APH

Question 1

Define APH

Answer 1

RCOG defines this as bleeding from or into the genital tract occurring in the period from 24 weeks gestation up to the birth of the baby. Revealed or concealed therefore vigilance is required for signs of shock.

Question 2

Incidence rate

Answer 2

3-5% of pregnancies

Question 3

Causes of APH

Answer 3

Placenta previa
Placental Abruption
Placenta Accreta/percreta /increta
Varicosities/polyps or trauma

Question 4

3 categories

Answer 4

Spotting/ minor <50 mls
Major 50-1000mls
Massive >1000mls or signs of clinical shock

Question 5

Risk Factors

Answer 5

Previous APH
Previous Abruption/ previa
Substance misuse
Grand multiparity
Pre-eclampsia/ PIH 
Intrauterine infection
Polyhydramnious

Question 6

Placental Abruption

Answer 6

Is the complete or partial detatchment of the placenta from the uterine wall prematurely. Trauma or spontaneously. 10x more likely if history of placental abruption. Increased risk of abruption with hypertension and chorioamniotitis.

Question 7

Symptoms of Placental abruption

Answer 7

Bleeding can be overt or concealed.
Continuous abdominal pain continuous in back or side.
Palpation should be avoided but on gentle palpation tense/rigid and large on palpation. Difficult to feel fetal parts. Pathological CTG and Shock.

Question 8

Placenta previa

Answer 8

Placenta implant in the lower part of the uterus close to or over the cervical os. Blood loss is never concealed,
Low lying (not occluding os)
Marginal (occlusion could occur)
Partial (partial occlusion of cervix)
Total (cervix is completely covered by it)
DO NOT VE UNTIL PREVIA IS RULED OUT WITH USS

Question 9

Placenta accreta/increta or percreta

Answer 9

Placenta is embedded in the uterine wall. Detected on USS.

Question 10

Why is quick intervention important?

Answer 10

Normal physiological changes in pregnancy mean women are likely to compensate longer but deteriorate quicker and lose blood rapidly. >1000mls lose ability to compensate.

Question 11

Potential outcome of APH

Answer 11

Hypovolaemic shock > loss of blood > decreased circulatory volume > decreased oxygen perfusion> anaerobic respiration> cell dysfunction> increased lactate, low pH> SIRS> MODS> Death

Question 12

What is there an increased risk of with APH?

Answer 12

Increased risk of PPH, anaemia and infection. Little reserves following APH for compensation. If MOH risk of coagulopathy and MODS.

Question 13

What should we prepare with APH?

Answer 13

Resuscitaire for NNR.
IUGR.
Premature delivery.
HIE as a result of Hypoxia

Question 14

What history is useful for APH?

Answer 14

Coagulopathy? USS? Trauma? Prev APH or Abruption? How much loss? Colour of loss? is it clotting? Fetal Movements? Rapid dilatation? Any pain?

Question 15

Rh Neg?

Answer 15

Take Kleihauer bloods to calculate dose of Anti D.

Question 16

What bloods would we need?

Answer 16

FBC (Hb & PLT (DIC)) 
Us&Es (kidney function)
LFTs (Liver function)
Clotting Studies (DIC?) 
Group and Save (Crossmatch 4 units)

Question 17

Initial Management

Answer 17

ABCDE O2 15l/min with non rebreathe mask
2x 16G cannulas (early access as peripheral veins with collapse in hypovolaemic shock)
Begin continuous monitoring with Dynamap and baby on CTG.
Catheterise using ANTT with foley indwelling catheter with urometer and fluid balance to prevent pulmonary oedema due to potential decreased kidney function.

Question 18

How to identify cause?

Answer 18

USS to rule out placenta previa & abruption.

Once previa is ruled out, further vaginal examination can be undertaken to assess dilatation etc.

Question 19

Further intervention

Answer 19

? expedite delivery, prepare for theatre.
May subside/stabilise.
?preterm corticosteroid e.g. dexamethasone
Prepare for NNR.
Cord Bloods.
Active 3rd stage recommended. 1:1 care on CDS ?ITU/HDU
Repeat bloods at 6 and 12 hours to observe Hb and PLT.
Adjust VTE
?SCBU/ HYPO pathway.
BFS, Pain relief, VTE adjusted, TWOC.
Document, DATIX, Debrief.