antepartum haemorrhage - GM Flashcards
define APH
genital tract bleeding from 24 weeks gestation and complicates 3-5% of pregnancies
three most important causes of APH
placenta praevia, placental abruption and vasa preavia
less serious causes of APH
lower genital tract sources eg. cervical polyps, vaginitis and cervicitis
why does placenta previa increase the likelihood of APH
poor attachment of the placenta to the uterine wall
marginal placenta praevia
less than 2cm from the os
complete placenta praevia
complete coverage of the cervical os
placental abruption define
complete or partial detachment of the placenta before delivery
risk factors for placental abruption
maternal age greater than 35
multiparity
current pre-eclampsia, HELLP
Hx of hypertension
Hx of previous abruptions
Hx of anti-phospholipid syndrome
Hx of thrombophilia
smoking during pregnancy
use of cocaine during pregnancy
tramua
over distension of the uterus - polyhydramnios, twins
History of placental abruption
abdo pain - posterior placental abruptions may present with back pain
vaginal bleeding
uterine contractions
dizziness and/or loss of consciousness
revealed vs. concealed placental abruption
amount of blood loss often correlates poorly with the degree of abruption
abruption may be revealed where blood tracks between membranes and out of the vagina
may however be concealed where the blood accumulates with no obvious external bleeding
clinical findings of placental abruption include
woody, tense uterus
fetal heart absent or distressed
imaging for placental abruption
US required to identify location of the bleed
lab investigations of placental abruption
FBC, U&Es, LFTs, helps exclude hypertensive conditions such as HELLP or pre-eclampsia
clotting profile
kleihauer test
group and save
crossmatch
differential diagnoses for placental abruption
placenta praevia
vasa praevia
marginal placental bleed: partial abruption
uterine rupture
local causes: polyps, carcinoma, cervical ectropion, infection
initial management for APH
call for help
AA-E
replace fluids
2 large bore cannulas
left lateral position
prepare for theatre if severe
IV fluids
FHR
rin relief, anti-D if negative blood group
consider corticosteroids
management of placental abruption if the fetus is alive
if there is no signs of fetal distress: observe closely and induce and deliver vaginally if over 36 weeks
if there is signs of fetal distress: immediate C-section
management of placental abruption if the fetus is dead
induce vaginal delivery
if the mother is haemodynamically compromised and/or ongoing massive haemorrhage, delivery should be expadited by c-section to arrest bleeding
complications of placental abruption for the mother
major haemorrhage: if suspected, the major haemorrhage protocol should be activated
shock: can result in sheehan syndrome
compression of uterine muscles prevents good contraction of muscles during labour
Release of thromboplastin from placental haematoma: can lead to DIC
post partum haemorrhage
complications of placental abruption for the fetus include
placental insufficiency: results in hypoxia and intrauterine growth restriction (IUGR) due to lack of nutrients
premature birth
stillburth
vasa praevia define
occurs when foetal blood vessels (the two umbilical arteries and single umbilical vein) are within the fetal membranes and run across the internal cervical os
aetiology of vasa praevia
normally, the fetal vessels are protected within the umbilical cord or placenta
in vasa praevia, the vessels are exposed which increases the risk of the vessels rupturing following the rupture of supporting membranes
types of vasa praevia
vasa praevia with velamentous umbilical cord insertion: the fetal vessels insert into the membranes and travel around to the placenta, rather than inserting directly into the placenta
vasa praevia with multi- lobed placenta: the fetal vessels are exposed as they travel to an accessory placental lobe
risk factors for vasa praevia
IVF pregnancy
multiple pregnancy
low lying placeta
Hx of vasa praevia
painless vaginal bleeding
rupture of membranes
fetal bradycardia
clinical examination of vasapraevia
soft non tender uterus
fetal bradycardia
differential diagnosis of vasa praevia
placenta praevia
placental abruption
uterine rupture
local causes: polyps, carcinoma, cervical ectropian, infection
bedside investigations for vasa praevia
vital signs: RR, BP, oxygen saturations, pulse and temperature
laboritory investigations for vasa praevia
FBC, U&Es, LFTs, helps to exclude hypertensive conditions such as HELLP or pre-eclampsia
clotting profile
kleihauer test
group and save
crossmatch
imaging for vasa praevia
ultrasound scan
cardiotocography is used to monitor the foetus
management of vasa praevia
if a woman is found to have vasa praevia on US, an elective c-section at 34-36 weeks is required
corticosteroids are given from 32 weeks to promote fetal lung maturity
vasa praevia in the event of APH
emergency caesarean section is required to deliver the foetus
main complication for vasa praevia is
major haemorrhage
vasa praevia presents usually as
painless vaginal bleeding but may also coincide with rupture of membranes
other uterine causes of APH
circumvallate placenta
placental sinuses
lower genital tract sources of APH include
cervical polyps
cervical erosions and carcinoma
carvicitis
vaginitis
vulval varicosities
which presentation is painful
placental abruption is painful
not vasa praevia or placenta praevia
which presentation causes a tender uterus
placental abruption causes a tender uterus
not vasa praevia or placenta praevia
which presentation includes an abnormal lie and/or presentation
placenta praevia may cause abnormal lie and/or presentation
vasa praaevia and placental abruption present with normal lie
how is fetal heart affected by these presentations
fetal heart rate is normal in placenta praeviaa
fetal heart rate is absent or distressed is placental abruption
fetal heart rate is bradycardic in vasa praevia
which presentations cause coagulation problems
coagulation problems are rare in placenta praevia and vasa praevia
coagulation problems will be present in placental abruption
