ANTEPARTUM HAEMORRHAGE Flashcards
What is APH?
- 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
What is the leading cause of perinatal and maternal mortality worldwide?
APH(and PPH)
What are the challenges to managing APH?
- 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
How does APH present?
-concealed bleeding I.e. internal bleeding -spotting -minor haemorrhage: <50ml -major haemorrhage: 50ml-1000ml -massive haemorrhage: >1000ml +/- signs of clinical shock
List early signs of shock and hypovolemja due to APH
- decreased blood to placenta
- decreased or dark urinary output
- pale skin
- headache, fatigue, weakness, thirst, dizziness
List the late signs of shock and hypovolemja that indicate APH ?
- confusion
- tachynea
- Hypotension
- increased pulse
What are the management principles of APH?
- call for help
- CAB
How is circulation assessed and restored during APH ?
- 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
List causes of APH
- 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
Explain the approach to a patient with APH
*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)
What are the maternal investigations of APH?
- 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)
List the fetal investigations of APH
- CTG
- U/S (fetal heart, EFW)
List the indications of delivery
- Fetal death
- Fetal distress or compromise
- maternal hemodynamic instability
What causes placental previa?
- 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
List the risk factors of Placenta previa
- previous placenta previa
- uterine surgery such as C/S, myomectomy
- uterine malformation
- assisted reproductive therapy
- smoking
- AMA
- Multiparous>nulliparious
List the clinical features of placenta previa
-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
Name the complications of placenta previa
- Maternal
- APH, PPH, shock, death
- chronic anemia
- Rh sensitisation
- coagulapathy/ DIC
- morbidly adherent placenta
- Fetal
- HIE
- cerebral palsy
- IU death
How is a placental previa managed after 34 weeks gestation?
- Stabilise mom(IV lines and stop bleeding) and deliver
- persistent bleeding=immediate delivery esp C/S
How is placental previa managed before 34 weeks?
- 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
List the types of abruptio placenta
- concealed: no pv bleeding but ab symptoms and shock
- revealed: pv blood loss
- mixed
List the risk factors of abruptio placenta
- 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
List the signs and symptoms of abruptio placenta
- pv bleeding
- uterine or ab pain
- woody hard uterus
- contractions
- FHR changes in CTG
- Maternal hypovolemic/ haemorrhaging shock
How is abruptio placenta managed?
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
List the maternal complications of abruptio placenta
- 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)
List the fetal complications of abruptio placenta
- HIE
- cerebral palsy
- IU death
- prematurity
- IUGR
What is the difference between placenta previa and abruptio?
- 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
What are the local causes of APH?
- cervitis, Ca, trauma
- vaginal infections
- diag with wet smear discharge and treated with metronidazole
What are the risk factors, diagnosis and management of vasa previa?
Risk factors: placenta previa, multiple preg, vilamentous placenta attachment
Diag: pv bleeding, TV U/S
Management: C/S If fetus alive
WhAt are the risk factors of uterine rupture?
- 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
What are the signs of uterine rupture?
- 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)
How is a ruptured uterus treated?
- immediate rescues
- emergency laparotomy to examine uterus and placenta
- repair uterus or total ab hysterectomy
