APH Flashcards
What is the definition of APH?
Vaginal bleeding from 24/52 gestation until prior to the birth of the baby
List the causes of APH.
Placenta praevia. Abruptio placenta. Local lesions. Vasa praevia. Infections. Coagulation defects. Polyps. Cancer.
What important questions must be answered on history?
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.
What is placenta praevia?
Implantation of the placenta in the lower segment of the uterus, where the placenta lies in front of the presenting part.
How is placenta praevia diagnosed?
On USS if the placenta is less than 3cm from the margin of the internal os
Who is at risk of placenta praevia?
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.
List the complications that can arise from placenta praevia.
PPH. Preterm delivery. IUGR/LBW. Maternal shock. PROM. Placenta accreta/ increta/ percreta. Anaemia. Infections. Fetal hypoxia. Fetal death.
List the symptoms of placenta praevia
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.
What are the characteristics of the bleeding in placenta praevia?
Painless. RecurrentNot continuousNot provokedMore heavy after 34/52Bright red.
What are patients with placenta praevia prone to and why?
PPH and abruptio Due to fewer oblique muscle fibres in the lower segment
How many different types of placenta praevia are there?
4
What is type 1 placenta praevia?
Lateralis (low-lying) placenta. Lower margin dips into lower uterine segment. Edge within 3cm of cervical os.
What is type 2 placenta praevia?
Marginal placenta. Within 2cm of cervical os but does not cover
What is a type 3 placenta praevia?
Partial or incomplete placenta. Placenta covers the os when closed but not when fully dilated
What is a type 4 placenta praevia?
Complete placenta.Covers the internal os completely and centrally, even when fully dilated.
What is the difference between a major placenta praevia and a minor?
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
How is placenta praevia diagnosed?
By transvaginal ultrasound
When is follow up scan performed in asymptomatic woman with minor placenta praevia?
32-36/52
When is the follow up scan done for an asymptomatic woman with major placenta praevia?
30-32/52
When is NVD allowed in placenta praevia?
Allowed with type 1 and 2Slight bleeding onlyVertex presentationPartially dilated cervix to allow amniotomyAdequate pelvis with no soft tissue obstruction
What factors influence the management of placenta praevia?
Amount of bleeding. Condition of mother and fetus. Location of placenta (type). Stage of pregnancy.
How is a patient managed if there is minimal bleeding which is settling?
Prolong the pregnancy until the fetus is mature, while monitoring fetal and maternal well-being
What must never be performed in placenta praevia?
VE
What is the emergency management of placenta praevia?
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?.
What is the perinatal mortality associated with abruptio placenta?
14-67%
What is abruptio placenta and how commonly does it occur?
Premature separation of a normally situated placenta Occurs 1:100
What proportion of fetuses are still born due to abruptio?
30%
What are the 4 outcomes of abruptio?
Can cause hypovolaemic shock and acute renal failureCan cause PPHCan 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)
What are the different types of bleeding in an abruptio?
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
What are the risk factors for abruptio?
Pre-eclampsia. Hypertension. Chorioamnionitis. ECV. Previous history of abruptio. Blunt abdominal trauma. Use of cigarettes, cocaine or Tik. Multiple pregnancy. Polyhydramnios. >35-40 yo.
What are the characteristics of a grade 1 abruptio?
Asymptomatic. Small retroplacental clot after delivery
What are the characteristics of a grade 2 abruptio?
Mild vaginal bleeding (revealed) with uterine tenderness.No signs of maternal shock, fetal distress or coagulopathy (48%)
What are the characteristics of a grade 3 abruptio?
ModerateUsually concealed bleed with earwig tent pain and atonic uterusIncreased maternal pulse, decreased BP, abnormal FHRCoagulopathy may be present (27%)
What are the characteristics of a grade 4 abruptio?
SevereCan be concealed or revealed with tetanic uterusMaternal shock, coagulopathy and fetal demise usually present (24%)
List the signs and symptoms of abruptio placenta
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
How do you manage abruptio placenta?
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.
