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HDP- Hypertensive Diseases in Pregnancy > ANTEPARTUM HAEMORRHAGE > Flashcards

ANTEPARTUM HAEMORRHAGE Flashcards

1
Q

What is APH?

A
  • Bleeding (500g or more) from the genital tract between 24 weeks and prior to birth
  • thrice as common in multiparous than nulliparous women
  • 67% of maternal deaths due to APH are preventable
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2
Q

What is the leading cause of perinatal and maternal mortality worldwide?

A

APH(and PPH)

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3
Q

What are the challenges to managing APH?

A
  • APH and PPH are recognised really late
  • Blood loss is underestimated because mom compensates for it due to physiological changes of pregnancy
  • compensation up to 35% (2000ml) of blood lost before showing hypovolemia
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4
Q

How does APH present?

A 
-concealed bleeding I.e. internal 
bleeding
-spotting
-minor haemorrhage: <50ml
-major haemorrhage: 50ml-1000ml
-massive haemorrhage: >1000ml +/- signs of clinical shock
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5
Q

List early signs of shock and hypovolemja due to APH

A
  • decreased blood to placenta
  • decreased or dark urinary output
  • pale skin
  • headache, fatigue, weakness, thirst, dizziness
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6
Q

List the late signs of shock and hypovolemja that indicate APH ?

A
  • confusion
  • tachynea
  • Hypotension
  • increased pulse
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7
Q

What are the management principles of APH?

A
  • call for help

- CAB

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8
Q

How is circulation assessed and restored during APH ?

A
  • Replace volume and stop bleeding
  • IV access by 2 large bore cannula
  • admin IV fluids and blood if available
  • send off blood samples
  • insert urine catheter
  • take note of potential coagulation disorders
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9
Q

List causes of APH

A
  • Early preg: abortion, miscarriage, ectopic pregnancy
  • Local causes: vulva, vagina, GUT, rectum, cervix
  • coagulation disorders
  • unknown
  • 3rd trimester: labour show, abruptio placenta, placenta previa, vasa previa, ruptured uterus
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10
Q

Explain the approach to a patient with APH

A 
*History
(rescusitate,control APH, IV fluid, blood)
-risk factors
-symptoms of shock
-potential cause
  • Examinations
  • Ab(ab and uterus tenderness, contractions and HAB if contractions, fetal heart)
  • Speculum(visualise bleeding, dilation, GUT)
  • Digital/pv ( only done after transvaginal U/S excludes placenta praevia)
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11
Q

What are the maternal investigations of APH?

A
  • FBC
  • U&E
  • LFTs
  • crossmatch for transfusion
  • transvaginal U/S to exclude placental previa
  • coagulation screen
  • Kleihauer bekte test if Rh neg(assess fetal blood in mom)
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12
Q

List the fetal investigations of APH

A
  • CTG

- U/S (fetal heart, EFW)

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13
Q

List the indications of delivery

A
  • Fetal death
  • Fetal distress or compromise
  • maternal hemodynamic instability
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14
Q

What causes placental previa?

A
  • placental factors
  • placentomegaly
  • abnormal formation
  • fetus factors
  • delayed growth and maturity of fetus
  • endometrium factors
  • uterus scarring
  • previous C/S
  • curettage where abnormal tissue in the endometrium lining is removed with curette
  • uterus abnormalities
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15
Q

List the risk factors of Placenta previa

A
  • previous placenta previa
  • uterine surgery such as C/S, myomectomy
  • uterine malformation
  • assisted reproductive therapy
  • smoking
  • AMA
  • Multiparous>nulliparious
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16
Q

List the clinical features of placenta previa

A

-painless, bright red pv bleeding(but no pv exam allowed until U/S rules out placental previa)

  • AB exam
  • non-tender, soft, irritable uterus
  • present or absent contractions
  • distended or high presenting part
  • abnormal/ unstable lie(always changing)
  • Maternal CVS compromise
  • Fetal compromise
17
Q

Name the complications of placenta previa

A
  • Maternal
  • APH, PPH, shock, death
  • chronic anemia
  • Rh sensitisation
  • coagulapathy/ DIC
  • morbidly adherent placenta
  • Fetal
  • HIE
  • cerebral palsy
  • IU death
18
Q

How is a placental previa managed after 34 weeks gestation?

