APH

Question 1

APH - def

Answer 1

Bleeding from genital tract in pregnancy at >20 wks’ gestation before onset of labour

Question 2

APH - causes

Answer 2

1. Placental abruption
2. Placenta previa
3. Vasa previa
4. Show
5. Ectropion, STI or genital tract tumour

Question 3

Placental abruption - def

Answer 3

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 (

Question 4

Placental abruption - symptoms

Answer 4

1. Vaginal bleeding (may be dark)
2. Abdominal pain (sudden onset, constant and severe)
3. Posterior placentas - severe backache
4. Many will be in labour (up to 50%) - contractions/uterine activity

Question 5

Placental abruption - signs

Answer 5

1. Uterus tender on palpation
2. Uterine activity common
3. Uterus may later become hard (‘woody’)
4. Maternal signs of shock
5. Fetal distress is common and precedes fetal death

Note - many women will be in labour

Question 6

Placental abruption - dx/ix

Answer 6

**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

Question 7

Placental abruption (and general APH?) - mx

Answer 7

1. Admit all women with vaginal bleeding or unexplained abdominal pain
2. Establish fetal wellbeing CTG; arrange U/S as soon as possible
3. IV access (2 x 16G cannulae) and bloods
4. If fetal distress or maternal compromise, resuscitate and deliver
5. If no fetal distress, and bleeding and pain cease, consider delivery by term

Resuscitation

1. If necessary, BLS. Establish airway and administer oxygen therapy or assist ventilation
2. Infuse fluids at approximately the rate that blood is being lost. Crystalloid or colloid
3. Insert in-dwelling urinary catheter; record hourly urine output
4. If blood component therapy consented to, seek advice from haematologist
5. Consider delivery to improve maternal haemodynamics. Medications (if time permits) = corticosteroids for fetal lung maturation, anti-D if Rhesus negative, analgesia

Minor/settling bleeding

1. 500IU anti-D immunoglobulin unless already sensitised [?]; more may be required based on Kleihauer
2. If bleeding settles and mother discharged, clear plan made for remaining pregnancy + extra fetal surveillance
3. Surveillance after due date may need to be increased. All women who have had APH = high risk. Increased risk of PPH

Question 8

Placenta previa - def

Answer 8

Implantation of placenta in lower segment of uterus (4 grades)

• Major = over os
• Minor = encroaching on os

Question 9

Placenta previa - ix/dx/presentation

Answer 9

• 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)

Question 10

Placenta previa - symptoms

Answer 10

1. Painless vaginal bleeding in third trimester (70-80% of cases)
2. But pain may occur if additional uterine activity or abruption (10-20%)
3. Most episodes of vaginal bleeding are small and self limiting. But may be serious maternal compromise (BP, pulse, central cyanosis)

Question 11

Placenta previa - signs

Answer 11

Digital vaginal examination should be deferred until U/S has excluded the dx
[?]

Question 12

Placenta previa - mx

Answer 12

1. Women with major PP who have previously bled should be admitted from 34 weeks’ gestation
2. 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
3. Delivery is likely to be CS if placental edge

Question 13

Placenta previa - RF

Answer 13

1. Previous PP
2. Previous CS
3. Multiple gestation
4. Multiparity
5. Advanced maternal age

Question 14

Placenta previa - cx

Answer 14

1. Placenta accreta
2. Preterm labour and PPROM
3. Malpresentation (non-cephalic)
4. IUGR
5. Vasa previa

Question 15

Placental abruption - RF

Answer 15

1. Previous abruption
2. Smoking
3. Cocaine/other drug use
4. HTN
5. Preeclampsia/eclampsia

Question 16

Vasa previa - def

Answer 16

Fetal vessels run in membranes below the presenting fetal part, unsupported by placental tissue or umbilical cord

Question 17

Vasa previa - RF

Answer 17

1. PP
2. IVF
3. Multiple gestation
4. Bilobed or succenturiate lobed (presence of accessory lobe) placenta

Question 18

Vasa previa - symptoms

Answer 18

May present with PV bleeding after rupture of fetal membranes

Question 19

Vasa previa - signs

Answer 19

Rapid fetal distress after rupture of fetal membranes (from exsanguination)

Question 20

Vasa previa - ix/dx

Answer 20

• *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

Question 21

Vasa previa - mx

Answer 21

1. CS prior to onset of labour (emergency)
   Deliver by CS if:
2. Labour
3. PROM
4. Repetitive variable decelerations refractory to tocolysis
5. Vaginal bleeding + fetal tachycardia, sinusoidal HR or evidence of pure fetal blood by Apt test

Question 22

APH - ax (what to do)

Answer 22

Hx - presenting problem

1. Gestational age
2. WWQQAA (including initiating factors (coitus/trauma)
3. Abdominal pain
4. Fetal movements
5. Leakage of fluid/mucus PV

Hx - phx

1. Previous episodes of PV bleeding in this pregnancy
2. Previous uterine surgery (including CS)
3. Smoking + illegal drugs (esp. cocaine)
4. Blood group and rhesus status (determines need for anti-D)
5. Previous obstetric hx (placental abruption, IUGR, PP)

Ex - maternal

1. Vitals - BP, pulse + other signs of haemodynamic compromise - central cyanosis [?]
2. Uterine palpation - size, tenderness, fetal lie, presenting part (if engaged, not PP)
3. Exclude PP before speculum + VE
4. Speculum - ax degree of bleeding and possible local causes of bleeding (trauma, polyps, ectropion) + determining if ROM present
5. VE for cervical changes indicative of labour

Ex - fetus
1. If fetal heart can be heard, commence FHR monitoring [?]