Antepartum Haemorrhage (APH) Flashcards
What is the definition of APH?
Bleeding from/into the genital tract from 24+0 to the birth of the baby
What percentage of women have APH’s?
3-5%
What percentage of global maternal deaths does it cause?
50%
Name 4 causes of APH
Placenta praevia
placental abruption
ruptured vasa praevia
uterine scar rupture
What minor things can cause an APH? (6)
Show Cervicitis Cervical Polyp Cervical cancer Cervical ectropion Vaginal Trauma
What is the definition of placental abruption?
When the placenta detaches from the uterus wall before delivery
What are the signs of placental abruption? (8)
Vaginal bleeding (in a revealed) +/- clots Abdo pain Hypertonic uterus Couvelaire uterus (concealed) Backache Fetal distress Maternal shock
Name some risk factors for placental abruption (11)
- Pre existing condition
- Previous placental abruption
- Pre-eclampsia
- Fetal growth restriction
- non vertex presentation
- polyhydramnios
- high mat age
- multiparity
- low bmi
- drug misuse
- domestic abuse
What percentage of pregnancies have an abruption?
1%
What is the recurrence rate of placental abruption?
19-25%
What should you never do until placental site is confirmed?
vaginal examination
Management of placental abruption (10 steps)
- prioritise mother
- call for help (bell/2222)
- left lateral
- ABC (oxygen, sats, BP, RR, pulse, temp)
- IV access + bloods
- indwelling catheter
- 3 Ps - pres part, position, progress
- stabilize mother
- then consider baby
What additional blood tests should you do for an abruption?
Blood tests - fbc, clotting, group and save, cross match, kleihauer if RH -
What other tests should you do for an abruption? (minus bloods)
MSU + urine
Speculum
USS - placental site
What is the definition of placenta praevia?
Placenta praevia is when the placenta is inserted wholly or in part of the lower segment of the uterus
How is placenta praevia diagnosed?
USS at 20 weeks, repeat follow ups
What percentage of pregnancies does placenta praevia occur in?
0.5-1%
What are the two classifications of placenta praevia?
Major- <2cm from or covering cervical os
Minor- >2cm from cervical os
What are the 8 signs of placenta praevia?
- Painless bright red vaginal bleeding (may be precipitated by intercourse)
- hx of smaller pv bleeds
- uterus may or may not be contracting
- maternal shock/collapse
- fetal distress
- malpresentation/unstable lie (placenta in the way)
- high head
- check the scan
What are the risk factors for placenta praevia? (10)
- prev CS
- prev uterine intrumentation
- high parity
- high mat age
- smoking
- multiple pregnancy
- maternal haemorrhage
- transfusion
- prematurity
- Placenta acreta, increta and percreta
What is placenta accreta, increta and percreta?
Placenta attaches too deeply into the uterus so remains after birth Locations Accreta - low side Increta - Side Percreta- top
Causes of placenta praevia (3 sections)
Endometrial scarring, increased placental mass, impeded endometrial circulation
What causes endometrial scarring? (3)
- prev lscs or myomectomy (fibroids)
- prev placenta praevia
- Multiparity - placenta likes to change site each pregnancy
What causes placental mass? (2)
- placental anomolies (succenturiate lobe or bipartite)
- multiple pregnancy - usually join into one big mass and stay in lower segment
What causes impeded endometrial circulation? (5)
Medical conditions (hypertension, diabetes) Increased maternal age Uterine tumours Smoking Drugs
Management of placenta praevia (11 steps)
- prioritise mother
- call for help (bell/2222)
- left lateral
- ABC (oxygen, sats, BP, RR, pulse, temp)
- IV access and bloods- x matched should be available
- Fluid resus
- indwelling catheter
- 3 P’s- pres part, position, progress
- USS
- stabilise mother
- then baby
What percentage of 20/40 scans show low lying placenta?
50%
How many placentas stay low after 20/40?
10%
What are the 12 potential complications of a severe APH?
- severe anaemia
- infection
- pph
- blood coagulation disorders
- acute renal failure
- sheehans syndrome
- psychological distress/ptsd
- hysterectomy
- fetal hypoxia
- neonatal anaemia/hypovolaemia
- preterm delivery
- intrauterine death
Management of severe APH (7)
- catheterise (urometer)
- strict fluid balance
- involve haemotologist
- may need blood products
- EMCS
- may need central line
- uterine rupture - possible hysterectomy
What is sheehans syndrome?
pituitary necrosis
What is vasa praevia?
Fetal blood vessels within the membranes covers the cervical os ahead of the presenting prat - often with velamentous insertion of the cord or succenturiate lobe
What causes rupture of vasa praevia?
membrane rupture- because they are unsupported by umbilical cord or placental tissue
Does ruptured vasa praevia cause bleeding?
Can in the 3rd trimester but may present in labour or with ROM
What are the possible poor outcomes with ruptured vasa praevia?
high fetal/perinatal mortality & can lead to fetal exsanguination
What is fetal exsanguination?
baby drained of blood
What is the definition of uterine rupture?
rupture of an unscarred uterus or dehiscence of a previous uterine scar
What is the incidence of uterine rupture?
- 2/1000 women
2. 1/1000 with a uterine scar
What are the 3 types of uterine rupture?
- complete- rupture involves the full thickness of the uterine wall and pelvic peritoneum
- Incomplete- involves the myometrium but not the pelvic peritoneum
- Scar dehiscence- thinning or tearing of the uterine wall at old scar
17 causes of uterine rupture
- prev surgery
- too much oxytocin
- high parity - more stretched
- obstructed/prolonged labour
- trauma
- perv perforation (ERPC, hysteroscopy)
- mid forceps delivery with cx tearing
- shoulder dystocia
- can occur pre-labour
- manipulation in pregnancy/labour
- congenital uterine abnormalities
- uterine over-distension
- vigorous external uterine pressure
- difficult placental removal
- morbidly adherent placenta
- placental abruption due to distension and abruption of uterine wall
- hypertonic uterus
How do they diagnose uterine rupture? (11)
- fetal distress/no fh
- complete rupture associated with sudden severe maternal collapse
- abdo tenderness + pain
- maternal tachycardia
- vaginal bleeding
- abdo girth may increase
- cessation of uterine contractions
- fetal parts easily visualised or palpated
- haematuria
- incomplete rupture - possible lack of symptoms
- may be diagnosed retrospectively
