Antipatum haemorrhage

Question 1

Definition of antepartum haemorrhage

Answer 1

Bleeding from the genital tract after the 28th week

Question 2

Should’ve actually exam be performed on a woman with antepartum Haemorrhage. why?

Answer 2

No Because A low-lying placenta must be excluded

Question 3

Causes of APH

Answer 3

Placenta praevia
Abruptio placenta
local lesion of the genital tract
Vasa praevia
Ruptured uterus
Idiopathic
Other source e.g. heamaturia, bleeding from a haemorrhoid

Question 4

Definition of placenta previa

Answer 4

A placenta that is situated in the lower segment of the uterus there are four types with major and minor grades . Major a grades cover the internal os and minor grades the lower segment

Question 5

Definition of abruptio placenta

Answer 5

Separation of the normally situated placenta from its site.

Question 6

Cause of abruptio placenta

Answer 6

Usually unknown but sometimes associated with hypertension or trauma it is unavoidable in the majority of cases

Question 7

How should a major placenta previa be delivered

Answer 7

By Caesarean section only

Question 8

What are the clinical features of a major placenta previa

Answer 8

Unstable lie
Fetal heart present
Soft uterus with an abnormal presenting part e.g. breach or very high

Question 9

How do you make a diagnosis of major placenta previa

Answer 9

Clinical suspicion

Ultrasound localisation of the placenta

Question 10

Management of major placenta previa before 37 weeks

Answer 10

No vaginal examinations

Conservative if bleeding is slight and ceases

Question 11

Management of major placenta previa after 37 weeks

Answer 11

No vaginal examinations
Top up transfusion if necessary
Crossmatch blood and keep in reserve
Bed resting hospital
Elective Caesarian section at 37 to 38 weeks
Beware that interuterine growth restriction may occur if there has been repeated bleeding therefore there is need for repeat ultrasound for fetal growth

Question 12

How should minor placenta previa be delivered

Answer 12

Can sometimes deliver vaginally

Question 13

How does one make the diagnosis of abruptio placenta

Answer 13

Diagnosis is usually made clinically investigations can be used to assist these include:
Low HB
Increased clotting time
Blood clotting screen
CTG for differential diagnosis as well as assessment of fetal Well being it will be pathological
Blood gas
Renal function derange to
Vaginal exam to assess the cervix if the diagnosis is uncertain

Question 14

How do you resuscitate patient with abruptio placenta

Answer 14

Correct
– Anaemia
– Blood coagulation defect:
– Maintain renal function
– Maintain cardiovascular dynamics

Question 15

What is the mechanism behind the coagulation defect in abruptio placenta

Answer 15

Tissue destruction from the placenta sharing results in the release of thromboplastin which causes D I C that results in Fibrinolysis and depletion of fibrinogen resulting in continued bleeding

Question 16

Management and Abruptio placenta

Answer 16

Fresh whole blood
Plasma constituents, platelet concentrations, fibrinogen concentrate, FFP
Renal function: catheterise,Monitor intake and Output
Cardiovascular system: look for shock and shocked lung, maintenance should be based on the pulse and blood pressure
Delivery: as soon as possible

Question 17

How much should delivery be managed in abruptio placenta

Answer 17

-Induction and vaginal delivery if the baby is dead
– Vaginal delivery if the baby is okayand a quick delivery is anticipated
– Caesarian section if baby in fetal distress and delivery not imminent
– Caesarian section with dead baby only if induction fails
– Epidural is contraindicated due to potential “coagulopathy and therefore danger of spinal-cord compression by haematoma

Question 18

Post delivery management of abruptio placenta

Answer 18

Continue to correct if clotting defect
Postpartum haemorrhage is common due to poor uterine contraction and oxytocin fusion should be maintained
Correct anaemia by blood transfusion

Question 19

Definition of vasa praevia

Answer 19

Rare condition. Rupture of blood vessels running through fetal membranes that lie over there internal cervical os. They may be running to join an accessory (succenturiate) placental lobe

Question 20

What is the mortality rate of vasa previa

Answer 20

75%

Question 21

How was the diagnosis of vasa praevia made

Answer 21

The diagnosis is made by blood examination, to detect fetal cells Kleihauer and Apt test

Question 22

Management of vasa praevia

Answer 22

Proceed with the delivery:
– Cesarian section if alive and normal CTG
– Vaginal delivery if fetus is dead

Question 23

Who is at risk for a ruptured uterus

Answer 23

Patients with previous uterine surgery e.g. previous Caesarian section or myectomy
Increased incidence after classical cesarian section

Question 24

Clinical features of a ruptured uterus

Answer 24

– Abdominal pain especially if persistent between contractions
– Blood loss vaginally
- fetal distress
– Heamaturia
– Abnormal line of the fetus – dead fetus
– Uterus felt abdominally separate to the fetus
– Maybe shock out of proportion with the blood loss

Question 25

Management of a ruptured uterus

Answer 25

– Correct the shock

– Laparotomy and the repair or abdominal hysterectomy