APH

Question 1

Define APH

Answer 1

Defined as bleeding from or in to the genital tract, occurring from 24 weeks of pregnancy and prior to the birth of the baby.

Question 2

How many of preterm babies are born in asssociation with APH

Answer 2

one fifth

the known association of APH w/ cerebral palsy is d.t preterm delivery

Question 3

APH complicates how many pregnancies ?

Answer 3

Complicates 3-5%

APH is a leading cause of perinatal and maternal mortality worldwide.

Question 4

Causes of APH

Answer 4

Placenta praevia
Placental abruption
Local causes (bleeding from the vulva, vagina or cervix)
Unexplained APH

Question 5

Indicators of blood volume depletion d.t. APH

Answer 5

Maternal - clinical shock
Fetal - compromise or demise

Question 6

Define -
Minor haemorrhage
Major haemorrhage
Massive haemorrhage
Recurrent APH

Answer 6

Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection
Minor haemorrhage – blood loss less than 50 ml that has settled
Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock
Massive haemorrhage – blood loss greater than 1000 ml and/or signs of clinical shock.
Recurrent APH is the term used when there are episodes of APH on more than one occasion.

Question 7

Risks and complication of APH

Answer 7

Maternal:
* anaemia
* infection
* maternal shock
* renal tubular necrosis
* consumptive coagulopathy
* PPH
* prolonged hospital stay
* psychological sequelae
* complications of blood transfusion.
Fetal:
* fetal hypoxia
* SGA
* FGR
* prematurity (iatrogenic and spontaneous)
* death.

Question 8

Can we predict APH

Answer 8

no
it has heterogenous pathophysiology

Question 9

Risk of recurrence with previous 1 and previous 2 abruption

Answer 9

Prev 1 - 4.4%
Prev 2 - 19-25%

Question 10

Which thrombophilia associated with increased risk of abruption ?

Answer 10

Heterozygous factor V Leiden

Question 11

Risk factors for placenta praevia ?

Answer 11

Previous previa
Previous lscs
Previous termination of pregnancy
Multiparty
Multiple pregnancy
Advance maternal age>40
Smoking
Assisted conception
Deficent endometrium

Question 12

How many cases of placental abruption occur in low risk pregnancies ?

Answer 12

70%

Question 13

Can APH be predicted or prevented ?

Answer 13

No

Question 14

Complications of APH ?

Answer 14

Maternal:
Anemia
Infection
Shock
Renal tubular necrosis
Dic
Pph
Prolong hospital stay
Complication of blood transfusion

Fetal:
Fetal hypoxia ,sga and fgr
Preterm labor
Fetal death

Question 15

What should be asked for in history if a female presents with repeated APH ?

Answer 15

Domestic violence

Question 16

Initial management for APH ?

Answer 16

The process of triage includes history taking to assess coexisting symptoms such as pain, an assessment of the extent of vaginal bleeding, the cardiovascular condition of the mother, and an assessment of fetal wellbeing.

Women presenting with a major or massive haemorrhage that is persisting or if the woman is unable to provide a history due to a compromised clinical state, an acute appraisal of maternal wellbeing should be performed and resuscitation started immediately.
The mother is the priority in these situations and should be stabilised prior to establishing the fetal condition.

If there is no maternal compromise a full history should be taken.

Question 17

After the history, what all should be looker for in examination of APH

Answer 17

Abdominal palpation - Assessed for tenderness or signs of an acute abdomen.
The tense or ‘woody’ feel to the uterus on abdominal palpation indicates a significant abruption.
Abdominal palpation may also reveal uterine contractions.
A soft, non-tender uterus may suggest a lower genital tract cause or bleeding from placenta or vasa praevia.

Speculum examination - to identify cervical dilatation or visualise a lower genital tract cause for the APH
2/3 - normal cervix

Digital vaginal examination
If placenta praevia is a possible diagnosis (for example, a previous scan shows a low placenta, there is a high presenting part on abdominal examination or the bleed has been painless), digital vaginal examination should not be performed until an ultrasound has excluded placenta praevia.
Digital vaginal examination can provide information on cervical dilatation if APH is associated with pain or uterine activity.

Question 18

Investigations to be done in case of APH

Answer 18

Maternal
Lab - CBC, Coagulation screen, Urea and electrolytes, LFTs, cross match 4 units for major haemorrhage, Rh neg - assess FMH
CBC, Group and save for minor haemorrhage
Imaging - USG

Fetal
Assessment of FHR by auscultation or USG
CTG if necessary

Question 19

USG fails to detect how many cases of abruption

Answer 19

3/4

Question 20

Role of tocolysis and corticosteroids in case of APH

Answer 20

Tocolysis - not used in major APH, or who is haemodynamically unstable, or if there is evidence of fetal compromise.
Contraindicated in placental abruption and is ‘relatively contraindicated’ in ‘mild haemorrhage’ due to placenta praevia
If tocolysis is employed, then the drug of choice in a woman with a history of APH should have fewest maternal cardiovascular side effects.
The calcium antagonist nifedipine has been associated with cases of maternal hypotension and is best avoided

Offer a single course of antenatal corticosteroids to women between 24+0 and 34+6 weeks of gestation at risk of preterm birth.
In women presenting with spotting, where the most likely cause is lower genital tract bleeding, where imminent delivery is unlikely, corticosteroids are unlikely to be of benefit, but could still be considered.

Question 21

Is hospitalisation necessary in APH

Answer 21

Women presenting with spotting who are no longer bleeding and where placenta praevia has been excluded can go home after a reassuring initial clinical assessment.

All women with APH heavier than spotting and women with ongoing bleeding should remain in hospital at least until the bleeding has stopped.

No evidence to support recommendations regarding duration of inpatient management following APH.

Each woman must be assessed on an individual basis and sound clinical judgment applied
If a woman presents with spotting and has a past history of IUFD resulting from placental abruption, then hospitalisation would be appropriate.

Question 22

Any change in ANC care following APH ?

Answer 22

Following single or recurrent episodes of APH from a cervical ectropion, subsequent antenatal care need not be altered.

Following APH from placental abruption or unexplained APH, the pregnancy should be reclassified as ‘high risk’ and antenatal care should be consultant-led.
Serial ultrasound for fetal growth should be performed