Antepartum haemorrhage Flashcards
What is antepartum haemorrhage?
Bleeding from the genital tract from 24+0 weeks gestation, prior to fetal delivery
What are dangerous causes of antepartum haemorrhage?
Placental abruption
Placenta praevia
Vasa praevia
What are other uterine sources of APH? Lower genital tract sources?
Uterine:
Circumvallate placenta
Placental sinuses
Lower genital tract: Cervical polyps Erosions Carcinoma Cervicitis Vaginitis Vulval varicosities
What is placental abruption
Part of placenta becomes detached from the uterine wall resulting in maternal haemorrhage into the intervening space.
Outcome depends on amount of blood loss and degree of separation
What is placental abruption associated with?
Pre-eclampsia Smoking IUGR PROM Multiple pregnancy Polyhydramnios Increased maternal age Thrombophilia Abdominal trauma Assisted reproduction Cocain use Infection Non-vertex presentation
What are consequences of placental abruption?
Placental insufficiency may cause fetal anoxia or death
Compression of uterine muscles by blood causes tenderness and may prevent good contraction at all stages of labour
Posterior abruptions may present with backache
May be uterine hyper contractility (>5 contractions per 10min)
Thromboplastin release may cause DIC
Concealed bleeding may cause maternal shock
What is the presentation of placental abruption?
Shock out of keeping with visible loss Pain constant Tender, tense uterus Normal lie and presentation Fetal heart: absent/distressed Coagulation problems Beware pre-eclampsia, DIC, anuria
What should you beware of in placental abruption
Shock leading to
Renal failure
Sheehan’s syndrome - postpartum pituitary gland necrosis –>agalacrottahea, amenorrhoea, hypothyroidism
What is placenta praevia?
Placenta lies in the lower uterine segment
What are the grades of placenta praevia?
I - placenta enriches the lower segment but does not reach the internal cervical os
II - placenta reaches the os but does not cover it
III - placenta partially covers the os
IV - placenta completely covers the os
What is the presentation of placenta praevia?
Shock in proportion to visible loss No pain Uterus not tender Lie and presentation may be abnormal Fetal heart usually normal Coagulation problems rare Small bleeds before large
Describe management of APH
Admit IVI Take bloods Raise legs O2 at 15L/min via mask with reservoir
If shocked give fresh ABO Rh compatible blood or O Rh-ve blood until systolic BP > 100
FBC, Clotting screen, cross match, U&E
Catheterise and maintain urine output > 30 ml/h
If bleeding is severe deliver - C-section for placenta praevia
IOL if APH at term
What are ddx of maternal bleeding?
Spontaneous abortion Ectopic pregnancy Hydatidifom mole Placental abruption Placenta praevia Vasa praevia
Describe bleeding in spontaneous miscarriage
Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks
Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear
Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled.
Incomplete miscarriage - heavy bleeding and crampy, lower abdo pain.
Complete miscarriage - little bleeding
Describe presentation of ectopic pregnancy
Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later.
Shoulder tip pain and cervical excitation may be present
