APH Flashcards

1
Q

APH - def

A

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

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2
Q

APH - causes

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

Placental abruption - def

A

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 (

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4
Q

Placental abruption - symptoms

A
  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
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5
Q

Placental abruption - signs

A
  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

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6
Q

Placental abruption - dx/ix

A

**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

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7
Q

Placental abruption (and general APH?) - mx

A
  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
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8
Q

Placenta previa - def

A

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

  • Major = over os
  • Minor = encroaching on os
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9
Q

Placenta previa - ix/dx/presentation

A
  • 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)
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10
Q

Placenta previa - symptoms

A
  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)
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11
Q

Placenta previa - signs

A

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

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12
Q

Placenta previa - mx

A
  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
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13
Q

Placenta previa - RF

A
  1. Previous PP
  2. Previous CS
  3. Multiple gestation
  4. Multiparity
  5. Advanced maternal age
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14
Q

Placenta previa - cx

A
  1. Placenta accreta
  2. Preterm labour and PPROM
  3. Malpresentation (non-cephalic)
  4. IUGR
  5. Vasa previa
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15
Q

Placental abruption - RF

A
  1. Previous abruption
  2. Smoking
  3. Cocaine/other drug use
  4. HTN
  5. Preeclampsia/eclampsia
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16
Q

Vasa previa - def

A

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

17
Q

Vasa previa - RF

A
  1. PP
  2. IVF
  3. Multiple gestation
  4. Bilobed or succenturiate lobed (presence of accessory lobe) placenta
18
Q

Vasa previa - symptoms

A

May present with PV bleeding after rupture of fetal membranes

19
Q

Vasa previa - signs

A

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

20
Q

Vasa previa - ix/dx

A
  • *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
21
Q

Vasa previa - mx

A
  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
22
Q

APH - ax (what to do)

A

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 [?]