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Antepartum Haemorrhage (APH) Flashcards

1
Q

How common is APH?

A

3-5%

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2
Q

What is the definition of APH?

A

Bleeding from the genital tract after 24 weeks gestation and up to delivery

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3
Q

What can cause APH?

A
  • placenta previa
  • placenta abruption
  • uterine rupture
  • vasa previa
  • unknown
  • cervical/vaginal issue such as cancer/trauma
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4
Q

What may cause some of the unknown caused APHs?

A

Smaller placental Abruptions

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5
Q

How does the degree of APH differ?

A
  • spotting
  • minor (<50ml) (about an egg cup)
  • major (50-1000ml) with no signs of shock
  • massive (>1000ml) or signs of shock
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6
Q

When does uterine rupture usually only occur?

A

In labour and with uterus with previous scar

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7
Q

What is cervical ectropium/eroision?

A

If columnar epthelium extends down, more predisposed to bleeding due to trauma

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8
Q

What is Placenta Praevia?

A

Placenta implanted in owner segment of the uterus

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9
Q

How common is placenta previa?

A

1 in 200 pregnancies at term

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10
Q

Do all initial low lying placentae remain placenta previa at term?

A

10% of initial low lying placentae are placenta previa at term

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11
Q

What is placenta previa more common in? (8)

A
  • twins
  • smoking
  • scarred uterus
  • preterm delivery
  • high maternal age
  • high parity
  • previous history
  • assisted reproduction
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12
Q

When is placenta previa often picked up?

A

@ anomaly scan

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13
Q

What can the placenta be described as at anomaly scan?

A

High & safe = will be high and safe at term too

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14
Q

Why is it that not all low lying placenta at anomaly scan stay to be placenta previa at term?

A

Can migrate up over time during stretching that forms the lower uterine segment

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15
Q

What does placenta previa look like?

A
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16
Q

What are the 3 ways of grading/classifying placenta previa?

A
  • marginal & major
  • grade 1-4
  • AIUM classification
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17
Q

What is the marginal grade of the placenta previa?

A

In lower segment but over the internal os

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18
Q

What is the major grade of placena previa?

A

Partially or completely covering internal cervical os

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19
Q

What is Grade 1 placenta previa?

A

Minor

= in lower segment but not reaching internal cervical os

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20
Q

What is grade 2 placenta previa?

A

Marginal

= in lower segment and reaching internal cervical os

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21
Q

What is grade 3 of placenta previa?

A

Partial

= partially covering internal cervical os

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22
Q

What is grade 4 of placenta previa?

A

Complete

= fully covering cervical os

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23
Q

What are the different grades of placenta previa?

A
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24
Q

What is the AIUM Classifcation of placenta previa divided into?

A

Placenta previa

Low-lying placenta

(Most up to date classification)

