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OBGYN > Antepartum Haemorrhage (APH) > Flashcards

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
Q

What does the AIUM classification define placenta previa as?

A

Placenta lying directly over internal os

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26
Q

What does AIUM Classification define low-lying placenta as?

A

Placental edge <2mm from internal os

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27
Q

What is defined as normal under the AIUM Classification of placenta previa?

A

If >20mm from internal os

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28
Q

What are the clinical features of placenta previa seen in the history?

A

PAINLESS PV bleeding (fresh, bright red)

  • increase in frequency and intensity over weeks
  • can be severe
  • 1/3 no bleed prior to delivery
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29
Q

What are the clinical features of placenta previa seen on examination of abdomen?

A
  • soft, non tender, + FH
  • more likely to have abnormal lies and presentations
  • head wont be engaged
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30
Q

What examination should you not do in the case of placenta previa?

A

pelvic exam

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31
Q

How is placenta previa diagnosed?

A

ultrasound: most now diagnosed prior to bleeding at the 20 week scan

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32
Q

What should be done if there is a low lying placenta at the anomaly scan (20 weeks)?

A

Repeat at 32 weeks (and at 36 weeks)

  • this can guide decisions regarding delivery
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33
Q

What maternal complications are seen with placenta previa? (8)

A
  • APH
  • PPH
  • placenta accreta/increta (10% PP and prev c-section)
  • placenta percreta
  • recurrence 4-8%
  • anemia/infection/DIC/shock
  • psychological
  • mortality
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34
Q

Why is there a risk of PPH with placenta previa?

A

Lower uterine segment isn’t as muscular so cant contract to stop the bleeding after delivery

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35
Q

What foetal complications are there of placenta previa? (3)

A
  • IUGR
  • preterm delivery
  • mortality
36
Q

Where should women with placenta praevia be cared for in the third trimester?

A

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
Q

How are women with placenta previa managed?

A
  • prevention of anaemia in pregnancy
  • avoidance of vaginal examination & intercourse
  • if bleeding:
  • admission & remain in hospital
  • IV access
38
Q

What investigations should be done for placentae previa?

A

Group and x-match

FBC

Coag

+/- U&E, CTG, U/S

39
Q

What test do some women need with placenta previa?

A

Kleihauer test and Anti-D (RH -ve)

40
Q

What is the Kleihauer test?

A

Test for seeing how many fetal cells have crossed over into the maternal circulation

41
Q

When do you give steroids to a mother with placenta previa?

A

If <34 weeks (RCOG 2018: steroids between 24-35+6 weeks if asymptomatic)

42
Q

When is a c-section done for placenta previa?

A

Bleeding severe

43
Q

At what gestation should planned delivery occur in placenta previa?

A

Uncomplicated 36-37

Bleeding 34-36+6

44
Q

What is Placenta Accreta?

A

Placenta implants more deeply than normal (‘morbidly adherent placenta’) often in previous caesarian section scar (and anterior placenta praevia)

45
Q

What are other risks for placenta accreta? (2)

A
  • previous accreta
  • uterine surgery (c-section) (e.g. myomectomy, manual removal of placenta, endometrial currettage)
46
Q

How is Placenta Accreta diagnosed?

A

USS
or
MRI

47
Q

What may happen at delivery with placenta accreta?

A

Massive haemorrhage at delivery may require hysterectomy

48
Q

What can imaging (US, MRI) for placenta accreta show? (5)

A
  • depth of invasion
  • interruptions in the myometrail border
  • placental lakes (vascular pools)
  • uterine bulging
  • Doppler studies/vascularisation
49
Q

How does placenta accreta compare to normal placenta?

A
50
Q

What is the spectrum of management of placenta accreta? (4)

A
  • 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
Q

What is placental abruption?

A

Complete or partial separation of placenta prior to delivery of foetus

52
Q

How common is placental abruption?

A

~1% of pregnancies

53
Q

What does placental abruption cause?

A

Maternal haemorrhage behind it

54
Q

What do 20% of placenta abruptions have?

A

A concealed haemorrhage (ie no PV bleeding)

55
Q

What are the risk factors linked to the mother for placental abruption? (3)

A
  • high parity
  • advanced maternal age
  • prev abruption (6%)
56
Q

What are the risk factors for placental abruption linked to vascular problems of placenta? (4)

A
  • PET
  • IUGR
  • maternal thrombophilias
  • smoking/cocaine
57
Q

What risk factors cause placental abruption b ripping the placenta away? (4)

A
  • ECV (external cephalic version = trying to turn the baby)
  • trauma
  • SROM in polyhydramnios
  • multiple pregnancies (especially in one sac)
58
Q

What are the clinical features of placental abruption?

