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Senior Obstetrics and Gynaecology > Antepartum haemorrhage > Flashcards

Antepartum haemorrhage Flashcards

1
Q

What is antepartum haemorrhage?

A

Vaginal bleeding from 24 weeks to delivery of the baby

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2
Q

How can APH be classified?

A

Placental

  • **Placental abruption
  • **Placenta previa
  • **Vasa Previa

VS

Local

  • **Cervical carcinoma
  • **Cervicitis
  • **Cervical ectropion
  • **Vaginal trauma
  • **Vaginal infections
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3
Q

What is the incidence of APH?

A

3%

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4
Q

A pale, tachycardic woman looking anxious with a
painful, firm abdomen, underwear soaked in fresh
blood and reduced fetal movements may be experiencing what?

A

possible placental
abruption and needs emergency
assessment and management

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5
Q

What are the important aspects of the history in a bleeding pregnant woman?

A
  • ** How much bleeding
  • ** Triggering factors like sex, trauma, a fall etc
  • ** Any pain or contractions?
  • **Is the baby moving?
  • **Last pap smear (date, was it normal or abnormal?
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6
Q

What are the important aspects of examination in a bleeding pregnant woman?

A

**Pulse and Blood Pressure
**Is the uterus soft or tender and firm?
**ASSESS FETAL WELL BEING (NST)Foetal heart auscultation /CTG
**ESTABLISH THAT THERE IS NO PLACENTA/VASA PREVIA preferably using a portable ultrasound
machine then do a Speculum vaginal examination, with particular
importance placed on visualizing the cervix and you can also look for vaginitis, or other signs of infection

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7
Q

What are the investigations you would do on a mother presenting with vaginal bleeding at or after 24 weeks?

A

** CBC, WBC differential to check for anemia and infection
**PT, PTT to rule out coagulopathy
**Group and cross match as she may need blood if she has abruption
** Ultrasound (fetal size, presentation,
amniotic fluid, placental position and
morphology) Transabdominal ultrasound more accurate
**if the mother is
Rhesus negative, send a Kleihauer test (to determine
whether any, or how much, fetal blood has leaked
into the maternal circulation) and administer anti-D.
**Maternal and fetal monitoring, vitals etc if admitted

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8
Q

What is placental abruption and how is it classified?

A

Placental abruption is the premature separation of the placenta from the uterine wall

is classified as abruption with: revealed haemorrhage concealed haemorrhage
mixed haemorrhage

total vs partial

blood is from mother or foetus or both

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9
Q

What is placenta previa and what is its classification?

A

A placenta covering or encroaching on the cervical os. It is associated with unprovoked or provoked bleeding and blood is from MATERNAL circulation.

ALso defined as abnormal placentation in the lower uterine segment (within 5 cm of the internal os)

Type 1 - Placenta mostly in upper segment but encroaches on lower segment

Type 2 - Edge of placenta within 2 cm of the margin of the internal os BUT does NOT cover any part of os

Type 3- Placenta partially/asymmetrically covers the internal os

Type 4-Placenta completely, CENTRALLY AND SYMMETRICALLY cover the internal os. If anterior or posterior, and still covers the os, it is not type 4.

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10
Q

What are the risk factors for placenta previa?

A 
• Multiple gestation
• Previous Caesarean section
• Uterine structural anomaly
• Assisted conception
*** Previous history of placenta praevia (4-8% recurrence)
*** Increased maternal age
*** Increased parity (more common in multiparous)
***Maternal smoking!!
***Any prior uterine trauma
a. Previous C-section
b. Previous Dilatation and Curettage
c. Previous induced abortion
d. Previous myomectomy
***Uterine tumour (Eg. Fibroids – distorts the normal uterine anatomy)
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11
Q

Define vasa previa

A

Vasa praevia is present when unprotected fetal vessels traverse the
fetal membranes over the internal cervical os.

it is associated with velamentous insertion of cord into membranes of placenta or succenturiate accessory lobe

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12
Q

What is the presentation of vasa previa?

A

The diagnosis is usually suspected when either
spontaneous or artificial rupture of the membranes
is accompanied by painless fresh vaginal bleeding from rupture of the fetal vessels.

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13
Q

What is the management of vasa previa?

A

Emergent C section

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14
Q

What are the clinical features of placenta previa?

