Antepartum Haemorrhage Flashcards
Definition of antepartum haemorrhage?
Bleeding during pregnancy from genital tract > 20 weeks gestation
What proportion of pregnancies are affected by APH?
2-5%
What are the 4 main causes of APH?
Placenta praevia
Placental abruption
Vasa praevia
Unclassified
What is the definition of placenta praevia?
Placenta inserted in lower uterine segment
Name 5 risk factors of placenta praevia
Age PMx of placenta praevia Smoking Parity Previous C/S
By how much does 1, 2 and 4 C/S increase your risk of placenta praevia?
1 - 0.65%
2 - 2.2%
4 - 10%
What is the usual presentation of placenta praevia? At what gestational age do they usually present?
Unprovoked, acute, painless vaginal bleeding
Usually presents around 32-34 weeks, 50% under 36 weeks
What test is necessary to diagnose placenta praevia?
U/S (transabdo or transvaginal)
What are the 4 grades of placenta praevia? What is a resolved praevia? Which grades of praevia are capable of resolving? Which grades are classified as minor and major praevia?
Grade 1 (low-lying) - edge of placenta within 2.5-3cm of internal cervical os Grade 2 (marginal) - edge within 2cm of internal os Grade 3 (partial) - covers a portion of internal os Grade 4 (complete) - covers entire internal os
Resolved = praevia that has migrated away from internal os. Grade 1-3 capable of resolving
Minor praevia = Grade 1 and 2
Major praevia = Grade 3 and 4
Name 5 complications/risks of placenta praevia to the mother
Death - 20% of maternal deaths in developing world
PPH
Anaesthetic and surgical complications (increased C/S rate)
Post-partum sepsis
Placenta accreta more likely in next pregnancy
10% recurrence risk in next pregnancy
Name 5 complications/risks of placenta praevia to the foetus
Prematurity Small for gestational age FDIU Malpresentation Umbilical cord accidents Congenital malformation
What is the definition of placental abruption?
Premature separation of a normally located placenta from uterine wall, before delivery of foetus
Name 5 risk factors for placental abruption
HTN Blunt trauma PHx Age Multiparity Smoking Cocaine
Name 5 risks/complications of placental abruption to mother
Hypovolaemic shock Acute renal failure DIC PPH Death Feto-maternal haemorrhage
Name 5 risks/complications of placental abruption to foetus
Small for gestational age Congenital malformation Anaemia Coagulation abnormalities Death
What is the usual presentation of placental abruption? How is it diagnosed?
Sudden onset abdominal/back pain + PV bleeding. Clinical diagnosis based on signs and symptoms (pain + bleeding + uterine contractions)
What is a concealed placental abruption? How common is it?
Bleeding only occurs behind placenta = pelvic pain but no PV bleeding. Occurs in 20% of abruptions
Name differences of presentation and clinical findings between placental praevia and placental abruption
Praevia - painless, soft abdomen on examination, foetus should be normal
Abruption - painful (abdo/back pain), uterine tenderness and rigid ‘board-like’ abdo on examination, foetal parts may be hard to palpate and non-reassuring CTG
What examination should you not perform on someone with undiagnosed APH and why?
Vaginal examination - might cause more bleeding if they have a placenta praevia
Go through standard immediate management of anyone with APH
Want to stabilise maternal condition:
- 16G IV access and fluid replacement
- Take blood for FBC, group and hold +/- crossmatch, coagulation screen and Kleihauer test (for possible feto-maternal haemorrhage)
- Give Anti-D if Rhesus-negative
- Insert urinary catheter (for fluid monitoring)
What are the two principles of management for placenta praevia? What are the indications to use one over the other and why?
Expectant management - indicated if bleeding is controlled and mother and foetus are stable. Aim is to wait until foetus is term before delivery at 37-38 weeks. Admit to hospital and monitor until asymptomatic. Consider tocolytics, corticosteroids, mag sulf if preterm. Avoid sexual intercourse. Follow up U/S at 32-34 weeks. Admit to hospital at 34 weeks if a major (partial or complete) placenta praevia.
Immediate delivery (via C/S) - indicated if bleeding uncontrolled, or maternal or fetal condition is compromised.
What are the two principles of management for placenta abruption? What are the indications to use one over the other and why?
Expectant management - indicated if bleeding is controlled and mother and foetus are stable. Observe via continuous CTG and serial haematocrit until 38 weeks, then deliver with induction of labour
Immediate delivery - indicated if bleeding uncontrolled, or maternal or fetal condition is compromised. If foetus already dead, aim for vaginal delivery. If foetus alive and mother deteriorating, perform emergency LUSCS (unless patient already fully dilated)
What is a vasa praevia? Who is more at risk from a vasa praevia - the mother or fetus? How is the diagnosis made antenatally? What two medical procedures can cause fetal death from vasa praevia? What is the management of it (briefly)?
Foetal vessels that traverse within the membranes over internal cervical os. Fetus at risk, not mother - fetal blood flow can be compromised. Can diagnose w U/S. Amniocentesis or AROM = fetal death
Management - elective C/S at 36 weeks
Name 5 Ddx of APH that are lumped under the ‘unclassified bleeding’ category
Marginal sinus rupture Show Trauma Infection Cervical polyp Cervical Ca Unexplained
