Antepartum Hemorrhage Flashcards
Normal amount of bleeding antenatal or before onset of labor
Zero
How much of COP Supplies the uterus,
Non preg: <1%
3rd trimester: 15% (700 ml/min)
Leading cause of death from a blood transfusion
- Transfusion associated circulatory overload
- Delay in transfusion
Practical method to calculate blood loss
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
Do we use D-dimer in diagnosis of VTE or Pulmonary embolism
No as it increases during pregnancy
What happens to coagulation factors in pregnancy
All increases except protein S decreases
Grades of APH
Spotting
Minor: <50 ml
Major: 50-1000 no signs of shock
Massive:>1000 ml &/or signs of shock
The most predictive risk factor for placental abruption
Abruption in a previous pregnancy
Risk of recurrence of placental abruption by CB CB as
After 1 abruption: 4.4%
After 2 abruption: up to 25%
Can APH be predicted
70% of PA occur in low risk pregnancies
Can APH be prevented
Avoid tobacco, cocaine and amphetamine also reduces LBW and PTL
Difference between pain of labour and PA
PA: continous
Labor: intermittent
Investigations in APH
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
Do we use US in diagnosing Placental abruption
No. Low sensitivity and specificity
Localization of placenta.
Detection of retroplacental clot is poor
Fetal investigation in placental abruption
CTG once the mother is stable. After 26 w
Abnoraml 69% -> poor fetal outcome-> expedited delivery
Normal-> expectant till maturity
The most common adverse obstetrics problem in a pregnancy conplicated by unexplained APH
Preterm delivery
What conplication that increased the most in case of unexplained APH
Oligohydramnios
Abdominal examination of a case of APH
Tense or woody uterus: significant abruption
- soft ot nontender suggest lower genital tract cause or placenta or vasa previa
Speculum examination of APH
Cx ectropion: 21%
Dilated cx 2%
Avoid PV if PP is suspected
What case of abruption need hospitalization
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
When to offer corticosteroids for patient with APH
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
When to give tocolytics
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
Mode of birth in case of APH
IUFD: vaginal (if stable) or cs for some
Fetal compromise: CS
Unexplained APH no compromise: senior obstetrician decision
Whnt p feliver if APH after 37w
Minor and major APH: IOL should be considered
Do we give anti-D in APH
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
Blood products used in APH
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
If women with APH DEVELOPS DIC
- Clotting studies + platelet count
- 4 units FFP (1L) + 10 units of cryo (2 packa)
Women with APH taking anticoagulant therapy
- Stop anticoagulant
- Admission
- Consider IV UFH until RF for hmg have resolved
- Thromboprophylaxis should be commenced or restarted
- In case of coagulopathy: UFH/ graduated compression stocking
Management of hmge up to 1000 ml with no shock
IV access (14 gauge cannulax1)
Give crystalloid infusion (hartmann’s infusion)
Management of massive hemorrhage >1000 ml or clinical shock
- ABC
- O2 mask at 10-15L/min
- IV ACCESS (14 gauge cannula)
- Left lateral tilt
- Transfuse blood asap
- Until blood is available: infuse up to 3.5 L of warmed crystalloid and/or colloid
Our therapuetic goal of fluid replacement in APH
Hb >8 g/dl
Plateletes >75x10^9/L
PT,aPTT< 1.5 of mean control
Fibrinogen >1 g/L
