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Midwifery Emergencies > Antepartum Haemorrhage (APH) > Flashcards

Antepartum Haemorrhage (APH) Flashcards

1
Q

What is the definition of APH?

A

Bleeding from/into the genital tract from 24+0 to the birth of the baby

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2
Q

What percentage of women have APH’s?

A

3-5%

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3
Q

What percentage of global maternal deaths does it cause?

A

50%

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4
Q

Name 4 causes of APH

A

Placenta praevia
placental abruption
ruptured vasa praevia
uterine scar rupture

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5
Q

What minor things can cause an APH? (6)

A 
Show
Cervicitis
Cervical Polyp
Cervical cancer
Cervical ectropion
Vaginal Trauma
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6
Q

What is the definition of placental abruption?

A

When the placenta detaches from the uterus wall before delivery

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7
Q

What are the signs of placental abruption? (8)

A 
Vaginal bleeding (in a revealed) +/- clots 
Abdo pain 
Hypertonic uterus 
Couvelaire uterus (concealed) 
Backache
Fetal distress
Maternal shock
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8
Q

Name some risk factors for placental abruption (11)

A
  • 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
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9
Q

What percentage of pregnancies have an abruption?

A

1%

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10
Q

What is the recurrence rate of placental abruption?

A

19-25%

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11
Q

What should you never do until placental site is confirmed?

A

vaginal examination

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12
Q

Management of placental abruption (10 steps)

A
  • 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
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13
Q

What additional blood tests should you do for an abruption?

A

Blood tests - fbc, clotting, group and save, cross match, kleihauer if RH -

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14
Q

What other tests should you do for an abruption? (minus bloods)

A

MSU + urine
Speculum
USS - placental site

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15
Q

What is the definition of placenta praevia?

A

Placenta praevia is when the placenta is inserted wholly or in part of the lower segment of the uterus

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16
Q

How is placenta praevia diagnosed?

A

USS at 20 weeks, repeat follow ups

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17
Q

What percentage of pregnancies does placenta praevia occur in?

A

0.5-1%

18
Q

What are the two classifications of placenta praevia?

A

Major- <2cm from or covering cervical os

Minor- >2cm from cervical os

19
Q

What are the 8 signs of placenta praevia?

A
  • 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
20
Q

What are the risk factors for placenta praevia? (10)

A
  • prev CS
  • prev uterine intrumentation
  • high parity
  • high mat age
  • smoking
  • multiple pregnancy
  • maternal haemorrhage
  • transfusion
  • prematurity
  • Placenta acreta, increta and percreta
21
Q

What is placenta accreta, increta and percreta?

A 
Placenta attaches too deeply into the uterus so remains after birth 
Locations 
Accreta - low side 
Increta  - Side 
Percreta- top
22
Q

Causes of placenta praevia (3 sections)

A

Endometrial scarring, increased placental mass, impeded endometrial circulation

23
Q

What causes endometrial scarring? (3)

A
  • prev lscs or myomectomy (fibroids)
  • prev placenta praevia
  • Multiparity - placenta likes to change site each pregnancy
24
Q

What causes placental mass? (2)

A
  • placental anomolies (succenturiate lobe or bipartite)

- multiple pregnancy - usually join into one big mass and stay in lower segment

25
Q

What causes impeded endometrial circulation? (5)

A 
Medical conditions (hypertension, diabetes) 
Increased maternal age 
Uterine tumours 
Smoking 
Drugs
26
Q

Management of placenta praevia (11 steps)

A
  • 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
27
Q

What percentage of 20/40 scans show low lying placenta?

A

50%

28
Q

How many placentas stay low after 20/40?

A

10%

29
Q

What are the 12 potential complications of a severe APH?

A
  • 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
30
Q

Management of severe APH (7)

A
  • catheterise (urometer)
  • strict fluid balance
  • involve haemotologist
  • may need blood products
  • EMCS
  • may need central line
  • uterine rupture - possible hysterectomy
31
Q

What is sheehans syndrome?

A

pituitary necrosis

32
Q

What is vasa praevia?

A

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

33
Q

What causes rupture of vasa praevia?

A

membrane rupture- because they are unsupported by umbilical cord or placental tissue

34
Q

Does ruptured vasa praevia cause bleeding?

A

Can in the 3rd trimester but may present in labour or with ROM

35
Q

What are the possible poor outcomes with ruptured vasa praevia?

A

high fetal/perinatal mortality & can lead to fetal exsanguination

36
Q

What is fetal exsanguination?

A

baby drained of blood

37
Q

What is the definition of uterine rupture?

A

rupture of an unscarred uterus or dehiscence of a previous uterine scar

38
Q

What is the incidence of uterine rupture?

A
  1. 2/1000 women

2. 1/1000 with a uterine scar

39
Q

What are the 3 types of uterine rupture?

A
  1. complete- rupture involves the full thickness of the uterine wall and pelvic peritoneum
  2. Incomplete- involves the myometrium but not the pelvic peritoneum
  3. Scar dehiscence- thinning or tearing of the uterine wall at old scar
40
Q

17 causes of uterine rupture

A
  • 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
41
Q

How do they diagnose uterine rupture? (11)

A
  • 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

Midwifery Emergencies (7 decks)

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