Antepartum Haemorrhage (APH) **** Flashcards
What is it?
After what gestation is it classed as APH?
Genital tract bleeding
24 wks
Dangerous causes:
Placental abruption - what is it?
Placenta praevia - what is it? why does it cause bleeding?
Vasa praevia - what is it?
Separation of the placenta from the uterus
Placenta in the lower uterus - at risk shearing off and bleeding
Fetal vessels traverse the internal cervical os and are at risk of rupture when membranes rupture
Other causes:
What could be mistaken for APH?
Other less dangerous causes?
Pre-labour passage of mucus plug
Polyps
Erosions
Vaginitis
Cancer
Placental Abruption:
What dictates the outcome?
What is it associated with?
Why may bleed present late? ---- Placenta praevia classification: Minor - Define grade 1 and grade 2 Major - Define grade 3 and grade 4
Amount of blood loss + degree of separation
PET IUGR Multiple pregnancies Smoking PROM
Bleeding may only be present in one localised area before presenting vaginally. ----- 1 - low lying PP - >2cm from os 2 - marginal PP - <2cm from os 3 - partial PP 4 - complete PP
S+S:
Abruption:
- Is bleeding concealed?
- What does the blood look like?
- Do you get abdo pain?
- How does the uterus feel?
- Can the uterus be painless?
- Why can they get uterine contractions? - 2
- Can you auscultate or monitor fetal HR? If so, what should you expect?
- What does lower back pain suggest?
- What happens if the bleeding is very severe?
Yes, it is often concealed - so may appear minimal and dark red
Yes - abdo pain
Hard and tender uterus
Yes, the uterus can be painless
May be provoked by abruption
Reflecting the fact that abruption may occur during labour
No
Distressed if you can hear it
A posterior abruption
SHOCK
S+S:
Placenta praevia:
- Is bleeding concealed?
- What does blood look like?
- Do they get pain?
- What is commonly abnormal about the foetus?
- Is there fetal distress?
- What happens if the bleeding is very severe?
No
Bright red PV bleeding
No pain
Abnormal foetal lie or presentation
No fetal distress
SHOCK
S+S:
Vasa praevia:
- Is it painful?
- What does vaginal bleeding happen after?
No - painless
Following membrane rupture
Distinguishing Abruption from Praevia:
Does the shock correspond to the visible loss?
Is it painful?
What is the uterus like?
Is the fetal lie and presentation normal?
Is the fetal HR normal?
Are there coagulation problems?
A - No P - Yes ---- A - Yes - constant pain P - No - painless ----- A - Uterus tender and hard/tense P - Non-tender ----- A - Normal lie and presentation P - Abnormal --- A - Absent/distressed P - Normal ---- A - Yes - DIC for example P - Rare to have coag issues
Risk factors:
Main ones - 2
Obstetrics history - 2
Lifestyle and demographics - 1
Maternal disease - 4
What form of artificial fertilisation increases the risk of PP?
Past history of APH
Multiple pregnancies
Increased parity
Scarring from CS or abortion
Older mother
Smoking
PET
HTN
DM
Thrombophilia
IVF
Investigations:
Bloods:
- Why do FBC?
- DIC may occur in severe disease. What bloods need to be done for this? - 1
- Why is crossmatching needed?
Foetus:
- USS - why do you do this? - 2
- USS - what could indicate abruption?
- Fetal monitoring - 1
Anaemia - FBC
Clotting studies
May require CS and checking rhesus status
—
To look for PP and check fetal wellbeing
Haematoma may be present - even though the diagnosis is clinical
CTG
Investigations:
Examinations:
- Why should a PP be ruled out before a vaginal exam?
- Once PP ruled out, why may a speculum be done?
- What do you look when palpating the uterus?
Diagnosis of PP in non-acute settling:
- It may be picked up on a 20 wk scan. What imaging is used to confirm it?
- Why is it rechecked at 32 wks?
It can trigger torrential bleeding “No PV until no PP”
To assess bleeding and look for local causes
TVUS
It may migrate
Management:
In acute bleeding, resus and monitor mum and baby:
- What is administered to resuscitate? - 1
- What is done to help venous return? - 1
- What if they are in shock? - 2
- What should be given if Rhesus negaitve?
- What if they are still not stabilised?
- What if bleeding resolves for PP patients?
IV fluids
Raise legs
Blood transfusion
Check urine output - catheterise
Anti-D
Delivery baby
Keep in until delivery - Abruption patients may be discharged
Management:
Placenta praevia:
- What should be done if they have a major PP and they have a bleed?
- What should be done if they have a major PP but haven’t bled? What should these women avoid?
- What is the mode of delivery is needed if the PP is major?
Abruption:
- When vaginal delivery possible?
- What should be offered at 37 wks to reduce risk of stillbirth?
Admit from 34 wks
Can remain home if they understand risks and can easily reach the hospital.
No penetrative sex
If mother and baby are stable and beyond 34 wks
Induction - IOL
Complications:
Abruption:
- Placental insufficiency - why is this bad for the baby?
- How may an abruption prevent good contraction during all stages of labour?
- What is likely to happen if there are poor contractions at the 3rd stage of labour?
- The release of thromboplastin causes what?
- What may cause renal failure?
Fetal hypoxia > death
Compression of uterine muscles by blood causes tenderness as well
PPH
DIC
Concealed bleeding - maternal shock - hypovolaemia
Complications:
PP - Placenta accreta:
- What is it?
Placenta adheres to myometrium instead of decidia at the site of the scar, increasing bleeding risk during placental delivery.
