Antepartum Haemorrhage Flashcards
Define APH
Bleeding from the genital tract after the 20th week of pregnancy.
Note: Occurs in 2-5% of all pregnancies
Differential diagnosis of APH
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
- What is placenta praevia?
- What are the grades of placenta praevia?
- Define major and minor.
- Insertion of the placenta partially or wholly in the lower uterine segment.
- 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.
Maternal risks of placenta praevia (10)
Fetal risks of placenta praevia (5)
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
Clinical presentation of placenta praevia.
-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)
Diagnosis of placenta praevia.
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.
Risk factors for placenta praevia.
- 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
What is placental abruption?
What is the incidence?
Premature separation of a normally situated placenta
0.5-2.0% of pregnancies. Most common pathological cause of APH in T3.
Maternal risks with placental abruption.
Fetal risks with placental abruption.
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
Clinical presentation of placental abruption
- 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.
Diagnosis of placental abruption.
Clinical dx
U/S to exclude placenta praevia, but not helpful in diagnosing abruption.
Ix to consider in placental abruption
- fetal monitoring (CTG: late decelerations, loss of variability, fetal bradycardia
- FBC: check Hb
- Coagulation studies
- Kleihauer-Betke test
- U/S
Management of placental abruption
- 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
History taking for APH
- 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.
Risk factors for placental abruption.
- Chronic hypertension
- Pre-eclampsia
- Smoking
- Cocaine use
- Trauma
- Uterine malformations
- chorioamnionitis
- previous placental abruption
- oligohydramnios