A
  • ** onset at approximately 30-32 weeks
  • **PAINLESS, NONTENDER BRIGHT RED RECURRENT VAGINAL BLEEDING
  • ** spontaneous or post coital
  • **Catastrophic bleed may be preceded by “warning haemorrhages”
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15
Q

Describe examination findings in placenta previa

A

**General: May reflect degree of haemorrhage (anaemia) & hypovolaemia (shock) (pallor, dry MMs, tachycardia etc.)
**Abdominal: Soft, non-tender abdomen/uterus
**Leopold’s maneuvers:
• Abnormal lie – [abnormal location of placenta = abnormal lie of fetus
**High head/presenting part – [placenta itself obstructing access to pelvic inlet
** NOTE WELL: AVOID Vaginal Examination AND DRE!!! ** until praevia ruled out by U/S

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16
Q

Can placenta previa resolve itself?

A

90-95% of praevias diagnosed in T2 resolve by T3!! (This is due to differential growth upper and lower segments of the uterus. In this case, if patient still asymptomatic at 32 weeks, repeat ultrasound)

17
Q

What is the Kleihauer-Betke test and what is its role in antepartum haemorrhage?

A

The K-B test is a test which indicates if there has been mixing of maternal and fetal blood.

it is an acid elution test which uses acid to wash out the adult heamoglobin from a maternal blood sample. the fetal hb will not wash out with acid

the blood film is then stained and the fetal blood cells look bright pink but the maternal blood cells look clear since their heamoglobin is washed out and are called ghost cells.

18
Q

What is the management of a female with placenta previa?

A
  1. Call for help! (if active bleeding)
  2. Initiate resuscitation by A, B, Cs a. O2 (Eg. 100%, 5 L/min via facemask) if necessary (OPA/ other airway if necessary)
    b. 2 Large bore (16/18 G) IV cannulae – give crystalloids
    c. Ucath. – to monitor urine output
  3. Take blood for CBC, PT/PTT, GXM
  4. Request 2 units of cross-matched blood from blood bank
  5. U/S when stable – *** To determine fetal viability, GA, and placental position (Confirm Dx.)
  6. (Don’t forget)Administer Rhogam (If mother Rh –ve AND NOT SENSITIZED) –
    a. Must perform Kleihauer-Betke test to quantify feto-maternal haemorrhage and determine correct dosage

CRITICAL: ADMIT ALL PATIENTS!! WITH SYMPTOMATIC PLACENTA PRAEVIA FOR THE
REMAINDER OF THE PREGNANCY!!!

AFTER THIS GO TO “A” OR “B”:
(34 weeks is used to determine management as this is when fetal lung maturity is reached)

A. If < 34 weeks (AND mild bleed): “EXPECTANT MANAGEMENT” (Know this term)

  • ** GOAL: Prolong pregnancy to 38 WEEKS (i.e. bring to TERM!!) – to benefit fetal wellbeing
    1. Admit to hospital + bed rest
    2. *Limited physical activity, *no sex, nothing per vagina
    3. Have cross-matched blood available
    4. **     OPTIMAL DELIVERY: AT 38 weeks VIA ELECTIVE C-SECTION!!

B. If > 34 weeks (WITH profuse bleeding):
1. URGENT OR EMERGENT C-SECTION!!

19
Q

What are the complications of placenta previa?

A

Foetal

  1. Perinatal mortality low but still higher than with a normal pregnancy
  2. ** Prematurity (bleeding often dictates early C/S)
  3. ** Intrauterine hypoxia (acute or IUGR)
  4. ** Fetal malpresentation
Maternal
1. *< 1% maternal mortality
2. ** Haemorrhage and hypovolemic shock -->
o Anaemia
o Acute renal failure
o Pituitary necrosis (Sheehan syndrome)
3. Placenta accreta - especially if previous uterine surgery, anterior placenta praevia
4. PPROM
5. Hysterectomy
20
Q

What are the risk factors for placental abruption?

A

Most important:

  • **Maternal hypertension
  • **Maternal smoking

Others:
** Previous abruption (recurrence rate = 5-16%)
** Advanced maternal age (Definition: Age ≥ 35 at time of delivery)
** Multiparity
** Sudden decompression + a distended uterus!!!!! (polyhydramnios, multiple gestation) [Eg. At SROM
or AROM]
**PPROM
**Trauma (Eg. MVA)
*** Uterine anomaly (E.g. Fibroids)

21
Q

What is the pathophysiology of placental abruption?

A

Vasospasm of uterine vessels leads to Rupture of arterioles into decidua basalis thenn Blood then dissects under the placenta, extending the separation, and can do any/all of 3 things:

  1. Pass through cervix into vagina
  2. Enter amniotic cavity through the membranes 3. Infiltrate myometrial muscle fibres then uterus contracts and turns bruised + purple (“COUVELAIRE UTERUS”)
22
Q

What are the clinical features of Placental abruption?

