APH Flashcards
APH - def
Bleeding from genital tract in pregnancy at >20 wks’ gestation before onset of labour
APH - causes
- Placental abruption
- Placenta previa
- Vasa previa
- Show
- Ectropion, STI or genital tract tumour
Placental abruption - def
Placenta separating partly or completely fom uterus before delivery of fetus (blood accumulates behind placenta in uterine cavity or is lost through cervix)
- Concealed = no external bleeding evident (
Placental abruption - symptoms
- Vaginal bleeding (may be dark)
- Abdominal pain (sudden onset, constant and severe)
- Posterior placentas - severe backache
- Many will be in labour (up to 50%) - contractions/uterine activity
Placental abruption - signs
- Uterus tender on palpation
- Uterine activity common
- Uterus may later become hard (‘woody’)
- Maternal signs of shock
- Fetal distress is common and precedes fetal death
Note - many women will be in labour
Placental abruption - dx/ix
**Clinical dx
1. CTG + U/S to confirm fetal wellbeing and exclude placenta previa
___
2. FBC
3. Kleihauer testing, if woman known to be RhD negatve (to determine extent of feto-maternal haemorrhage and if more anti-D required)
4. Group and hold
5. Coagulation screen
Placental abruption (and general APH?) - mx
- Admit all women with vaginal bleeding or unexplained abdominal pain
- Establish fetal wellbeing CTG; arrange U/S as soon as possible
- IV access (2 x 16G cannulae) and bloods
- If fetal distress or maternal compromise, resuscitate and deliver
- If no fetal distress, and bleeding and pain cease, consider delivery by term
Resuscitation
- If necessary, BLS. Establish airway and administer oxygen therapy or assist ventilation
- Infuse fluids at approximately the rate that blood is being lost. Crystalloid or colloid
- Insert in-dwelling urinary catheter; record hourly urine output
- If blood component therapy consented to, seek advice from haematologist
- Consider delivery to improve maternal haemodynamics. Medications (if time permits) = corticosteroids for fetal lung maturation, anti-D if Rhesus negative, analgesia
Minor/settling bleeding
- 500IU anti-D immunoglobulin unless already sensitised [?]; more may be required based on Kleihauer
- If bleeding settles and mother discharged, clear plan made for remaining pregnancy + extra fetal surveillance
- Surveillance after due date may need to be increased. All women who have had APH = high risk. Increased risk of PPH
Placenta previa - def
Implantation of placenta in lower segment of uterus (4 grades)
- Major = over os
- Minor = encroaching on os
Placenta previa - ix/dx/presentation
- Dx usually made during routine morphology U/S in second trimester in asymptomatic women
- Dx = transvaginal U/S (safe and more accurate than transabdominal U/S)
Placenta previa - symptoms
- Painless vaginal bleeding in third trimester (70-80% of cases)
- But pain may occur if additional uterine activity or abruption (10-20%)
- Most episodes of vaginal bleeding are small and self limiting. But may be serious maternal compromise (BP, pulse, central cyanosis)
Placenta previa - signs
Digital vaginal examination should be deferred until U/S has excluded the dx
[?]
Placenta previa - mx
- Women with major PP who have previously bled should be admitted from 34 weeks’ gestation
- Women with asymptomatic major PP may remain at home if they:
a. Are close to hospital
b. Are fully aware of risks to themselves and baby
c. Have a constant companion
d. Have telecommunication and transport - Delivery is likely to be CS if placental edge
Placenta previa - RF
- Previous PP
- Previous CS
- Multiple gestation
- Multiparity
- Advanced maternal age
Placenta previa - cx
- Placenta accreta
- Preterm labour and PPROM
- Malpresentation (non-cephalic)
- IUGR
- Vasa previa
Placental abruption - RF
- Previous abruption
- Smoking
- Cocaine/other drug use
- HTN
- Preeclampsia/eclampsia
Vasa previa - def
Fetal vessels run in membranes below the presenting fetal part, unsupported by placental tissue or umbilical cord
Vasa previa - RF
- PP
- IVF
- Multiple gestation
- Bilobed or succenturiate lobed (presence of accessory lobe) placenta
Vasa previa - symptoms
May present with PV bleeding after rupture of fetal membranes
Vasa previa - signs
Rapid fetal distress after rupture of fetal membranes (from exsanguination)
Vasa previa - ix/dx
- *1. Dx = transvaginal U/S with colour flow Doppler
2. Or clinical dx:
a. Palpation of fetal vessels in membranes overlying cervical os on VE, or
b. ROM followed by PV bleeding and acute fetal bradycardia
Vasa previa - mx
- CS prior to onset of labour (emergency)
Deliver by CS if: - Labour
- PROM
- Repetitive variable decelerations refractory to tocolysis
- Vaginal bleeding + fetal tachycardia, sinusoidal HR or evidence of pure fetal blood by Apt test
APH - ax (what to do)
Hx - presenting problem
- Gestational age
- WWQQAA (including initiating factors (coitus/trauma)
- Abdominal pain
- Fetal movements
- Leakage of fluid/mucus PV
Hx - phx
- Previous episodes of PV bleeding in this pregnancy
- Previous uterine surgery (including CS)
- Smoking + illegal drugs (esp. cocaine)
- Blood group and rhesus status (determines need for anti-D)
- Previous obstetric hx (placental abruption, IUGR, PP)
Ex - maternal
- Vitals - BP, pulse + other signs of haemodynamic compromise - central cyanosis [?]
- Uterine palpation - size, tenderness, fetal lie, presenting part (if engaged, not PP)
- Exclude PP before speculum + VE
- Speculum - ax degree of bleeding and possible local causes of bleeding (trauma, polyps, ectropion) + determining if ROM present
- VE for cervical changes indicative of labour
Ex - fetus
1. If fetal heart can be heard, commence FHR monitoring [?]
