APH

Question 0

General approach in someone with APH?

Answer 0

DRS ABC
- head down, large bore cannula, bloods out, fluids in

HISTORY

• gestational age is key > 20 weeks (worrying)
• characteristics of bleeding (painless - PP, abruption - severe pain, abdominal contractions)
• obstetric Hx of complications
• 25% of cases of 2nd trimester cases dt low-lying placenta/abruption

Examination
- speculum only after ruling out vaginal exam

Initial Ix

• TV US
• blood group and kleihauer
• Hb

Principles of treatment

• resuscitate
• anti-D if Rh-ve with kleihauer to quantify bleed

Question 1

What are the causes of APH?

Answer 1

Obstetric

• placenta previa
• placental abruption
• vasa previa

Uterine rupture

Local

• cervical erosion
• cervical cancer

Question 2

What is placenta previa? How can it cause bleeding?

Answer 2

When the placenta is inserted wholly/partially in the lower uterine segment near or over the cervical os.

If partial detachment (from shearing forces) -> maternal bleeding +/- foetal bleeding if foetal vessel involved

Question 3

How is placenta previa classified?

Answer 3

Low lying
Marginal
Partial
Complete

Question 4

RFs for placenta previa?

Answer 4

• Previous placenta previa
• advanced maternal age
• multiple gestation, multiparity
• previous Caesarian delivery (PP accreta)

Question 5

What is the significance of the gestational age being > 20 weeks?

Answer 5

10% of low-lying placentas at 16-20 week US will remain low lying at term

Question 6

What are the risks associated with PP?

Answer 6

Placenta accreta
PTL
Malpresentation

Question 7

S + S of pp?

Answer 7

Painless bleeding in a woman > 20 weeks gestation
Uterine contractions
PV exam contraindicated

Foetal

• Unstable foetal HR
• transverse or oblique lie

Often asymptomatic and identified at 20 week morph scan

Question 8

Ix for pp?

Answer 8

LAB

• Hb
• if Rh-, kleihauer: quantifies fetomaternal haemorrhage allowing for anti-D dose
• blood group

US - diagnostic, also excluded placenta accreta

Question 9

What is a placental abruption?

Answer 9

It’s when the placenta detaches from the uterine wall which ruptures the blood vessels.

This leads to foetal compromise/death

Question 10

What are your risk factors of abruption?

Answer 10

Trauma
Vasoactive drugs 
- cocaine
- smoking
Previous abruption 
Hypertension 
Pre-eclampsia/eclampsia

Question 11

S + S of Placental abruption?

Answer 11

Abrupt painful PV bleeding, usually in those with gestation > 20 weeks
ABDO pain +/- back pain
Uterine contractions

Question 12

Ix for placental abruption?

Answer 12

LAB 
CBE EUC LFT CRP
Blood group 
Kleihauer 
D-dimer 
If concerned about DIC -> COAGS 

RAD
US for retroplacental haematoma

Question 13

Management of P. Abruption?

Answer 13

If acute severe -> resuscitation

If severe, or > 36 weeks -> urgent delivery. Vaginal delivery +/- oxytocin.
If mother unstable -> Caesarian

For non-severe abruption
expectant management. If foetal compromise -> delivery. Optimise with beta methasone +/- MgSo4 for foetal neuroprotection

Question 14

Complications of p. Abruption?

Answer 14

Mother

• haemorrhage/shock
• > AKI, ARDS, multi-organ failure
• DIC

Foetus

• hypoxia
• prematurity