APH Flashcards
What is APH
Haemorrhage from genital tract >24 weeks but before delivery
What causes APH
Placenta praevia Placenta abruption Placenta accreta Vasa praevia Blood conditions Local lesions - polyp / ectropion Infection Trauma Cancer Uterine rupture
What local lesions cause APH
Cervical erosions due to high oestrogen Polyps Cervical cancer Cervicitis Trichomonas / thrush Lochia UTI STI
Do speculum when praevia excluded and smear test
What blood conditions can lead to APH
ITP Anti-coagulant Von Hillebrand Leukaemia Hodkings Anti-phospholipid syndrome = Haematology input
What do you want to know in regards to bleeding / examination and investigation
Timeframe and amount of bleeding Amount, onset, duration, progress Any pain Other Sx Fetal movement Contractions / rupture of membrane Full gynaecologist Hx RF
Signs of shock
Abdo exam
USS
VE only if praevia excluded by USS
How do you manage bleeding
Admit to assessment unit
Mx depends on amount of bleeding, condition of mother, gestation
What is mild moderate severe
Mild = <50ml
Moderate = 50-1000ml no signs of shock
Massive >1000ml or signs of shock
What do you do if very severe / maternal shock or fatal distress
ABCDE
Resus
Delivery
What do you do if discharge
High risk pregnancy
Anti-D
What is placenta praaevia
All or part of placenta attached to lower segment of uterus
Grade 1 = encroaches internal cervical os
Grade 2 = placenta reaches internal os
Grade 3 = placenta covers os
Grade 4 = central
What is minor and what is major
Minor = grade 1 and 2 Major = grade 3 and 4
What are the symptoms of placenta praevia
Painless PV bleed Often small before large Soft non-tender uterus Malpresentation High foetal head Abnormal lie Heart normal Coag normal Maternal condition correlates with amount of bleeding
What are RF for placenta praaevia
Multiple pregnancy Multipariy Smoking Age - older Previous praevia Previous C-section - low scar Uterine abnormality e.g. fibroid Assisted conception
How do you Dx placenta praevia
USS - may be Dx before symptoms MRI - not widey use Abdo exam CTG NO VAGINAL EXAM AS RISK OF RUPTURE
What type of USS and what does it show
Transvaginal safe Usually picked up at 20 week scan Shows location of placenta May show abruption - DDX More accurate if anterior placenta
What do you do with regards to labour if picked up
Planned C-section at 37 due to risk of haemorrhage
Posterior better as see baby first
May need easier if major bleed
What do you do if spotting or bleeding stopped
FBC
G+S
Anti-D
Monitor as high risk
What do you do if severe bleed / shock / distress
ABCDE Resus 2 large bore cannula IV fluid X match FBC, U+E, LFT, cotting High flow O2 Transfusion to maintain BP >100 Catheterise Monitor urine >30ml / hour Arrange USS CTG Steroid for lung maturity
When would you deliver
If near EDD
If heavy bleeding
If fatal distress / severe IUGR
What are risks of praevia
Hypovolaemic shock
premature
Hypoxia -> cerebral palsy
PPH
What causes PPH
Uterus can’t contact
May require emergency hysterectomy
When do you give steroid in planned C-section
48 hours - 7days before birth
What is placental abruption
Haemorrhage from placenta separating it from uterine wall before birth
Usually still in normal place
What is revealed
Major haemorrhage thrugh cervical os
What is concealed
Haemorrhage between placenta and uterine wall
Fundal height larger than age due to blood
Uterus can look bruised as bloods penetrates
What are symptoms of abruption
Severe abdominal pain Constant pain and contractions Vaginal bleeding - can be minimal Usually just a single episode Hard, tender, enlarged uterus Increased activity and tone Fatal heart abnormal Fetal distress Maternal shock - may not correlate to level of bleeding Lie usually normal
What should you beware of
Anuria
What are RF for abruption
Multiple pregnancy Multiparity Age Trauma Smoking Cocaine Previous abruption Previous C-section PET / HELLP Trauma Polyhydramnio Infection
How do you Dx
Mostly on clinical signs - Hard woody uterus - Women in pain USS poor but still get if you suspect Apply CTG to assess heart beat May have evidence of coagulopathy
What do you do for mild
Settle
Close supervision
If severe / distress
ABCDE X-match + bloods + ABG + coag IV access MAJOR OBSTETRIC HAEMORRHAGE Fluid resus Blood resus - may need FFP Deliver baby Vaginal if small C-section if large
What do you give post natal
VTE
Clinical incident
Asses neonatal team
Anti-D
What are complications for mother
Anaemia Infection Maternal shock Collapse DIC Renal failure due to DIC Renal tubular necrosis PPH Ischaemia or distal organs
What are fatal complications
Fetal distress- quicker than praaevia Hypoxia Lactic acidosos Encephalopathy Still birth Pre-mature IUGR if chronic Anaemia
What is placenta acretia
Placenta invades myometrium
What are symptoms. of placenta acretia
Massive obstetric haemorrhage
POSTPARTUM
Prolonged 3rd stage
Bleeding
What are the RF for placenta accrete
Previous C-section Placenta praevia Previous PID Congenital uterine defect Fibroid Ectopic
How do you Dx
MRI
Suspect if low lying anterior placenta on USS and refer
How do you plan for labour if known
Planned C-section
How do you treat if discovered post partum
Hysterectomy
Leave placenta in situ as removing causes major haemorrhage
Ergometrine and oxytocin may help
What is placenta percreta
Placenta invades past myometrium into bladder
Hx C-section / praaevia
Present frank haematuria
What is Vasa Praevia
Blood loss due to rupture of foetal vessel not contained in umbilical cord when membrane ruptures
What are the symptoms of vasa praevia
Painless PV bleeding AFTER rupture Fetal distress - Brady Hard to differentiate from praaevia but occurs after rupture of membranes Major risk to fetes not mother
How do you treat
Urgent C-section as risk of hypoxia and death
What causes uterine rupture
Usually in labour or 3rd trimester
C-section scar dishescence
Stimulation for IOL when obstruction
What are the symptoms of uterine rupture
Pain Vaginal bleeding Maternal shock Tachy Inability to palpate present part Cessation of contraction Fetal distress
When would you consider rupture in post partum
Continuous PPH with well contracted uterus or after vaginal repair
If PPH - usually due to atony and poor contraction
What are RF for rupture
C-section Previous uterine surgery Breech Forcep Obstructed labour Oxytocin / induction Previous cervical surgery Obesity
How do you treat rupture
High mortality Emergency laparotomy to stop any bleeding / repair uterus or can remove uterus then Emergency C-section Emergency resus O2 X-match Transfusion Uterine repair Hysterectomy if large tear
What do you give post op
Ax
