APH Flashcards
What is an APH?
Is defined as bleeding from the genital tract from 24+0 and before the birth of the baby. It is a serious complication that may result in the death of mum and baby
(Mayes 2012)
Main varieties of APH
Placenta praevia = bleeding from the separation of an abnormally situated placenta, where the placenta is lying partly or wholly in the lower uterine segment and bleeding is inevitable when labour begins
Placental abruption = bleeding from separation of a normally situated placenta
(Mayes 2012)
What are other less common causes of APH?
Cervical pop = small, red gelatinous growth attached by a pedicle to the cervix, close to the external os. This can cause irregular bleeding
Ectropion of the cervix = cervical erosion is formed when the columnar epithelium lining the cervical canal proliferates owing to the action of pregnancy hormones.
Cervical cancer = need to have CD delivery. Treatment after delivery may be a radical hysterectomy
(Mayes 2012)
Classifications of placenta praevia
Low lying placenta = placenta mainly in the upper segment but encroaching on the lower segment
Marginal = placenta reaching to but does not cover the internal os
Partial = placenta covers the internal os when closed but not completely when dilated
Total = placenta completely covers the internal os
(Mayes 2012)
Risk factors of placenta praevia
- Multiparity = the increased size of the uterine cavity following repeated pregnancies may predispose to placenta praevia as placenta doesn’t tend to implant on scar tissue from other placenta sites - Multiple pregnancy = the larger placental site is more likely to encroach on the lower segment of the uterus - Age - Scarred uterus = one previous LCSC doubles the risk - Previous myomectomy or hysterotomy - Smoking = the exact mechanism is unclear but the relative hypoxia induced by smoking may cause enlargement of the placenta in order to compensate for the reduced oxygen supply - Placental abnormality = bipartite and succenturiate placenta may cause placenta praevia - Fetal sex = may be an association with a male fetus (Mayes 2012)
Placenta accreta
Associated with low lying placenta, whereby the combination of the relatively thin decidua in the lower segment and potential presence of scar tissue increases the likelihood of trophoblastic invasion of the myometrium. This can result in a torrential haemorrhage if there is an attempt to separate the placenta
(Mayes 2012)
At what point with placenta praevia is vaginal delivery contraindicated?
If placental tissue is within 2cm of the internal os
Mayes 2012
Midwife’s role
- Priority is always mum
- Call emergency buzzer/2222
- Left lateral position
- ABC
- IV access and bloods
- Fluid resuscitation
- Indwelling catheter
- Presenting part and fetal position
- USS
- Stabilise mother, then consider baby
- Never do a VE
After delivery …
There is a risk of PPH after due to there being few oblique muscle fibres to control bleeding from the placental site in the lower uterine segment
(Mayes 2012)
Incidence of placental abruption
1% of pregnancies
Mayes 2012
Risk factors associated with placental abruption
- Hypertensive disease
- Sudden decompression of
the uterus such as may
follow SROM with
polyhydramnios - Preterm labour
- Previous history
- Trauma e.g. following ECV,
road traffic accident, a fall or
blow - Smoking
- Drug abuse
- Folate and vitamin B12
deficiency
(Mayes 2012)
Types of placental abruption
Revealed bleeding = occurs when the site of detachment is at the placental margin. The blood thus dissects between the membranes and the decidua and escapes through the os. The degree of shock is proportional to the visible vaginal blood loss.
Concealed bleeding = occurs when the site of detachment is close to the centre of the placenta. This blood cannot escape and a large retroplacental clot forms. There is no visible blood loss but the pain and shock may be severe as the intrauterine tension rises. Increasing abdominal girth or rising fundal height are suspicious signs of concealed haemorrhage. May also experience back pain if posteriorly situated placenta.
(Mayes 2012)
What is a couvelaire uterus?
When there is a concealed bleed, the blood may infiltrate the myometrium, sometimes as far as the peritoneal covering, causing a marbled pattern of bleeding
(Mayes 2012)
Classifications of placental abruption
Mild placental abruption = loss is usually slight and bleeding may be entirely concealed, although often there a slight trickle. The women may experience no more than mild abdo pain, the uterus is not tender and the fetus is alive. There is no sign of maternal shock
Moderate placental abruption = the blood loss is heavier, the abdo pain is more severe and on palpation the uterus may be tender and firm. The mother may be hypotensive and have tachycardia and usually there is some sign of fetal distress
Severe placental abruption = an obstetric emergency. More than half of placentas will have seperated , the EBL will exceed 1 litre and the mother will be very shocked. Abdo pain will be +++ severe. On palpitation, the uterus may be hard and tender, and on auscultation, FH will not be heard. There is an increased risk of coagulation disorders. It is essential to remember that the amount of bleeding is no guide to the degree of separation
(Mayes 2012)
What is the main thing to ask if a women calls triage with bleeding?
Needs to find out how much. If heavy bleeding, need an ambulance to prevent delay of transfer to hospital
(Mayes 2012)