A
  • constant PAIN with exacerbations

And/or

  • dark vaginal bleeding
  • foetal distress
59
Q

What are the clinical features of placental abruption seen on examination?

A
  • vitals: tachy (blood loss > visualised loss), hypotension (massive loss)
  • abdomen: uterus tender, contracting, severe- woody
  • FH: abnormal or absent
60
Q

Why is there uterine contractions in placental abruption?

A

Blood irritates the uterus causing contractions

61
Q

What is a woody uterus?

A

Firm, constantly contracting uterus, hard to feel fetal parts

62
Q

What are the late clinical features of placental abruption? (2)

A
  • DIC
  • Oliguria
63
Q

What kind of diagnosis is placental abruption?

A

A clinical diagnosis

64
Q

What investigations of the foetus aid placental abruption diagnosis?

A
  • CTG - foetal distress, erratic uterine activity
  • u/s - exclude PP, may not see PA
65
Q

What investigations of the mother are done for placental abruption?

A

Labs:
* FBC: coag screen, group & x-match
* U&E

+/- catheter to monitor output, CVP

66
Q

What are the maternal complications of placental abruption? (7)

A
  • DIC
  • Hypovolemic shock
  • renal failure
  • infection/anaemia
  • PPH (uterus tired after delivery due to constant contractions)
  • mortality
  • recurrence (3-10%)
67
Q

What are the foetal complications of placental abruption? (3)

A
  • IUGR
  • perinatal M&M
  • foetal death 30%
68
Q

How is placental abruption managed?

A

Admit

IV fluids

Analgesia (paracetamol and then opiates)

+/- Anti-D, steroids

69
Q

What mode of delivery is done if there is placental abruption + foetal distress?

A

Emergency c-section

70
Q

What mode of delivery is done if there is placental abruption + no foetal distress and >37 weeks?

A

IOL (induction of labour)

71
Q

What mode of delivery is done if there is placental abruption + foetal death?

A

IOL

72
Q

How is placental abruption managed if there is no foetal distress and they are preterm?

A

Conservative - initial on ward observation and subsequent OPD growth scans

73
Q

What are the DDx for placental abruption? (6)

A
  • placenta previa
  • uterine rupture
  • degeneration of fibroid
  • rectus sheath haematoma
  • acute hydramnios (rapid increase in fluid)
  • acute surgical condition
74
Q

What is Vasa praevia?

A

Foetal blood vessel runs in the membranes in front of the presenting part unprotected by placental tissue or umbilical cord

75
Q

What is marginal insertion?

A

Cord inserted into edge of placenta (ie normal). If placenta migrates then it can become a velamentous insertion (trophotrophism)

76
Q

What can vasa praevia occur in?

A
  • velamentous insertion
  • vessels running between 2 lobes of a placenta
77
Q

What is velamentous insertion?

A

Vasa praevia type 1

Umbilical cord attached to membranes rather than placenta

78
Q

What are vessels running between 2 lobe of a placenta?

A

Vasa praevia type 2

79
Q

What are the risk factors for vasa praevia? (4)

A
  • bilobed placenta
  • low lying placenta in second trimester
  • multiple pregnancy
  • IVF
80
Q

What is ruptured vasa praevia?

A

When membranes rupture vessel may rupture with massive foetal bleeding

SEVERE FETAL BLOOD LOSS

81
Q

What are the clinical features of ruptured vasa praevia?

A

PAINLESS moderate PV bleed & severe foetal distress

82
Q

How common is ruptured vasa praevia?

A

1 in 5000 pregnancies

83
Q

What is the treatment plan for a ruptured vasa praevia?

A

C-section often not able to save foetus (mortality up to 60%)

84
Q

What are two other causes of APH?

A
  • uterine rupture = rarely, can occur scarred or abnormal uterus
  • gynaecological causes = cervical carcinoma or polyp or ectropion or vaginal causes
85
Q

What are CI to amniotomy?

A
  • head not well engaged (can cause cord prolapse)
  • malpresentation
  • known vasa praevia
86
Q

What are the differences between placental previa and abruption?

A

OBGYN (25 decks)

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