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Antepartum Haemorrhage Flashcards

1
Q

What is antepartum haemorrhage?

A

It is defined as external bleeding from the genital tract of a pregnancy woman after 22 weeks gestation

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2
Q

What is bleeding before 22 weeks classified as?

A

It is a threatened or inevitable miscarriage

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3
Q

What does the bleeding entail?

A

Usually fresh blood or clots or soaking of a pad

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4
Q

Why must we be worried if a woman presents with antepartum haemorrhage?

A
  1. It is a medical emergency

2. Transfer the mother to the nearest hospital with ultrasound, blood transfusion and c-section facilities

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5
Q

What are the 4 major causes of antepartum haemorhhage?

A
  1. Abruptio placentae
  2. Placenta praevia (including vasa praevia
  3. Antepartum Haemmorhage from local lesions including cancer of the cervix
  4. Antepartum haemorrhage of unknown origin
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6
Q

What is the management of antepartum haemorhhage?

A
  • the first thing we need to do is resuscitate the patient

- the second thing is to find the diagnosis

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7
Q

How do we resuscitate the patient?

A
  1. Make sure you check vital signs: blood pressure and heart rate ands assess colour off mucous membranes
  2. Give an infusion of ringers lactate
  3. If there’s heavy bleeding insert two large bore(16G) intravenous cannulae , do a blood transfusion and prepare to do a C-section if necessary
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8
Q

How do we get to the diagnosis of a patient with antepartum haemorrhage?

A
  1. Start with history-previous pregnancies, previous antepartum haemorrhages, current pregnancy, abdominal pain, discharge, fetal movements, recent external or genital injuries
  2. Then examine-vital signs, abdominal exam, type of vaginal bleeding, vaginal speculum exam
  3. Special investigations
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9
Q

What special investigations would you do in as patient with antepartum haemorrhage?

A
  1. Hb or haematocrit
  2. Ultrasound(to look at fetal size and placental position)
  3. Resus blood group
  4. Clotting time
  5. Cardiotocogrtaphy from 24 weeks
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10
Q

Why would we not do a vaginal examination in a patient with antepartum haemorrhage?

A

-this is because we still need to exclude placenta praevia as a cause for the bleeding
The examining fingers may dislodge the placenta from the uterine decides and cause life-threatening haemmorhage

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11
Q

What is abruptio placenta?

A

It is when there is premature separation of the normally situated placenta
This separation causes haemorhhage from the deciduous basalis with bleeding between the placenta and the uterine wall

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12
Q

How does abruptio placentae usually present?

A

It presents with vaginal bleeding but can also cause a retroplacental haemmorhage and clot with no external bleeding

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13
Q

What percentage of pregnancies experience abruptio placentae?

A

0,5-2% and causes fetal death in 25-30% of cases

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14
Q

What is the grading system for abruptio placenta?

A
  1. Mild

2. Severe

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15
Q

What is mild abruptio placenta?

A

The mom shows no signs of haemodynamic instability and the baby is still alive

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16
Q

What is severe abruptio placenta?

A

The fetus has died or the mother is shocked

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17
Q

What are the causes /risk factors of abruptio placenta?

A
  1. Pre-eclampsia
  2. Cigarette smoking
  3. Cocaine
  4. Blunt abdominal trauma to the mother
  5. Pre-labour rupture of the membranes
  6. Chorioamnionitis
  7. Previous abruptio placentae
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18
Q

What are the causes of antepartum haemorrhage?

A
  1. Abruptio placentae
  2. Placenta praevia
  3. Vasa praevia
  4. Deciduous bleeding
  5. Ruptured uterus
  6. Cancer of the cervix
  7. Other local lesions
  8. APH of unknown cause
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19
Q

What are the symptoms of early abruptio placentae?

A
  1. Tender uterus
  2. Irritable uterus
  3. Decreased fetal movement
  4. Pain between uterine contractions
  5. Uterine or lower abdominal pain
  6. Small or no antepartuma haemmorhage
20
Q

How does a severe abruptio placenta present?

A

The uterus is usually hard and tender and is large for gestational age because of the accumulation of blood

21
Q

What can we expect on ultrasound of the patient in abruptio placenta?