A
  • Stabilise mom(IV lines and stop bleeding) and deliver

- persistent bleeding=immediate delivery esp C/S

19
Q

How is placental previa managed before 34 weeks?

A
  • admit mom
  • stabilise with IV fluids and control bleeding
  • admin steroids for Fetal lung maturity
  • POA for expectant management
  • C/S after 34 weeks or immediately if massive bleeding
20
Q

List the types of abruptio placenta

A
  • concealed: no pv bleeding but ab symptoms and shock
  • revealed: pv blood loss
  • mixed
21
Q

List the risk factors of abruptio placenta

A
  • pt factors: AMA, increased parity
  • cocaine and smoking
  • vascular disease: HT, PET, APLS eg. SLE
  • mechanical factors: trauma, decompression, multiple pregnancy, polyhydramnios
  • uterine factors, myomas, fibroids, PROM
22
Q

List the signs and symptoms of abruptio placenta

A
  • pv bleeding
  • uterine or ab pain
  • woody hard uterus
  • contractions
  • FHR changes in CTG
  • Maternal hypovolemic/ haemorrhaging shock
23
Q

How is abruptio placenta managed?

A

Depends on fetus viability, HR and distress

  • if fetus dead, stabilise mom and do NVD
  • if fetus alive, stabilise and tocolyse mom and do C/S
  • resuscitation( IV fluids, RBC, FFP)
  • monitor BP and urine output using catheter
  • AROM
  • AOL
  • monitor for PPH

*if pt doesn’t have NVD within 6hrs review them depending on maternal condition

24
Q

List the maternal complications of abruptio placenta

A
  • PPH, APH, shock, death
  • amniotic fluid embolism
  • organ dysfunction incl tubular necrosis
  • Rh sensitisation in Rh- mom
  • Sheehan’s syndrome(PPH or low BP during of after birth> hypoxia> damage to pituitary gland)
25
Q

List the fetal complications of abruptio placenta

A
  • HIE
  • cerebral palsy
  • IU death
  • prematurity
  • IUGR
26
Q

What is the difference between placenta previa and abruptio?

A
  • PREVIA : shock uncommon, nontender uterus, fetus normally alive, breech oblique or transverse presentation, rare coagulopathy
  • ABRUPTIO: shock common, uterus tender, fetus usually dead, normal presentation, common coagulatopathy
27
Q

What are the local causes of APH?

A
  • cervitis, Ca, trauma
  • vaginal infections
  • diag with wet smear discharge and treated with metronidazole
28
Q

What are the risk factors, diagnosis and management of vasa previa?

A

Risk factors: placenta previa, multiple preg, vilamentous placenta attachment

Diag: pv bleeding, TV U/S

Management: C/S If fetus alive

29
Q

WhAt are the risk factors of uterine rupture?

A
  • previous C/S
  • scarred uterus: fibroids, hysterectomy, myomectomy
  • unscarred uterus: IOL agents, surgery eg, forceps
  • pain and bleeding more severe for rupture of unscarred uterus than scarred
30
Q

What are the signs of uterine rupture?

A
  • excessive uterine activity
  • overdistended uterine segment
  • oedema in cervical os
  • difficult urination and bloody discharge
  • pathological contractile bandl ring (separates upper and lower uterine segments and indicates obstructed labour)
31
Q

How is a ruptured uterus treated?

A
  • immediate rescues
  • emergency laparotomy to examine uterus and placenta
  • repair uterus or total ab hysterectomy

HDP- Hypertensive Diseases in Pregnancy (4 decks)

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