APH Flashcards
1
Q
APH incidence
A
3-5 % of pregnancies
1/5 th of preterm with APH and cerebral palsy
2
Q
woman 30-32 weeks, uneventful pregnancy, US norma, mild APH <50 ml, most important step for diagnosis
A
Local causes, ectropian
perspeculum
3
Q
Can APH be prevented?
A
- advise, encourage and help to change modifiable risk factors (such as smoking & drug misuse).
- placenta praevia: good practice to avoid vaginal and rectal examinations & to avoid penetrative sexual intercourse.
4
Q
Is APH associated with any specific pregnancy complications and outcomes?
A
- domestic violence in pregnancy may result in APH.
- APH is associated with maternal and perinatal morbidity and mortality. Clinicians managing be aware of potential consequences.
5
Q
Where should the woman presenting with APH be managed?
A
- advise to report all vaginal bleeding to care provider.
- presenting to midwifery-led maternity unit, GP or A & E assessed, stabilised if necessary and transferred to hospital maternity unit with facilities for resuscitation (such as anaesthetic support and blood transfusion
resources) and performing emergency operative delivery. - MDT including midwifery and obstetric staff, with immediate access to laboratory, theatre, neonatal and anaesthetic services, should provide clinical assessment.
6
Q
What is the role of clinical assessment in women presenting with APH?
A
- role of clinical assessment in women presenting with APH is first to establish whether urgent intervention is required to manage maternal or fetal compromise.
- process of triage includes history taking to assess coexisting symptoms such as pain, an assessment of extent of vaginal bleeding, cardiovascular condition of mother, and an assessment of fetal wellbeing.
7
Q
Maternal investigations in APH
A
- Investigations performed to assess extent & physiological consequences of APH.
- maternal investigations performed will depend on amount of bleeding.
- Kleihauer test: performed in RhD-negative women to quantify fetomaternal haemorrhage (FMH) in order to gauge dose of anti-D Ig required.
- Kleihauer test is not a sensitive test for diagnosing abruption.
- Ultrasound can be used to diagnose placenta praevia but does not exclude abruption.
- Placental abruption is a clinical diagnosis and there are no sensitive or reliable diagnostic tests available. Ultrasound has limited sensitivity in the identification of retroplacental haemorrhage.
8
Q
Fetal investigation in APH
A
- assessment of fetal heart rate should be performed, usually with CTG presenting with APH once mother is stable or resuscitation has commenced, to aid decision
making on mode of delivery. - Whenever possible, CTG monitoring should be performed where knowledge of fetal condition will
influence the timing and mode of delivery. - Ultrasound to establish fetal heart pulsation if fetal viability cannot be detected using external auscultation.
- In context of suspected vasa praevia various tests exist that can differentiate between fetal and maternal blood, but are often not applicable.
9
Q
Should women with APH be hospitalised, and if so, for how long?
A
- presenting with spotting who are no longer bleeding and where placenta praevia excluded can go home after a reassuring initial clinical assessment.
- All with APH heavier than spotting and women with ongoing bleeding should remain in hospital at least until the bleeding has stopped.
10
Q
Should corticosteroids be administered to women who present with APH before term?
A
- offer single course of antenatal corticosteroids to women between 24+0 and 34+6 wks, at risk of preterm birth.
- In women presenting with spotting, where most likely cause is lower genital tract bleeding, where imminent delivery is unlikely, corticosteroids are unlikely to be of benefit, but could still be considered.
11
Q
Should tocolytic therapy be used in women presenting with APH who have uterine activity?
A
- Tocolysis should not be used to delay delivery in a woman presenting with major APH, or who is
haemodynamically unstable, or if there is evidence of fetal compromise. - senior obstetrician should make any decision regarding initiation of tocolysis in event of an APH.
12
Q
Should the antenatal care of a woman be altered following APH?
A
- Following single or recurrent episodes of APH from a cervical ectropion, subsequent antenatal care need
not be altered. - Following APH from placental abruption or unexplained APH, pregnancy should be reclassified as ‘high risk’ and antenatal care should be consultant-led.
- Serial ultrasound for fetal growth should be performed.
13
Q
When should women with APH be delivered and what mode of delivery should be employed in women
whose pregnancies have been complicated by APH?
A
- If fetal death diagnosed, vaginal birth is recommended mode of delivery for most women (provided maternal condition is satisfactory), but CS birth will need to be considered for some.
- If fetus is compromised, CS is appropriate method of delivery with concurrent resuscitation of mother.
- Women with APH and associated maternal and/or fetal compromise are required to be delivered immediately.
- optimum timing of delivery of women presenting with unexplained APH and no associated maternal
and/or fetal compromise is not established. - senior obstetrician should be involved in determining timing and mode of birth of these women.
14
Q
What intrapartum fetal monitoring should be employed for women whose pregnancies were complicated by APH?
A
-in labour with active vaginal bleeding require continuous electronic fetal monitoring.
- In women who are in preterm labour whose pregnancies have been complicated by major APH or
recurrent minor APH, or if there has been any clinical suspicion of an abruption, then continuous electronic fetal monitoring should be recommended. - who experienced one episode of minor APH, in which there have been no subsequent concerns regarding maternal or fetal wellbeing, intermittent auscultation is appropriate.
- with minor APH with evidence of placental insufficiency (such as fetal growth restriction or oligohydramnios) should be recommended to undergo continuous electronic fetal monitoring.
15
Q
What is the optimal mode of anaesthesia for women who have experienced APH?
A
- Regional anaesthetic is recommended for operative delivery unless there is a specific contraindication.
- In case of APH where maternal or fetal condition is compromised and CS required, GA should be considered to facilitate control of maternal resuscitation and to expedite delivery.
- consultant anaesthetist should be involved in intrapartum care of women with APH with associated compromise.
