Antepartum Heamorrage Flashcards
LEARN ABOUT ANTEPARTUM HEAMORRAGE
What is the definition of antepartum haemorrhage ?
Bleeding from or in to the genital tract , occuring from 24th weeks of pregnancy a d prior to the baby , occuring from 24 +0 weeks of pregnancy and prior the birth of the baby .
What is the most common causes of the APH ?
- Placenta previa .
2. Placenta abruption.
What are the risk factors for placental abruption ?
- Abruption in previous pregnancy.
- Pre-eclampsia .
- Fetal growth restriction.
- Non-vertex presentations.
- Polyhydromnios
- Advance maternal age.
- Multiparity
- Low body mass index .
- pregnancy followed assisted reproductive techniques.
- Intrauterine infection
- Premature rupture of membranes
- Abdominal trauma [ both accidental or as result of domestic violence ]
- Smoking
- Drug misuse [ cocaine and Amphetamines ] during the pregnancy .
- Maternal thrombophilias
What are the risk factors for placenta praevia ?
- Previous placenta previa
- Previous caeserean section.
- Previous termination of pregnancy .
- Multiparity
- Advance maternal age ( >40 Years old )
- Multiple pregnancy
- Smoking
8.Deficient endometrium due to presence or history of :
A. Uterine scar
B. Endometritis
C. manual removal of placenta
D. curettage
E. Submucous fibroid - Assisted conception .
Can APH be predicted ?
APH as a heterogenous pathophysiology and cannot reliably be predicted.
What are the prevention of APH ?
- Woman should be advised , encouraged and helped to change modifiable risk factors ( such as smoking and drug misuse ).
- It is considered good practice to avoid vaginal and rectal examinations in women with placenta praevia , and to advise these women to avoid penetrative sexual intercourse.
What are the complications of APH ?
Maternal complication :
- Anemia
- Infecion
- Maternal shock
- Renal tubular necrosis
- Consumptive coagulopathy
- Postpartum haemorrhage
- Prolonged hospital stay
- psychological sequelae
- Complications of blood transfusion
Fetal complication
- Fetal hypoxia
- Small for gestational age and fetal growth restriction
- Prematurity ( iatrogenic and spontaneous )
- fetal death
#Notes : Complications are more likely to occur when haemorrhage is dues to a placental cause ( abruption or placenta praevia ).
Where should the woman presenting with APH be managed ?
It is recommended that woman be advised to report All vaginal bleeding to their antenatal care provider.
What is the role of clinical assessment in women presenting with APH?
To establish whether urgent intervention is required to manage maternal or fetal complication.
What are the process of the triage ?
- History taking to assess coexisting symptoms such as pain .
2) Assessment of the extend of vaginal bleeding .
3) The cardiovascular condition of the mother.
4) Assessment of fetal wellbeing.
What are the full history that should be taken ?
- Clinical history whether there is pain associated with the haemorrhage. if :
Placental abruption: pain is contionuous .
Labour : Pain is intermittent - Identify the risk factors abruption and placenta praevia.
- Asking the woman about her awareness of fetal movement and attempts should be made to auscultate the fetal.
- Bleeding from rupture vasa previa should be considered = If the APH is associated with spontaneous or iatrogenic rupture of the fetal membrane.
- Previous cervical smear history may be useful in order to assess the possibility of a neoplastic lesion of the cervix as the cause of bleeding .
What the are the examinations that is needed in APH ?
#Note : The basic priniciple of resucitation should be adhered to in All women presenting with collapse or major haemorrhage.
- Record the pulse and blood pressure of all women presenting with APH .
- Abdominal palpitation : [
A. Significant abruption : The tense or “woody” feel to the uterus on Abdominal palpation .
B. Lower genital tract cause or bleeding from placenta or Vasa praevia : soft , non-tender uterus.
- Speculum Examination : [ A. Identify cervical dilation,
B. Visualize a lower genital tract cause for the APH . ] - Digital vaginal examination :
[ A. Digital vaginal examination should not be performed until an ultrasound has excluded placenta praevia if palcenta preavia is a possible diagnosis.
B. Digital vaginal examination can provide information on cervical dilation if PAH is associated with pain or uterine activity. ]
What are the investigations that can we do in APH ?
Maternal Investigations
* It is performed to assess the extent and the physiological consequences of APH and it is depend on the amount of the bleeding .
- Blood tests [ A. Full blood count .
B. Coagulation screen
C. Urea
D.Elctrolytre
C. liver functon test.
* All woman who are RhD-negative , a Kleihauer test should be performed to quantify FMH to Guage the dose of Anti-D Ig required.
*The kleihauer test is not a sensitive test for diagnosis placental abruption. - Ultrasound scan :
A.To confirm or exclude placenta praevia .
B. Determine placental location and in the diagnosis of placenta praevia. ]
FETAL INVESTIGATION :
1. Assessment of the fetal heart rate should be performed , usually with a cardiotograph( CTG ) - in woman presenting with APH once the mother is stable or resuscitation has happen t help in decision making on the mode of delivery .
- CTG monitoring should be performed where knowledge of fetal condition will influence the timing and mode of delivery .
- Ultrasound should be carried out to establish fetal heart pulsation if fetal viability cannot be detected using external auscultation .
Should woman with APH be hospitalised , and if so , for how long ?
Woman presenting with spotting who are no longer bleeding and where placenta praevia has been excluded can go home after a reassuring initial clinical assessment.
All woman with APH heavier than spotting and women with ongoing bleeding should remain in hospital at least until the bleeding has stopped.
Should corticosteroids be administered to women who present with APH before term ?
Clinicians should offer a single course of antenatal corticiosteriods to women between 24+0 and 34+6 weeks of gestation at risk of preterm birth.
In women presenting with spotting , where the most likely cause is lower genital tract bleeding , where imminent delivery us unlikely , corticosteriods are unlikely to be benefit , but could still be considered.
