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Obs & Gynae > APH > Flashcards

APH Flashcards

1
Q

What is APH

A

Haemorrhage from genital tract >24 weeks but before delivery

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2
Q

What causes APH

A 
Placenta praevia 
Placenta abruption 
Placenta accreta 
Vasa praevia 
Blood conditions
Local lesions - polyp / ectropion 
Infection 
Trauma
Cancer 
Uterine rupture
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3
Q

What local lesions cause APH

A 
Cervical erosions due to high oestrogen 
Polyps 
Cervical cancer
Cervicitis 
Trichomonas / thrush 
Lochia 
UTI
STI

Do speculum when praevia excluded and smear test

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4
Q

What blood conditions can lead to APH

A 
ITP 
Anti-coagulant 
Von Hillebrand 
Leukaemia 
Hodkings 
Anti-phospholipid syndrome
= Haematology input
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5
Q

What do you want to know in regards to bleeding / examination and investigation

A 
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

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6
Q

How do you manage bleeding

A

Admit to assessment unit

Mx depends on amount of bleeding, condition of mother, gestation

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7
Q

What is mild moderate severe

A

Mild = <50ml
Moderate = 50-1000ml no signs of shock
Massive >1000ml or signs of shock

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8
Q

What do you do if very severe / maternal shock or fatal distress

A

ABCDE
Resus
Delivery

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9
Q

What do you do if discharge

A

High risk pregnancy

Anti-D

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10
Q

What is placenta praaevia

A

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

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11
Q

What is minor and what is major

A 
Minor = grade 1 and 2
Major = grade 3 and 4
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12
Q

What are the symptoms of placenta praevia

A 
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
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13
Q

What are RF for placenta praaevia

A 
Multiple pregnancy
Multipariy
Smoking
Age - older
Previous praevia
Previous C-section - low scar
Uterine abnormality e.g. fibroid 
Assisted conception
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14
Q

How do you Dx placenta praevia

A 
USS - may be Dx before symptoms 
MRI - not widey use 
Abdo exam
CTG 
NO VAGINAL EXAM AS RISK OF RUPTURE
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15
Q

What type of USS and what does it show

A 
Transvaginal safe
Usually picked up at 20 week scan
Shows location of placenta
May show abruption - DDX
More accurate if anterior placenta
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16
Q

What do you do with regards to labour if picked up

A

Planned C-section at 37 due to risk of haemorrhage
Posterior better as see baby first
May need easier if major bleed

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17
Q

What do you do if spotting or bleeding stopped

A

FBC
G+S
Anti-D
Monitor as high risk

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18
Q

What do you do if severe bleed / shock / distress

A 
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
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19
Q

When would you deliver

A

If near EDD
If heavy bleeding
If fatal distress / severe IUGR

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20
Q

What are risks of praevia

A

Hypovolaemic shock
premature
Hypoxia -> cerebral palsy
PPH

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21
Q

What causes PPH

A

Uterus can’t contact

May require emergency hysterectomy

22
Q

When do you give steroid in planned C-section

A

48 hours - 7days before birth

23
Q

What is placental abruption

A

Haemorrhage from placenta separating it from uterine wall before birth
Usually still in normal place

24
Q

What is revealed

A

Major haemorrhage thrugh cervical os

25
Q

What is concealed

A

Haemorrhage between placenta and uterine wall
Fundal height larger than age due to blood
Uterus can look bruised as bloods penetrates

26
Q

What are symptoms of abruption

A 
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
27
Q

What should you beware of

A

Anuria

28
Q

What are RF for abruption

A 
Multiple pregnancy
Multiparity
Age 
Trauma 
Smoking
Cocaine
Previous abruption 
Previous C-section 
PET / HELLP 
Trauma
Polyhydramnio
Infection
29
Q

How do you Dx

A 
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
30
Q

What do you do for mild

A

Settle

Close supervision

31
Q

If severe / distress

A 
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
32
Q

What do you give post natal

A

VTE
Clinical incident
Asses neonatal team
Anti-D

33
Q

What are complications for mother

A 
Anaemia 
Infection 
Maternal shock
Collapse 
DIC 
Renal failure due to DIC
Renal tubular necrosis
PPH
Ischaemia or distal organs
34
Q

What are fatal complications

A 
Fetal distress- quicker than praaevia
Hypoxia 
Lactic acidosos
Encephalopathy 
Still birth
Pre-mature
IUGR if chronic 
Anaemia
35
Q

What is placenta acretia

A

Placenta invades myometrium

36
Q

What are symptoms. of placenta acretia

A

Massive obstetric haemorrhage
POSTPARTUM
Prolonged 3rd stage
Bleeding

37
Q

What are the RF for placenta accrete

A 
Previous C-section 
Placenta praevia
Previous PID
Congenital uterine defect
Fibroid
Ectopic
38
Q

How do you Dx

A

MRI

Suspect if low lying anterior placenta on USS and refer

39
Q

How do you plan for labour if known

A

Planned C-section

40
Q

How do you treat if discovered post partum

A

Hysterectomy
Leave placenta in situ as removing causes major haemorrhage
Ergometrine and oxytocin may help

41
Q

What is placenta percreta

A

Placenta invades past myometrium into bladder
Hx C-section / praaevia
Present frank haematuria

42
Q

What is Vasa Praevia

A

Blood loss due to rupture of foetal vessel not contained in umbilical cord when membrane ruptures

43
Q

What are the symptoms of vasa praevia

A 
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
44
Q

How do you treat

A

Urgent C-section as risk of hypoxia and death

45
Q

What causes uterine rupture

A

Usually in labour or 3rd trimester
C-section scar dishescence
Stimulation for IOL when obstruction

46
Q

What are the symptoms of uterine rupture

A 
Pain
Vaginal bleeding
Maternal shock
Tachy
Inability to palpate present part
Cessation of contraction
Fetal distress
47
Q

When would you consider rupture in post partum

A

Continuous PPH with well contracted uterus or after vaginal repair
If PPH - usually due to atony and poor contraction

48
Q

What are RF for rupture

A 
C-section
Previous uterine surgery 
Breech
Forcep
Obstructed labour
Oxytocin / induction 
Previous cervical surgery
Obesity
49
Q

How do you treat rupture

A 
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
50
Q

What do you give post op

A

Ax

Obs & Gynae (23 decks)

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