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Gaby’s Green Top Guidelines > 2011 63 APH > Flashcards

2011 63 APH Flashcards

1
Q

What is the definition of APH?

A

Bleeding from or into the genital tract
From 24/40

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2
Q

What is the incidence of APH, a) generally, b) in preterm babies?

A

a) 3.5% of pregnancies
b) 20%

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3
Q

What are the most important causes of APH?

A

Placental abruption
Placenta praevia

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4
Q

What proportion of maternal deaths are attributable to haemorrhage a) globally, b) nationally?

A

a) 50%
b) 7%

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5
Q

What are the categorisations of levels of APH?

A

Spotting
Minor: < 50ml
Major: 50-1000ml
Massive: > 1000ml &/or signs of shock

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6
Q

What are the risk factors for placental abruption?

A
  1. Previous abruption
  2. Pre-eclampsia
  3. FGR
  4. Non-vertex presentations
  5. Polyhydramnios
  6. Advanced maternal age
  7. Multiparity
  8. Low BMI
  9. Assisted reproduction
  10. Intrauterine infection
  11. PPROM
  12. Abdominal trauma
  13. Smoking
  14. Drugs esp cocaine, amphetamines
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7
Q

What is the risk of placental abruption with a) 1 previous, b) 2 previous?

A

a) 4%
b) 19-25%

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8
Q

What are the risk factors for placenta praevia?

A
  1. Previous placenta praevia
  2. Previous CS(s)
  3. Previous TOP
  4. Multiparity
  5. Advanced maternal age > 40
  6. Multiple pregnancy
  7. Smoking
  8. Damaged endometrium
  9. Assisted reproduction
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9
Q

What types of endometrial damage can increase the risk of placental abruption praevia?

A
  1. Uterine scar
  2. Endometritis
  3. MROP
  4. Curettage
  5. Submucisal fibroids
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10
Q

What proportion of placental abruptions occur in low-risk pregnancies?

A

70%

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11
Q

What are the maternal complications of APH?

A
  1. Anaemia
  2. Infection
  3. Shock
  4. Renal tubular necrosis
  5. Consumptive coagulopathy
  6. PPH
  7. Prolonged hospital stay
  8. Psychological sequelae
  9. Complications from blood transfusions
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12
Q

What are the fetal complications of APH?

A
  1. Hypoxia
  2. SGA & FGR
  3. Prematurity
  4. Fetal death
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13
Q

How should women presenting to midwives or GP with APH be managed?

A
  1. Assess
  2. Stabilise
  3. Transfer to hospital
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14
Q

What is the incidence of cervical cancer in pregnancy?

A

7.5 in 100,000

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15
Q

What clinical assessment is needed in APH?

A
  1. A-E & act on maternal or fetal compromise
  2. History
  3. Abdominal palpation
  4. Speculum for dilation or lower genital tract cause
  5. VE unless placenta praevia
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16
Q

What blood tests should be carried out in APH?

A
  1. Kleihauer if Rh -ve to quantify FMH
  2. All: FBC & G&S
  3. Major: Cross-match (4 units), coagulation screen, U&E, LFT
17
Q

What fetal investigations are indicated in APH?

A
  1. US for placenta unless praevia excluded
  2. CTG
18
Q

How long should women with APH stay in hospital?

A
  1. Spotting & stopped: home
  2. Heavier & ongoing: stay at least until stopped (local: 24 hours)
19
Q

In APH, in what situations should steroids be offered?

A
  1. 24+0 to 34+6
  2. If at risk of preterm birth eg pain suggestive of uterine activity or abruption
20
Q

In APH, in which circumstances should tocolysis be considered?

A
  1. Extreme preterm
  2. To facilitate transfer
  3. To allow completion of steroid course
  4. Not if maternal or fetal compromise
  5. Avoid nifedipine as can drop BP
21
Q

How should antenatal care be altered following APH?

A
  1. Genital tract cause: no need
  2. Abruption or unexplained: reclassify as high risk, perform serial growth scans
22
Q

How should delivery be timed in APH?

A
  1. Maternal or fetal compromise: EmCS
  2. < 37/40 & settled: don’t change
  3. > 37/40 consider IOL unless blood-stained show
23
Q

Which women with APH need continuous CTG in labour?

A
  1. Active bleeding
  2. Major or recurrent minor in pregnancy
  3. Evidence of placental insufficiency
24
Q

How should the 3rd stage be managed in APH?

A
  1. Active due to risk of PPH
  2. Syntometrine if no HTN
25
Q

How should anti-D be given in APH?

A
  1. Give to all non-sensitised Rh -ve women, regardless of prophylaxis
  2. If recurrent, give at minimum 6-weekly intervals
  3. If > 20/40, give 500 units & test for FMH
  4. If > 4ml RBCs, give more
26
Q

How should patients with APH on anticoagulants be managed?

A
  1. Stop LMWH & warfarin
  2. If ongoing treatment essential, give IV unfractionated heparin
27
Q

What fluids & blood products can be used in APH?

A
  1. Crystalloid: up to 2L Hartmann’s
  2. Colloid: up to 1-2L whilst awaiting blood
  3. Blood: cross-matched, group-specific or O -ve
  4. FFP: 4 units (12-15ml/kg or total 1L)
    * for every 6 units RBCs
    * if PT or APTT > 1.5x mean control
  5. Platelets if <50
  6. Cryoprecipitate if fibrinogen <1
28
Q

What blood levels should be maintained in APH?

A
  1. Hb >80
  2. Platelets > 75
  3. PT & APTT < 1.5 x mean control
  4. Fibrinogen > 1

Gaby’s Green Top Guidelines (51 decks)

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