Antepartum Hemorrhage

Question 1

Normal amount of bleeding antenatal or before onset of labor

Answer 1

Zero

Question 2

How much of COP Supplies the uterus,

Answer 2

Non preg: <1%
3rd trimester: 15% (700 ml/min)

Question 3

Leading cause of death from a blood transfusion

Answer 3

1. Transfusion associated circulatory overload
2. Delay in transfusion

Question 4

Practical method to calculate blood loss

Answer 4

SHOCK INDEX= Heart rate / systolic BP

In non obstetric patient= 0.5-0.7
> 0.9 in PPH -> inc risk of blood transfusion, surgical intervention & icu admission

Question 5

Do we use D-dimer in diagnosis of VTE or Pulmonary embolism

Answer 5

No as it increases during pregnancy

Question 6

What happens to coagulation factors in pregnancy

Answer 6

All increases except protein S decreases

Question 7

Grades of APH

Answer 7

Spotting
Minor: <50 ml
Major: 50-1000 no signs of shock
Massive:>1000 ml &/or signs of shock

Question 8

The most predictive risk factor for placental abruption

Answer 8

Abruption in a previous pregnancy

Question 9

Risk of recurrence of placental abruption by CB CB as

Answer 9

After 1 abruption: 4.4%
After 2 abruption: up to 25%

Question 10

Can APH be predicted

Answer 10

70% of PA occur in low risk pregnancies

Question 11

Can APH be prevented

Answer 11

Avoid tobacco, cocaine and amphetamine also reduces LBW and PTL

Question 12

Difference between pain of labour and PA

Answer 12

PA: continous
Labor: intermittent

Question 13

Investigations in APH

Answer 13

Minor:
1. FBC
2. Coagulation screen if abnormal platelet count
3. Group and save

Major or massive:
1. FBC
2. Coagulation screen
3. U&E and liver function
4. 4 units cross matched

Question 14

Do we use US in diagnosing Placental abruption

Answer 14

No. Low sensitivity and specificity

Localization of placenta.
Detection of retroplacental clot is poor

Question 15

Fetal investigation in placental abruption

Answer 15

CTG once the mother is stable. After 26 w
Abnoraml 69% -> poor fetal outcome-> expedited delivery
Normal-> expectant till maturity

Question 16

The most common adverse obstetrics problem in a pregnancy conplicated by unexplained APH

Answer 16

Preterm delivery

Question 17

What conplication that increased the most in case of unexplained APH

Answer 17

Oligohydramnios

Question 18

Abdominal examination of a case of APH

Answer 18

Tense or woody uterus: significant abruption
- soft ot nontender suggest lower genital tract cause or placenta or vasa previa

Question 19

Speculum examination of APH

Answer 19

Cx ectropion: 21%
Dilated cx 2%

Avoid PV if PP is suspected

Question 20

What case of abruption need hospitalization

Answer 20

Spotting topped+ no PP -> reassure and go home
Heavier than spotting or ongoing bleeding: remain in hospital till bleeding stops
Spotting+ hx of IUFD from.PA: hospitalization

Question 21

When to offer corticosteroids for patient with APH

Answer 21

Between 24-34+6 w to any woman at risk of preterm delivery

• bleeding associated w/ pain -> inc risk of preterm-> give single course of corticosteroids

Question 22

When to give tocolytics

Answer 22

Give it when: very preterm needs NICU
Don’t give:
- major APH
- fetal compromise
- CI in PA
- relatively CI in mild hmge d.t. PP

Question 23

Mode of birth in case of APH

Answer 23

IUFD: vaginal (if stable) or cs for some
Fetal compromise: CS
Unexplained APH no compromise: senior obstetrician decision

Question 24

Whnt p feliver if APH after 37w

Answer 24

Minor and major APH: IOL should be considered

Question 25

Do we give anti-D in APH

Answer 25

to all non-sensitized women after any APH After 20w 500 IU+KBT ADDITIONAL DOSE should be give as required at a minimum 6 w intervals

Question 26

Blood products used in APH

Answer 26

Crystalloid 2 L Colloid 1-2 L Crossmatch; till its ready give O -ve 4 units FFP (12-15ml/kg) for every 6 PRBCs if PT or aPTT >1.5 Platelets: if count <50x10^9/L Cryo: if fibrinogen <1g/L

Question 27

If women with APH DEVELOPS DIC

Answer 27

1. Clotting studies + platelet count 2. 4 units FFP (1L) + 10 units of cryo (2 packa)

Question 28

Women with APH taking anticoagulant therapy

Answer 28

1. Stop anticoagulant 2. Admission 3. Consider IV UFH until RF for hmg have resolved 4. Thromboprophylaxis should be commenced or restarted 5. In case of coagulopathy: UFH/ graduated compression stocking

Question 29

Management of hmge up to 1000 ml with no shock

Answer 29

IV access (14 gauge cannulax1) Give crystalloid infusion (hartmann’s infusion)

Question 30

Management of massive hemorrhage >1000 ml or clinical shock

Answer 30

1. ABC 2. O2 mask at 10-15L/min 3. IV ACCESS (14 gauge cannula) 4. Left lateral tilt 5. Transfuse blood asap 6. Until blood is available: infuse up to 3.5 L of warmed crystalloid and/or colloid

Question 32

Our therapuetic goal of fluid replacement in APH

Answer 32

Hb >8 g/dl Plateletes >75x10^9/L PT,aPTT< 1.5 of mean control Fibrinogen >1 g/L