APH

Question 1

What is the definition of an APH?

Answer 1

Bleeding from or into the genital tract, occuring from 24+0 weeks - prior to birth of the baby.

(RCOG)

Question 2

There are no consistent definitions of the severity of an APH, but in what 4 catergories is it typically broken down into?

Answer 2

Spotting- staining/streaking of blood in underwear or on pad

Minor haemorrhage- blood loss >50mls and settles

Major haemorrhage- blood loss of 50-1000mls with no signs of clinical shock

Massive haemorrhage- Blood loss >1000mls with signs of clinical shock

Question 3

What are the two most important causes of APH?

Answer 3

Placenta praevia and Placental Abruption

(Although not the most common causes)

(RCOG)

Question 4

What are the risk factors for placental abruption?

Answer 4

• previous abruption (reoccurs in 19-25% of those who have had 2x previous)
• pre-eclampsia
• FGR
• Low BMI
• Abdominal trauma (Accident/Dom Violence)
• Polyhydramnios
• FGR
• PROM
• Advanced maternal age and multiparity
• Smoking and drug use (amphetamines/cocaine) during pregnancy

Question 5

What are the risk factors for placenta praevia?

Answer 5

• previous praevia
• previous LSCS
• previous TOP
• multiparity
• advanced maternal age >40
• smoking
• assisted conception
• deficient endometrium due to: uterine scars, fibroids, prev manual removal of placenta or previous endometrisis (inflammation of endometrium/inner lining of uterus)

Question 6

What are the maternal complications of an APH?

Answer 6

• Anaemia
• infection
• Maternal Shock
• Renal Tubular necrosis
• PPH
• complications of a blood transfusion
• Risk of DIC

Question 7

What are the fetal complications of an APH?

Answer 7

• Hypoxia
• SGA and FGR
• Premature delivery
• Fetal Death

Question 8

How is placenta praevia clinically presented?

Answer 8

-Signs of hypovolaemia (pale, sweating, tachycardia, increased RR, decreased BP and urine output)

• Painless bleeding
• Soft Uterus
• Often no fetal compromise

Question 9

How is placental abruption clinically presented?

Answer 9

• signs of hypovolaemia
• concealed or revealed bleeding
• severe, constant abdominal pain
• tender, rigid uterus
• fetal compromise
• risk of DIC

Question 10

How is a uterine rupture clinically presented?

Answer 10

• signs of hypovolaemia
• sudden onset of constant pain
• presenting part is high
• bleeding, which may be concealed
• pathological CTG
• contractions may cease
• haematuria

Question 11

How is vasa praevia clinically presented?

Answer 11

• PV bleeding following ROM
• Acute fetal compromise
• Sinusoidal CTG trace
• Fetal Bradycardia
• No change in maternal condition

(Fetal blood- catastrophic to fetus)

Question 12

Management of Massive APH?

Answer 12

• Obstetric emergency- call for soaps. 2222 for neonatologist (may need to transfuse baby) and haematoligist.
• Lay mother on left lateral positon
• Give high flow oxygen 15L/min
• Gain IV access x2
• take bloods: FBC, clotting, g&s, Xmatch 4 units and check Rh status.
• Rapid fluid replacement x2 of crystalloid, haartmans or 0.9% saline
• Assess fetal wellbeing via continuous CTG
• Maternal obs (resps, BP, pulse and sats)
• find source of bleed, clinical history
• examine abdomen for tone/pain
• measure blood loss
• fluid balance
• consider expediting birth and mode of birth
• advise active management of 3rd stage followed by IV syntocinon infusion for 4 hours (40iu of synt to 46ml of saline)
• hourly fluid balance assessment following birth