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Women's Health > APH > Flashcards

APH Flashcards

1
Q

What is APH?

A

Bleeding from the genital tract >5mL occurring 20/40 - birth.
Important causes:
- placenta previa
- placental abruption

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2
Q

What is the leading cause of perinatal and maternal mortality worldwide?

A

APH

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3
Q

How is APH classified?

A

Spotting / minor / major / massive.

  • Spotting: staining, streaking or spotting on underwear or sanitary protection.
  • Minor: less than 50mL that has settled
  • Major: 50 - 1000mL with no signs of clinical shock
  • Massive: more than 1000mL +/- clinical signs of shock
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4
Q

What are the RFx for abruption?

A
  • Previous abruption
  • PEt
  • IUGR
  • Non vertex presentation
  • Polyhydramnios / multiparity
  • Advanced maternal age
  • Trauma
  • HTN
  • Increased parity
  • Poor nutrition
  • ECV
  • Sudden reduction in uterine volume (e.g. after delivery of first twin).
  • Chorioamnionitis
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5
Q

What are the RFx for placenta praevia?

A
  • Previous previa
  • Previous LUSCS
  • Previous termination
  • Multiparity
  • 40yo +
  • Smoking
  • Deficient endometrium (scar, endometritis, curettage, fibroid)
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6
Q

What are the maternal complications of APH?

A
  • Anaemia
  • Infection
  • Shock
  • ATN
  • Consumptive coagulopathy
  • PPH
  • Prolonged hospital stay
  • Psychological sequelae
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7
Q

What are the foetal complications of APH?

A
  • Foetal hypoxia
  • IUGR / SFDs
  • Prematurity
  • FDIU
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8
Q

Why is it important to ascertain pain status on Hx in APH?

A
  • Continous: ? abruption

- Intermittent: ? labour

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9
Q

Hx features APH?

A
  • Pain
  • RFx: previa and abruption
  • Foetal movements
  • ROM
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10
Q

What are the causes of APH?

A
  • Placenta praevia (30% APH)
  • Placental abruption (25% APH)
  • Marginal bleed
  • Vasa praevia (rare condition; + ROM)
  • Uterine rupture
  • Local causes: cervix, vagina (45% APH)
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11
Q

What are potential causes of local bleeding in APH presentation?

A
  • Ectropion
  • Dysplasia
  • Cervicitis
  • Polyps
  • Carcinoma
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12
Q

What is the first aim of APH assessment?

A

Categorise into two groups:

1) Major haemorrhage from APH
2) APH where resuscitative measures are not required

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13
Q

Components of initial APH assessment?

A

HOPC

  • Timing
  • Blood loss
  • AFx: abdo pain, contractions
  • Provoking factors: trauma, sexual intercourse
  • Foetal movements

Current Pregnancy:

  • Previous episodes of bleeding
  • Review of US scans performed earlier esp for placental site on 20w scan or later
  • Complete past obstetric, gynaecological, medical and surgical history.
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14
Q

What features on Hx may help diagnose cause of APH?

A
  • Pain
  • RFx for abruption / previa
  • Foetal movements
  • ROM
  • Pap smear Hx
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15
Q

PEx features to diagnose cause of APH?

A
  • Abdo palpation
  • Spec examination
  • VE: not until US excludes praevia
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16
Q

What is suggested by a tense or woody abdomen in the setting of APH?

17
Q

What is the purpose of spec examination in APH?

A
  • Identify cervical dilation

- visualise lower genital tract cause

18
Q

Emergency mx of major APH?

A
  • Call for help
  • Basic life support: ABCs
  • IV access, bloods, fluid replacement: 16g, crystalloid or colloid
  • Insert IDC and record output
  • Abdo PEx and spec
  • CTG and US
  • Medications (if time permits)
  • Consider delivery
  • Document
  • Communicate
19
Q

Blood Ix in major APH?

A
  • FBE
  • Group and crossmatch
  • Coagulation profile
  • Kleihauer
  • ABG in severe cases
  • Consider blood products if bleeding severe
20
Q

Purpose abdo palp in APH?

A
  • foetal presentation and lie
  • assess uterine activity
  • assess for pain, tenderness
21
Q

Why is US NOT investigation to diagnose abruption?

A

Will either be substantive and therefore clinically apparent OR not seen on US

22
Q

PEx features suggestive of abruption?

A
  • Tense, tender uterus
  • Large for dates
  • Shock out of proportion with visible bleeding
23
Q

PEx features suggestive of praevia?

A
  • High presenting part
  • Abnormal lie
  • No contractions
  • Soft, non-tender uterus
24
Q

Mx of placenta praevia?

A
  • Resuscitation
  • Foetal assessment and delivery (Major APH)
  • Insert IV and crossmatch
  • Confirm diagnosis on US
  • Expectant Mx if preterm and blood loss small
  • Serial growth scans to exclude IUGR
  • Admit and plan for ongoing hospital admission until C section if major grade
  • Steroid prophylaxis for lung maturity if premature
  • Anti D if Rh -ve
  • C section if large bleed, continuing
  • Watch for PPH,
  • counsel re possible hysterectomy
  • Avoid digital examination and intercourse in T3
25
Q

How is placenta praevia diagnosed?

A 
Diagnosis 
by US: inferior edge of placenta and os measured
- asymptomatic minor: f/u scan 32-36w
- asymptomatic major: f/u scan 30-32w
- symptomatic: individual Mx
26
Q

What is placenta praevia?

A

Placenta attached to lower segment of uterus, may cover cervix.
Placental site usually >5cm from os.

27
Q

What is placental abruption?

A

Haemorrhage from decidual detachment of a normally situated placenta.

28
Q

Mx placental abruption?

A
  • Resuscitate and restore volume
  • IV access with 2x 16g
  • Cross match, (+ platelets and FFP if MTP ?required).
  • Ix: FBE, coags, UEC, LFTs, Kleihauer test
  • Monitor urine output
  • Anti D
  • ASAP foetal assessment and continuous monitoring
  • Rx: steroids, MgSO4 (if under 30w and delivery planned)
  • Consider delivery
29
Q

Considerations for delivery in placental abruption in premature gestation?

A 
PREMATURE (32-37) : 
Conservative for minor abruption.
Delivery if
- susbstantive blood loss
- significant uterine tenderness
- coagulopathy or 
- foetal compromise.
30
Q

Considerations for delivery in very and extreme prem APH due to abruption?

A

VERY PREM (28-32) and EXTREME preterm (<28)

  • Conservative management even if susbstantive bleeding but only if both maternal and foetal conditions stable. Weigh risks of early delivery and continuing pregnancy.
  • C section if mother / foetus unstable. Stabilise both.
31
Q

Should women with abruption be admitted?

A

Nearly all abruption admitted. Will often remain in hospital until delivery.

32
Q

Follow up following delivery in cases of abruption?

A
  • Send placenta for path
  • Maternal screening for thrombophilias
  • Advise drug and smoking cessation
33
Q

What are the serious complications of abruption?

A
  • FDIU
  • Maternal haemorrhage and shock
  • PPH
  • DIC
34
Q

Amount of blood to cross match in major APH?

35
Q

Should antenatal care be altered following APH?

A
  • Cervical ectropion: no

- Abruption or unexplained APH: high risk; consultant led ANC

36
Q

What is appropriate management of third stage of labour in women with APH?

A
  • PPH should be anticipated
  • Counsel need for active management
  • Consider Syntometrine (ergometrine + oxytocinon) if no HTN

Women's Health (39 decks)

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