Antipatum haemorrhage Flashcards
Definition of antepartum haemorrhage
Bleeding from the genital tract after the 28th week
Should’ve actually exam be performed on a woman with antepartum Haemorrhage. why?
No Because A low-lying placenta must be excluded
Causes of APH
Placenta praevia Abruptio placenta local lesion of the genital tract Vasa praevia Ruptured uterus Idiopathic Other source e.g. heamaturia, bleeding from a haemorrhoid
Definition of placenta previa
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
Definition of abruptio placenta
Separation of the normally situated placenta from its site.
Cause of abruptio placenta
Usually unknown but sometimes associated with hypertension or trauma it is unavoidable in the majority of cases
How should a major placenta previa be delivered
By Caesarean section only
What are the clinical features of a major placenta previa
Unstable lie
Fetal heart present
Soft uterus with an abnormal presenting part e.g. breach or very high
How do you make a diagnosis of major placenta previa
Clinical suspicion
Ultrasound localisation of the placenta
Management of major placenta previa before 37 weeks
No vaginal examinations
Conservative if bleeding is slight and ceases
Management of major placenta previa after 37 weeks
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
How should minor placenta previa be delivered
Can sometimes deliver vaginally
How does one make the diagnosis of abruptio placenta
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
How do you resuscitate patient with abruptio placenta
Correct – Anaemia – Blood coagulation defect: – Maintain renal function – Maintain cardiovascular dynamics
What is the mechanism behind the coagulation defect in abruptio placenta
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
Management and Abruptio placenta
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
How much should delivery be managed in abruptio placenta
-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
Post delivery management of abruptio placenta
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
Definition of vasa praevia
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
What is the mortality rate of vasa previa
75%
How was the diagnosis of vasa praevia made
The diagnosis is made by blood examination, to detect fetal cells Kleihauer and Apt test
Management of vasa praevia
Proceed with the delivery:
– Cesarian section if alive and normal CTG
– Vaginal delivery if fetus is dead
Who is at risk for a ruptured uterus
Patients with previous uterine surgery e.g. previous Caesarian section or myectomy
Increased incidence after classical cesarian section
Clinical features of a ruptured uterus
– 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
