Antepartum Haemorrhage Flashcards

1
Q

Define APH

A

Bleeding from the genital tract after the 20th week of pregnancy.

Note: Occurs in 2-5% of all pregnancies

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2
Q

Differential diagnosis of APH

A

Placental abruption (most common pathological cause in T3)
Placenta praevia
Unclassified bleeding
- Marginal
- Show (most common etiology in T3)
- Cervical lesion (cervicitis, polyp, ectropian, cervical cancer)
- Trauma (uterine rupture)
- Vulvovaginal varicosities
-Other: bleeding from bowel or bladder, abnormal coagulation, placenta accreta
- Genital infections
- Vasa praevia

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3
Q
  1. What is placenta praevia?
  2. What are the grades of placenta praevia?
  3. Define major and minor.
A
  1. Insertion of the placenta partially or wholly in the lower uterine segment.
  2. Grade 1: <2cm from cervical os
    Grade 2: Abutting, but not covering cervical os
    Grade 3: Partially covering cervical os
    Grade 4: Completely covering cervical os

Grade 1-2 is minor, grade 3-4 is major.

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4
Q

Maternal risks of placenta praevia (10)

Fetal risks of placenta praevia (5)

A

haemorrhage/hypovolaemic shock (anaemia, acute renal failure, sheehan’s, APH, PPH) Caesar, hysterectomy, recurrence of risk, placenta accreta

Pre-term birth, intrauterine hypoxia (acute or IUGR) PPROM,congenital, malformations, malpresentation

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5
Q

Clinical presentation of placenta praevia.

A

-Unprovoked, painless vaginal bleeding or after sexual intercourse.
-May be pain (10% have co-existing abruption)
-Malpresentation or failure of engagement of fetal head.
O/E: uterus soft and non-tender, presenting fetal part high or displaced. FHR usually normal, shock (if enough blood is lost)

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6
Q

Diagnosis of placenta praevia.

A

DO NOT PERFORM BIMANUAL UNTIL PLACENTA PRAEVIA IS EXCLUDED. CONTRAINDICATED IN PLACENTA PRAEVIA

-transvaginal U/S –> if the placenta lies between 20mm of overlap and 20m away from the internal os after 20wks transvaginal U/S should be repeated in T3 as placenta is likely to move.

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7
Q

Risk factors for placenta praevia.

A
  • Previous placenta praevia
  • Previous c-section
  • increased maternal age
  • Increased parity
  • Large placentas –> multiple gestation, erythroblastosis (Haemolytic disease of the newborn)
  • Maternal hx of smoking
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8
Q

What is placental abruption?

What is the incidence?

A

Premature separation of a normally situated placenta

0.5-2.0% of pregnancies. Most common pathological cause of APH in T3.

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9
Q

Maternal risks with placental abruption.

Fetal risks with placental abruption.

A

Maternal mortality, hypovolaemic shock, acute renal failure, DIC (in 20% of abruptions), anaemia, Sheehan syndrome, amniotic fluid embolus.

Fetal mortality, pre-term delivery, IUGR (intrauterine hypoxia), fetal anaemia

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10
Q

Clinical presentation of placental abruption

A
  • USUALLY PAINFUL (80%) - pain is sudden onset, constant and localised to lower back and uterus.
  • Vaginal bleeding (bleeding may not be present if abruption is concealed)
  • Uterine tenderness, uterine contractions.
  • Shock out of proportion with apparent blood loss
  • +/- fetal distress, fetal demise (15% present with demise), bloody amniotic fluid.
  • +/- coagulopathy

O/E - abdominal tenderness with “woody hard” uterus.

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11
Q

Diagnosis of placental abruption.

A

Clinical dx

U/S to exclude placenta praevia, but not helpful in diagnosing abruption.

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12
Q

Ix to consider in placental abruption

A
  • fetal monitoring (CTG: late decelerations, loss of variability, fetal bradycardia
  • FBC: check Hb
  • Coagulation studies
  • Kleihauer-Betke test
  • U/S
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13
Q

Management of placental abruption

A
  • ABCD: large bore IV access, fluid, O2
  • Monitor vitals, urine output, blood loss, blood work (Hct, Hb, PTT?PT, platelets, type and cross match, fibrinogen)
  • CTG
  • Blood products if necessary
  • Anti-D if mother is rhesus -ve. (Consider Kleihauer-Betke)
  • Monitor and deliver when possible
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14
Q

History taking for APH

A
  • Blood loss: amount, colour, consistency, and pattern
    of bleeding. (absence of blood clots can indicate clotting abnormalities)
  • Pain Assessment: Note the pattern of pain including the site, time of commencement, frequency, strength and duration.
  • Assess if contractions are present.
    -Note the uterine tone: Increased uterine
    tone (e.g. tense, rigid or ‘woody’) may indicate placental abruption.
    -Note any triggering factors e.g. sexual activity, trauma, exertion.
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15
Q

Risk factors for placental abruption.

A
  • Chronic hypertension
  • Pre-eclampsia
  • Smoking
  • Cocaine use
  • Trauma
  • Uterine malformations
  • chorioamnionitis
  • previous placental abruption
  • oligohydramnios
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