor onset.
Occurs in 2-5% of pregnancies.
Causes:
- Placenta Previa: Placenta implanted in the lower uterine segment.
  - Accounts for 1/3 of APH cases.
  - Can lead to morbidly adherent placenta (accreta, increta, percreta).
- Abruptio Placenta: Premature separation of the placenta from the uterine wall.
  - Accounts for 1/3 of APH cases.
  - Can be concealed or revealed.
- Local Causes in the Vagina and Cervix:
  - Cervical erosion, polyp, genital tract infection.
  - Account for 1/3 of APH cases.
- Other Causes: Vasa praevia, blood dyscrasias, and undetermined causes.

Placenta Previa

Occurs when the placenta is implanted in the lower uterine segment, which stretches during labor.
Risk factors:
- Multiparity (especially grand multiparity), multiple pregnancy, increasing maternal age, prior C-section or uterine surgery, IVF, smoking, history of D&C, and excessive cervical dilation.
Classified into four grades based on the extent of placenta covering the cervical internal os.
- Grade I (Marginal): Placenta reaches the lower segment but not the internal os.
- Grade II (Lateral): Placenta reaches the internal os but does not cover it.
- Grade III (Accenteric/Partial): Placenta covers the internal os before dilation but not after.
- Grade IV (Central/Complete): Placenta completely covers the internal os.
Associated with: abnormal fetal lie and presentation, premature rupture of membranes, intrauterine growth restriction, and increased risk of operative delivery.
Diagnosis:
- Ultrasound (US) is the primary diagnostic tool.
- MRI may be considered in complex cases.
- Previously, X-ray was used to assess presentation and distance between fetal presenting part and maternal pelvis.
- Angiography can be helpful in certain situations.
Management:
- Initial management (same as for abruptio placenta):
  - Stabilize the mother’s hemodynamic status (IV fluids, blood transfusion).
  - Assess gestational age and monitor fetal heart rate continuously.
- Subsequent management depends on: gestational age, maternal and fetal stability, and amount of bleeding.
- Delivery is indicated if: non-reassuring fetal heart rate despite resuscitation, life-threatening maternal hemorrhage, or gestational age ≥ 34 weeks with known fetal lung maturity.
- Between 24 and 36 weeks: expectant management can be attempted if maternal and fetal stability is assured.
  - Hospitalization until bleeding stops.
  - Hydration, blood transfusions, and continuous fetal monitoring.
  - Bed rest, restricted activity, stool softeners, iron supplementation, and steroid to promote fetal lung maturity if gestational age ≤ 34 weeks.
- After steroid treatment:
  - Home therapy may be considered if no uterine activity or bleeding.
  - Patient should return to the hospital if experiencing contractions or bleeding.
  - Regular US to assess fetal growth, amniotic fluid index, and placental location.
- At 36-37 weeks:
  - Grades 3 and 4 placenta previa: cesarean section between 37 and 38 weeks.
  - Possible hysterectomy.
  - If presenting part is below the lower edge of the placenta in Grade 1 or 2 anterior, trial of labor could be considered.

Placenta Accreta Spectrum

Placenta adheres abnormally to the uterine wall.
Classified into three types:
- Placenta Accreta: Abnormal adherence with an incompletely developed fibrinoid layer.
- Placenta Increta: Invasion into the myometrium.
- Placenta Percreta: Penetration through the myometrium and potential invasion into nearby viscera.
Major risk factor for postpartum hemorrhage (PPH) due to lack of contraction in the lower uterine segment.
Cesarean hysterectomy is required in 2/3 of cases.
Other surgical options for uterine preservation include:
- Removing the placenta and oversewing the uterine defect.
- Resecting the accreted area and repairing the uterus.
- Leaving the placenta in place (if no active bleeding) and treating with antibiotics and methotrexate postpartum.

Abruptio Placenta

Premature separation of the normally situated placenta after 24 weeks of gestation.
Can occur antepartum or intrapartum.
Risk factors:
- Hypertension, multiparity, folate deficiency, trauma (ECV, seat belt injuries, blunt abdominal trauma).
Presentation:
- May be concealed or revealed.
- Separation of more than 1/3 is life-threatening to both mother and fetus.
Management:
- Stabilize the mother’s hemodynamic status (IV fluids, blood transfusion).
- Assess gestational age and monitor fetal heart rate continuously.
- Manage coagulopathy if developed (fresh frozen plasma, platelets).
- Delivery is usually required.
Prevention:
- No intervention proven to prevent abruptio placenta.
- Counseling against smoking and cocaine abuse, as well as controlling maternal blood pressure, may reduce the risk.

Comparison of Placenta Previa and Abruptio Placenta

Feature	Placenta Previa	Abruptio Placenta
Predisposing Event	No	Yes
Associated with ↑BP	No	Yes
Pain	Painless	Painful
Fetal Distress	Unusual	Common
Abdomen	Soft, non-tender	Tender, tense, woody
Fetal Parts Palpable	Palpable	May not feel fetal parts
Fetal Lie	Abnormal	Usually cephalic
CTG	Normal	Abnormal
Coagulopathy	Late (if at all)	Occurs early

Other Causes of Vaginal Bleeding in Pregnancy

Urinary or anal bleeding may be mistaken for vaginal bleeding.
Causes:
- Cervicitis and Vaginitis: Especially with Candida.
- Cervical Polyp: Scanty bleeding may be seen with speculum examination.
- Cervical Erosion:
- Cervical Ectropion:
- Varicosities of the Vagina:
Cancer of the Cervix:
- Rare but important.
- Irregular bleeding and discharge.
- If before 24 weeks: hysterectomy and immediate Wertheim hysterectomy followed by radiation therapy according to the stage.
- If after 24 weeks: wait until 32 weeks, then caesarean Wertheim hysterectomy followed by radiation therapy according to the stage.

Extremely Rare Causes of Vaginal Bleeding

Idiopathic thrombocytopenia:
Von Willebrand disease:
Leukemia:
Hodgkin's disease:

Vasa Praevia

Occurs when fetal blood vessels (vasa) cross the cervical os due to velamentous insertion of the umbilical cord.
Presents with scanty bleeding at the time of membranes rupture.

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Description

Test your knowledge on Antepartum Hemorrhage (APH) and its complications, focusing on conditions like Placenta Previa. This quiz covers definitions, causes, and risk factors associated with APH, providing insight into its significance in prenatal care.