A

PAINFUL VAGINAL BLEEDING

bleeding may not be present if concealed

Pain is usually
▪▪ ** SUDDEN! onset
▪▪ ** CONSTANT! & PROGRESSIVE
▪▪ ** IN UTERUS AND LOWER BACK

23
Q

What examination findings will be seen in placental abruption?

A 
General:
1. May reflect degree of haemorrhage (anaemia) & hypovolaemia (shock) (pallor, dry MMs, tachycardia, weak thready pulse, hypotension etc.) • *** IMPORTANT – DON’T FORGET TO MENTION: SHOCK/ANAEMIA THAT IS “OUT OF PROPORTION” to the apparent blood loss in abruption
2. *Also +/- signs of DIC (Eg…) • * NOTE VERY WELL: Abruptio placentae is the most common cause of DIC in pregnancy
Abdominal:
3. Tender abdomen
4. WOODY hard uterus
Leopold’s maneuvers:
1. +/- fetal parts impalpable
2. +/- fetal heart inaudible
24
Q

What investigations should be done in placental abruption?

A
  1. ** NOTE!!!: Diagnosis is MAINLY CLINICAL. ** Ultrasound NOT sensitive for abruption (ONLY 15% sensitive):
    • But if ultrasound is done, looking for retroplacental clots!!
    • Ultrasound also to rule out praevia, and can proceed to..
  2. ..speculum to rule out other causes. ONLY AFTER placenta praevia excluded
  3. Blood investigations: See below
  4. And as usual, remember: Maternal and fetal monitoring (CTG)
25
Q

What is the management for placental abruption?

A

Resuscitation (To stabilize then monitor) – [similar to praevia but DIC considerations added]
1. Call for help (if active bleeding)
2. Initiate resuscitation by A, B, Cs
Wayne Robinson, MBBS Class of 2015
• O2 (via facemask?) if necessary (OPA/other airway if necessary)
• 2 Large bore IV cannulae – give crystalloids
• Ucath. – to monitor urine output
3. Take blood for CBC, PT/PTT, GXM and Fibrinogen + FDP!! (remember risk of DIC)
4. Request 2 units of cross-matched blood from blood bank
• + AND Blood products!!! (PRBCS, plts, cryoprecipitate, FFP) (remember DIC risk)
5. Fetal monitoring with CTG
6. Administer Rhogam (If mother Rh –ve AND NOT SENSITIZED) –
• Must perform Kleihauer-Betke test to quantify feto-maternal haemorrhage and determine correct dosage
AFTER THIS:
IF VERY MILD
1. Admit to hospital
2. Have cross-matched blood and other blood products available
3. OPTIMAL DELIVERY: AT 38 weeks VIA INDUCED VAGINAL
a. Amniotomy – (Must precede syntocinon infusion to prevent amniotic fluid embolism)
b. Then syntocinon infusion
Moderate OR severe cases:
1. Correct coagulation defect & blood loss (i.e. TRANSFUSION where necessary)
2. Have cross-matched blood and other blood products available
3. ** IOL with amniotomy then syntocinon IF vaginal delivery not contraindicated (AND no evidence of maternal/fetal distress) 4. ** BUT!! IF FETAL DISTRESS!! do C-SECTION!!!
*** VERY IMPORTANT: Most critical time for patient is third stage of labour. HIGH SYNTOCINON INFUSION continued postpartum!!!! to reduce PPH esp. due to Couvelaire’s uterus.

26
Q

What are the complications of placental abruption?

A

***Maternal complications:
1. < 1% maternal mortality
2. DIC (in 20% of abruptions)
From the bleeding:
3. Acute renal failure
4. Anaemia
5. Haemorrhagic shock
6. Pituitary necrosis (Sheehan syndrome)
7. Amniotic fluid embolus

  • **Fetal complications:
    1. Perinatal mortality 25-60%
    2. Prematurity
    3. Hypoxia
27
Q

What are the clinical features of VASA PREVIA?

A

***PAINLESS VAGINAL BLEEDING

***FETAL DISTRESS (tachy to brady arrhythmia)

50% perinatal mortality, increasing 75% if membranes rupture (most infants die of exsanguination)

28
Q

What are the investigations necessary for vasa previa?

A

IMMEDIATELY do an Apt test (NaOH mixed with blood) to determine if the surce of bleeding is fetal (supernatant will turn pink) or maternal (supernatant will turn yellow)

Wright stain on blood smear and look for nucleated red blood cells (in cord, not maternal blood)

Senior Obstetrics and Gynaecology (11 decks)

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