A
  1. Blood- mixed clot, serum and fresh blood between the placenta and uterine wall
  2. We can see if the fetus is alive or not-
22
Q

What do we measure on the ultrasound?

A

The bi-parietal diamter, femur length and abdominal circumference to allow estimation of mass and viability

23
Q

What size fetus is not viable in public hospitals?

A

1 kilogram (28 weeks)

24
Q

What bloods would you order for a patient with abruptio placentae?

A
  1. Hb and haematocrit for potential transfusion
  2. Clotting profiles and platelet counts
  3. Urea and creatinine-renal function
25
What are the complications of having an abruptio placentae?
1. Severe blood loss 2. Disseminated intravascular coagulation-due to thromboplastin release 3. Renal failure
26
What is the most common cause of maternal death in abruptio placentae?
Post partum haemorrhage due to DIC -Increase in fibrin degradation products in the blood which leads to decreased uterine contractions and uterine atony and thus haemorrhage
27
Why does renal failure occur in patients with abruptio placentae?
The cumulative effects of hypovolaemic shock, intravascular clotting and pre-eclampsia cause reversible tubular necrosis
28
If the fetus is alive what do we need to do for management?
1. If the baby is viable we can do a c-section | 2. If the baby is not viable we can give an oxytocin infusion
29
What is the management of abruptio placentae with a dead fetus?
1. Resus the patient with fluids 2. Take patient to level 2 or 3 hospital 3. Conduct blood tests for haemoglobin, urea, creatinine and clotting profile 4. Transfuse 2-4 units of blood 5. Rupture membrane and induce labour 6. Measure BP, heart rate, urine output and central venous pressure hourly 7. If fetus is still undelivered in 12 hours do c-section 8. Give oxytocin after delivery(10 units IM) then 20-40 units in the ringers lactate
30
What does antepartum mean?
It refers to anything after the period of 20 weeks
31
What is placenta praevia?
It is when the placenta is at the lower segment of the uterus or simply at the opening part -it is either major(covering the cervical os) or minor(not covering the cervical os)
32
What is the typical clinical presentation of patients with placenta praevia?
1. Non-tender and non-irritable uterus 2. Painless bleeding 3. Hypovolaemic shock 4. Usually third trimester of pregnancy
33
What kind of bleeding is associated with placenta praeveia?
Bright red and intermittent continuous bleeding over days and weeks
34
What is the management of placenta praevia?
1. Admit the patient if <37 weeks for bloods and observation and possible blood transfusion if the patient gets worse 2. If <34 weeks then give betamethasone(12mg IM) and repeated once after 24 hours to stimulate lung maturity 3. Do a c-section at 37 weeks
35
What is the biggest risk factor for developing a placenta praevia?
C-section
36
Why does a ruptured uterus occur?
Usually due to previous c-section and multiparity and commonly occurs during labour
37
How does a ruptured uterus present?
The patient usually occurs during labour | -painful vaginal bleeding, fetal movements absent, abdominal tenderness
38
How do we manage patients with ruptured uterus?
We need immediate laparotomy to control and prevent maternal death
39
What is decidual bleeding?
Disruption of the blood vessels in the deciduous in the lower uterine pole -it is self-limiting
40
What is vasa praevia?
Rupture of the membranes leads to tearing of the vessels leading to blood loss
41
What are the local lesions that can cause antepartum haemmorhage?
-polyps, warts and ulcers
42
What is the management of APH?
1. If >37 weeks then induce labour | 2. If between 26-37 weeks then do CTG’s for 2 days and discharge if no further bleeding
43
What is a courvelar uterus?
It is a uterus where there is retro-placental bleeding in the myometrium and causes decreased uterine contraction/atony
44
What is the next step in managing a patient with antepartum haemorrhage if we have excluded abruptio placenta and placenta praevia?
Start by suspecting other local lesions of the bleeding-do vaginal examination with speculum
45
How long do we observe a patient and wait and decide that there is no abruptio?
Wait 24 hours and then another 24 hours to ensure there is no delivery and then send the patient home ensuring that the patient is able to come back to hospital easily
46
What is the Ap test that we do in vasa praevia?
It helps us decide whether the blood is foetal or maternal blood

Obstetrics (18 decks)

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