APH

Question 0

List the causes of APH.

Answer 0

Placenta praevia. Abruptio placenta. Local lesions. Vasa praevia. Infections. Coagulation defects. Polyps. Cancer.

Question 1

What is the definition of APH?

Answer 1

Vaginal bleeding from 24/52 gestation until prior to the birth of the baby

Question 2

What important questions must be answered on history?

Answer 2

Onset/ why/ how. Character of pain. Contractions?. Discharge?. Recent VE?. Amount of blood loss. Colour of blood. FM. Precious C/S. History of placenta praevia or abruptio.

Question 3

What is placenta praevia?

Answer 3

Implantation of the placenta in the lower segment of the uterus, where the placenta lies in front of the presenting part.

Question 4

How is placenta praevia diagnosed?

Answer 4

On USS if the placenta is less than 3cm from the margin of the internal os

Question 5

Who is at risk of placenta praevia?

Answer 5

Asian women. Fetal malpresentations. Multiple pregnancies. Tobacco/ cocaine/ methamphetamine use. Age >35. Previous TOP. Previous C/S or other surgery. Previous placenta praevia. Uterine abnormalities.

Question 6

List the complications that can arise from placenta praevia.

Answer 6

PPH. Preterm delivery. IUGR/LBW. Maternal shock. PROM. Placenta accreta/ increta/ percreta. Anaemia. Infections. Fetal hypoxia. Fetal death.

Question 7

List the symptoms of placenta praevia

Answer 7

Painless bleeding. Bright red blood. Presence of FM and FHR. Low Hb. May be shocked. Uterus soft non-tender on palpation. Uterus normal size for dates. Fetal parts easily felt. Presence of abnormal presentation. Head easily balot-able above pelvis.

Question 8

What are the characteristics of the bleeding in placenta praevia?

Answer 8

Painless. 
Recurrent
Not continuous
Not provoked
More heavy after 34/52
Bright red.

Question 9

What are patients with placenta praevia prone to and why?

Answer 9

PPH and abruptio

Due to fewer oblique muscle fibres in the lower segment

Question 10

How many different types of placenta praevia are there?

Answer 10

4

Question 11

What is type 1 placenta praevia?

Answer 11

Lateralis (low-lying) placenta. Lower margin dips into lower uterine segment. Edge within 3cm of cervical os.

Question 12

What is type 2 placenta praevia?

Answer 12

Marginal placenta. Within 2cm of cervical os but does not cover

Question 13

What is a type 3 placenta praevia?

Answer 13

Partial or incomplete placenta.

Placenta covers the os when closed but not when fully dilated

Question 14

What is a type 4 placenta praevia?

Answer 14

Complete placenta.

Covers the internal os completely and centrally, even when fully dilated.

Question 15

What is the difference between a major placenta praevia and a minor?

Answer 15

Major the placenta lies over the cervical os and minor the placenta is not lying over the os but encroaching on the lower uterine segment

Question 16

How is placenta praevia diagnosed?

Answer 16

By transvaginal ultrasound

Question 17

When is follow up scan performed in asymptomatic woman with minor placenta praevia?

Answer 17

32-36/52

Question 18

When is the follow up scan done for an asymptomatic woman with major placenta praevia?

Answer 18

30-32/52

Question 19

When is NVD allowed in placenta praevia?

Answer 19

Allowed with type 1 and 2
Slight bleeding only
Vertex presentation
Partially dilated cervix to allow amniotomy
Adequate pelvis with no soft tissue obstruction

Question 20

What factors influence the management of placenta praevia?

Answer 20

Amount of bleeding. Condition of mother and fetus. Location of placenta (type). Stage of pregnancy.

Question 21

How is a patient managed if there is minimal bleeding which is settling?

Answer 21

Prolong the pregnancy until the fetus is mature, while monitoring fetal and maternal well-being

Question 22

What must never be performed in placenta praevia?

Answer 22

VE

Question 23

What is the emergency management of placenta praevia?

Answer 23

USS localize placenta. Resus and stabilize. IV ringers. Vital signs. FHR-CTG. Hb. Refer to level 2-3 hospital. C/S. AntiD/ cross match/ GOH bloods?.

Question 24

What is the perinatal mortality associated with abruptio placenta?

Answer 24

14-67%

Question 25

What is abruptio placenta and how commonly does it occur?

Answer 25

Premature separation of a normally situated placenta

Occurs 1:100

Question 26

What proportion of fetuses are still born due to abruptio?

Answer 26

30%

Question 27

What are the 4 outcomes of abruptio?

Answer 27

Can cause hypovolaemic shock and acute renal failure
Can cause PPH
Can cause DIC (due to uncontrolled activation of coagulation system, concealed and retro placental)
Can cause couvelaire uterus (–> uterine rupture due to increased pressure during contractions)

Question 28

What are the different types of bleeding in an abruptio?

Answer 28

Revealed bleeding - lower part of the placenta where blood escapes from the vagina.
Concealed bleeding - blood seeps between placenta and uterine wall (–> Couvelaire uterus)
Mixed bleeding

Question 29

What are the risk factors for abruptio?

Answer 29

Pre-eclampsia. Hypertension. Chorioamnionitis. ECV. Previous history of abruptio. Blunt abdominal trauma. Use of cigarettes, cocaine or Tik. Multiple pregnancy. Polyhydramnios. >35-40 yo.

Question 30

What are the characteristics of a grade 1 abruptio?

Answer 30

Asymptomatic.

Small retroplacental clot after delivery

Question 31

What are the characteristics of a grade 2 abruptio?

Answer 31

Mild vaginal bleeding (revealed) with uterine tenderness.

No signs of maternal shock, fetal distress or coagulopathy (48%)

Question 32

What are the characteristics of a grade 3 abruptio?

Answer 32

Moderate
Usually concealed bleed with earwig tent pain and atonic uterus
Increased maternal pulse, decreased BP, abnormal FHR
Coagulopathy may be present
(27%)

Question 33

What are the characteristics of a grade 4 abruptio?

Answer 33

Severe
Can be concealed or revealed with tetanic uterus
Maternal shock, coagulopathy and fetal demise usually present (24%)

Question 34

List the signs and symptoms of abruptio placenta

Answer 34

Continuous bleeding. Dark red blood. Sudden onset abdominal pain. Severe constant pain. Back pain if posterior placenta. Tense, tender uterus (woody uterus). Reduced or no FM. No fetal parts felt. Maternal tachycardia. Uterus larger than dates

Question 35

How do you manage abruptio placenta?

Answer 35

Exclude risk factors at booking. Refer if + hx, and IOL. Advise FM monitoring and stop smoke/drug. Treat degree of shock, resus, stabilize. Vital signs, USS, CTG, Hb, urine output. GA/viability of fetus. IV ringers. Analgesia. FBC, Xmatch, clotting studies.