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25
What does the AIUM classification define placenta previa as?
Placenta lying directly over internal os
26
What does AIUM Classification define low-lying placenta as?
Placental edge <2mm from internal os
27
What is defined as normal under the AIUM Classification of placenta previa?
If >20mm from internal os
28
What are the clinical features of placenta previa seen in the history?
**PAINLESS** PV bleeding (fresh, bright red) * increase in frequency and intensity over weeks * can be severe * 1/3 no bleed prior to delivery
29
What are the clinical features of placenta previa seen on examination of abdomen?
* soft, non tender, + FH * more likely to have abnormal lies and presentations * head wont be engaged
30
What examination should you not do in the case of placenta previa?
pelvic exam
31
How is placenta previa diagnosed?
ultrasound: most now diagnosed prior to bleeding at the 20 week scan
32
What should be done if there is a low lying placenta at the anomaly scan (20 weeks)?
Repeat at 32 weeks (and at 36 weeks) - this can guide decisions regarding delivery
33
What maternal complications are seen with placenta previa? (8)
* APH * PPH * placenta accreta/increta (10% PP and prev c-section) * placenta percreta * recurrence 4-8% * anemia/infection/DIC/shock * psychological * mortality
34
Why is there a risk of PPH with placenta previa?
Lower uterine segment isn’t as muscular so cant contract to stop the bleeding after delivery
35
What foetal complications are there of placenta previa? (3)
* IUGR * preterm delivery * mortality
36
Where should women with placenta praevia be cared for in the third trimester?
Paucity of evidence: individualised basis In General all women with APH heavier than spotting should be admitted for assessment at least until bleeding stops. In general care including hospitalisation should be tailored to individual circumstances including -distance from the hospital -availability of transport -previous bleeding episodes -haematology results -acceptance of donor blood or blood products
37
How are women with placenta previa managed?
* prevention of anaemia in pregnancy * avoidance of vaginal examination & intercourse * if bleeding: - admission & remain in hospital - IV access
38
What investigations should be done for placentae previa?
Group and x-match FBC Coag +/- U&E, CTG, U/S
39
What test do some women need with placenta previa?
Kleihauer test and Anti-D (RH -ve)
40
What is the Kleihauer test?
Test for seeing how many fetal cells have crossed over into the maternal circulation
41
When do you give steroids to a mother with placenta previa?
If **<34 weeks** (RCOG 2018: steroids between 24-35+6 weeks if asymptomatic)
42
When is a c-section done for placenta previa?
Bleeding severe
43
At what gestation should planned delivery occur in placenta previa?
Uncomplicated 36-37 Bleeding 34-36+6
44
What is Placenta Accreta?
Placenta implants more deeply than normal (‘morbidly adherent placenta’) often in previous caesarian section scar (and anterior placenta praevia)
45
What are other risks for placenta accreta? (2)
* previous accreta * uterine surgery (c-section) (e.g. myomectomy, manual removal of placenta, endometrial currettage)
46
How is Placenta Accreta diagnosed?
USS or MRI
47
What may happen at delivery with placenta accreta?
Massive haemorrhage at delivery may require hysterectomy
48
What can imaging (US, MRI) for placenta accreta show? (5)
* depth of invasion * interruptions in the myometrail border * placental lakes (vascular pools) * uterine bulging * Doppler studies/vascularisation
49
How does placenta accreta compare to normal placenta?
50
What is the spectrum of management of placenta accreta? (4)
* c-section hysterectomy (with placenta in situ) * uterus preserving surgery (partial myomectomy: further studies needed) * expectant management (risk of bleeding/infection) * interventional radiology (Further studies needed)
51
What is placental abruption?
Complete or partial separation of placenta prior to delivery of foetus
52
How common is placental abruption?
~1% of pregnancies
53
What does placental abruption cause?
Maternal haemorrhage behind it
54
What do 20% of placenta abruptions have?
A concealed haemorrhage (ie no PV bleeding)
55
What are the risk factors linked to the mother for placental abruption? (3)
* high parity * advanced maternal age * prev abruption (6%)
56
What are the risk factors for placental abruption linked to vascular problems of placenta? (4)
* PET * IUGR * maternal thrombophilias * smoking/cocaine
57
What risk factors cause placental abruption b ripping the placenta away? (4)
* ECV (external cephalic version = trying to turn the baby) * trauma * SROM in polyhydramnios * multiple pregnancies (especially in one sac)
58
What are the clinical features of placental abruption?
* constant **PAIN** with exacerbations And/or * dark vaginal bleeding * foetal distress
59
What are the clinical features of placental abruption seen on examination?
* vitals: tachy (blood loss > visualised loss), hypotension (massive loss) * abdomen: uterus tender, contracting, severe- woody * FH: abnormal or absent
60
Why is there uterine contractions in placental abruption?
Blood irritates the uterus causing contractions
61
What is a woody uterus?
Firm, constantly contracting uterus, hard to feel fetal parts
62
What are the late clinical features of placental abruption? (2)
* DIC * Oliguria
63
What kind of diagnosis is placental abruption?
A clinical diagnosis
64
What investigations of the foetus aid placental abruption diagnosis?
* CTG - foetal distress, erratic uterine activity * u/s - exclude PP, may not see PA
65
What investigations of the mother are done for placental abruption?
Labs: * FBC: coag screen, group & x-match * U&E +/- catheter to monitor output, CVP
66
What are the maternal complications of placental abruption? (7)
* DIC * Hypovolemic shock * renal failure * infection/anaemia * PPH (uterus tired after delivery due to constant contractions) * mortality * recurrence (3-10%)
67
What are the foetal complications of placental abruption? (3)
* IUGR * perinatal M&M * foetal death 30%
68
How is placental abruption managed?
Admit IV fluids Analgesia (paracetamol and then opiates) +/- Anti-D, steroids
69
What mode of delivery is done if there is placental abruption + foetal distress?
Emergency c-section
70
What mode of delivery is done if there is placental abruption + no foetal distress and >37 weeks?
IOL (induction of labour)
71
What mode of delivery is done if there is placental abruption + foetal death?
IOL
72
How is placental abruption managed if there is no foetal distress and they are preterm?
Conservative - initial on ward observation and subsequent OPD growth scans
73
What are the DDx for placental abruption? (6)
* placenta previa * uterine rupture * degeneration of fibroid * rectus sheath haematoma * acute hydramnios (rapid increase in fluid) * acute surgical condition
74
What is Vasa praevia?
Foetal blood vessel runs in the membranes in front of the presenting part unprotected by placental tissue or umbilical cord
75
What is marginal insertion?
Cord inserted into edge of placenta (ie normal). If placenta migrates then it can become a velamentous insertion (trophotrophism)
76
What can vasa praevia occur in?
* velamentous insertion * vessels running between 2 lobes of a placenta
77
What is velamentous insertion?
Vasa praevia type 1 Umbilical cord attached to membranes rather than placenta
78
What are vessels running between 2 lobe of a placenta?
Vasa praevia type 2
79
What are the risk factors for vasa praevia? (4)
* bilobed placenta * low lying placenta in second trimester * multiple pregnancy * IVF
80
What is ruptured vasa praevia?
When membranes rupture vessel may rupture with massive foetal bleeding SEVERE FETAL BLOOD LOSS
81
What are the clinical features of ruptured vasa praevia?
**PAINLESS** moderate PV bleed & severe foetal distress
82
How common is ruptured vasa praevia?
1 in 5000 pregnancies
83
What is the treatment plan for a ruptured vasa praevia?
C-section often not able to save foetus (mortality up to 60%)
84
What are two other causes of APH?
* uterine rupture = rarely, can occur scarred or abnormal uterus * gynaecological causes = cervical carcinoma or polyp or ectropion or vaginal causes
85
What are CI to amniotomy?
* head not well engaged (can cause cord prolapse) * malpresentation * known vasa praevia
86
What are the differences between placental previa and abruption?

OBGYN (25 decks)

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