APH Flashcards by Eilidh Seaton

What is APH

Haemorrhage from genital tract >24 weeks but before delivery

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What causes APH

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

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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

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What blood conditions can lead to APH

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

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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

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How do you manage bleeding

Admit to assessment unit

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

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What is mild moderate severe

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

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

ABCDE
Resus
Delivery

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What do you do if discharge

High risk pregnancy

Anti-D

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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

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What is minor and what is major

Minor = grade 1 and 2
Major = grade 3 and 4

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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

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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

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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

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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

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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

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What do you do if spotting or bleeding stopped

FBC
G+S
Anti-D
Monitor as high risk

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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

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When would you deliver

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

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What are risks of praevia

Hypovolaemic shock
premature
Hypoxia -> cerebral palsy
PPH

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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