APH Flashcards
What is APH?
Bleeding from the genital tract, occurring from 24w of pregnancy + prior to birth
What are the 3 most important causes of APH?
Placenta praevia
Placental abruption
Vasa praevia
Give 6 non-pregnancy related causes of APH
Infection
Cervicitis
Cervical ectropion
Cervical carcinoma
Cervical polyp
Trauma
Give 3 risk factors for vasa praevia
Low lying placenta
IVF pregnancy
Multiple pregnancy
What is vasa praevia?
Fetal vessels run across internal cervical os, due to velamentous insertion of umbilical cord/ presence of accessory placental lobe
Proximity to os means when ROM occurs, these bleed profusely
How does vasa praevia present?
Heavy painless PV bleeding following ROM
Give 7 risk factors for placental abruption
PREVIOUS abruption
Pre-eclampsia
Age >35
Polyhydramnios
PROM
Multiparity
Chorioamnionitis
What 2 substances increase risk of abruption?
Cocaine
Smoking
Give 5 risk factors for placenta praevia
PREVIOUS praevia
Hx C-section
Hx TOP
Multiparity
Age >40
What is placental abruption ?
premature separation of the normal-sited placenta from the uterus
usually in 3rd trimester but can happen any time after 20w
What are the 2 presentations of placental abruption?
Revealed: PV bleeding
Concealed: No visible bleeding
Give 4 signs/ symptoms of abruption
Abdo pain (most common): posterior abruptions may present with back pain
PV bleeding
Uterine contractions
Dizziness +/or loss of consciousness
Describe the uterus on palpation in abruption
“Woody”, tense uterus
Tender
What bloods are performed in abruption?
FBC, U+Es, LFTs
Clotting profile
Group + save
Cross match
Kleihauer test
What investigations are performed in abruption?
Bloods
CTG: fetal hypoxia- bradycardia, decals
USS (doesn’t exclude abruption)
What is the immediate management for placental abruption?
A-E approach
Gain 2x IV access
Bloods
Continuous foetal monitoring
Kleihauer test + anti-D
Fluid, antifibrinolytics, blood
What is the management of abruption if the mother is haemodynamically unstable or there are signs of foetal distress?
Emergency C-section (irrespective of gestation)
What is the management of abruption if the mother is haemodynamically stable and there are NO signs of foetal distress?
If <35w: steroids + admit for monitoring
If >37w: IOL
What is placenta praevia?
placenta lying directly over the internal os.
What is low lying placenta?
placental edge is <20 mm from the internal os on transabdominal or transvaginal scanning (TVS)
How does placenta praevia present?
PainLESS PV bleeding
Soft uterus
How should suspected praevia be examined?
AVOID PV exam
Which scan is superior for diagnosing praevia?
TVUSS
How should incidental finding of placenta praevia/ low lying placenta be managed?
Advise to avoid sex
Rescan at 32w (only 10% still low lying)
If still low/ praevia: Rescan at 36w
If still low/ praevia: Elective C section at 36-37w
How should symptomatic presentation (painless bleeding) placenta praevia/ low lying placenta be managed?
A-E
Gain IV access
Bloods
Continuous fetal monitoring
Anti-D
Decide on delivery
What is indicated in haemodynamic unstable mothers/ evidence of fetal distress in placenta praevia/ low lying placenta?
Emergency C section
What is the management if a mother is haemodynamically stable and there are no signs of fetal distress in placenta praevia/ low lying placenta??
Give steroids + admit until bleeding stops
Rescan at 36w
If still low, elective C section at 34-36w
Are tocolytics used in APH?
generally CONTRAINDICATED
senior obstetrician should make any decision regarding the initiation of tocolysis in APH
