Antepartum haemorrhage Flashcards
What is the definition of antepartum haemorrhage?
Bleeding >24wks.
What are the causes of APH?
Common: Idiopathic, Placental abruption, Placenta praevia.
Rare: Incidental urogenital tract pathology, Uterine rupture, Vasa praevia.
What are the classes of placenta praevia?
Marginal: in lower segment, not over os.
Major: partially or completely covering the os.
What are the complications of placenta praevia?
Obstructs engagement of head - necessitates C-S.
Haemorrhage.
May not seperate if implanted in previous C-S scar (placenta accreta) - may cause massive haemorrhage necessitating hysterectomy.
May penetrate through C-S scar into surrounding structures (placenta percreta).
How does placenta praevia present?
Intermittent painless bleeds that increase in frequency and intensity. (1/3 don’t have a bleed before delivery).
O/E: breech presentation and transverse lie are common. Fetal head isn’t engaged. DON’T VE UNTIL YOU’VE EXCLUDED PRAEVIA.
Also incidental finding on USS.
How would you investigate a placenta praevia?
If posterior - TVUSS at 32wks.
If anterior and under C-S scar - 3D power doppler USS.
How would you manage a placenta praevia?
If bleeding: Admit. Often need to stay in until delivery due to haemorrhage risk. Keep blood available. Give steroids if <34wks.
If asymptomatic: Admit at 37wks / delivery, provided they can get to hospital quickly.
Delivery by C-S at 39wks by senior consultant - intra/postpartum haemorrhage common due to lower segment not contracting well.
Deliver early if severe bleeding.
What is a placental abruption?
Separation of the placenta from the uterus before delivery of the fetus.
Occurs in 1% of pregnancies.
What are the complications of placental abruption?
Fetal death (30% of abruptions).
Haemorrhage necessitating transfusion.
DIC.
Renal failure.
What are the major risk factors for placental abruption?
IUGR.
Pre-eclampsia.
Pre-existing HTN.
Maternal smoking.
Previous abruption.
How does an abruption present?
Painful bleeding, often dark blood. (“revealed” abruption)
Degree of bleeding doesn’t reflect severity of abruption - some may not escape.
If pain and no bleeding, likely to be a “concealed” abruption.
O/E: Tachycardia, tender uterus (“woody” if severe).
What investigations would you do in ?abruption?
Fetal: CTG, USS to estimate fetal weight and rule out praevia.
Maternal: FBC, coagulation screen, cross-match, catheterisation for urine output, regular FBC, coagulation, U&E, CVP if severe.
How would you manage an abruption?
Admit if pain and uterine tenderness.
IV fluids, steroids if gestation <34wks, analgesia, anti-D if Rh-ve.
Stabilise mother before considering delivery.
If fetal distress: emergency C-S.
If no fetal distress and >37wks: induce labour by amniotomy and monitor closely.
If fetus is dead: coagulopathy is likely. Give blood products and induce labour.
If no fetal distress, pregnancy is preterm and abruption is minor - steroids and close monitoring.
How does vasa praevia present?
Can be detected on USS, but seldom are.
Painless moderate bleeding at rupture of membranes with severe fetal distress.
