APH Antepartum Haemorrhage Flashcards
What is the incidence of Placenta Previa at term? What are the risk factors for it ?
1 / 200
The incidence increased
1- in women with previous CS
2- maternal smoking
3- assisted reproductive technology
4- increased maternal age
What is the prevalence of placenta accreta?
1/ 300 - 1 / 2000
What is the chance of placental migration if diagnosed at 20 w ?
90% at 32w
What is the definition of :
- placenta praevia
- low lying placenta?
🚩placenta praevia: placenta lies directly over the internal os
🚩 low lying placenta: at > 16 w
placental edge is less than 20 mm from the internal os on TAS or TVS
At what gestation should we screen for placenta praevia, and when to follow up?
*At anomaly scan
*Follow up: TVS is recommended at
32 w to diagnose persistent low lying placenta
* further TVS at 36 w in women remain asymptomatic
What is the role & what are the risks of TVS in low lying placenta?
Is superior to TAS & is safe
Helpful for :
1-placenta localization Especially:for posterior placentas
2- To measure the cervical length
What is the role of measuring cervical length in the management decisions for women with placenta praevia?
A short cervical length( < 25 mm) on TVS before 34 w:
increases the risk of preterm emergency delivery & massive haemorrhage at CS
Where should women with low lying placenta be cared for in 3rd trimester, if she had recurrent bleeding?
Depends on women’s circumstances
( distance from the hospital, hb,..)
* if she was admitted to hospital: assess the risk factors for venous thromboembolism & balance the risk against the risk of bleeding
* if she was treated at home : should attend to the hospital immediately if : any bleeding or pain or contractions
Is there a place for cervical cerclage in women with low lying placenta?
IS NOT RECOMMENDED
At what gestation should women with placenta praevia be offered antenatal steroids?
SINGLE dose is recommended between 34 - 35 w
& delivery 1 w after
& prior to 34 in women with high risk of preterm delivery
Is there a place for tocolytics in women with symptomatic placenta praevia?
Maybe considered for 48h to administer antenatal steroids
At what gestation should planned delivery occur in women with low lying placenta?
- Uncomplicated placenta praevia:
36 - 37 w - history of vaginal bleeding or
High risk of preterm delivery
Late preterm delivery 34 - 36 w
What anaesthetic procedure is most appropriate for women having CS for placenta praevia?
Regional anesthesia
Is considered safe & associated with lower risk of haemorrhage than general anaesthesia
What blood products should be available in the delivery of women with placenta praevia?
1- rapid infusion & fluid warming devices should be available
2- cell salvage for women who decline blood products
⚠️ the decision to transfuse should be made on individual basis EVEN if preoperative hb < 70
What surgical approach should be used for women with placenta praevia?
1- consider vertical skin and / or uterine if the fetus is transverse lie particularly below 28w
2- consider preoperative & intraoperative US
3- if the placenta is transected during uterine incision 👉 immediately clamp the umbilical cord after fetal delivery
4- to control the haemorrhage:
- pharmacology
- intrauterine tamponade
- radiological techniques
- early hysterectomy
If placenta praevia is detected in 32 w , what is the percentage of it will resolve by term ?
50 %
How many of placentas diagnosed as low lying at routine anomaly scan TVS will reclassify them?
26 - 60 % of them
Compare CS for placenta praevia with CS for other indications, regarding risk of massive haemorrhage/ the need for blood transfusion?
The risk of massive haemorrhage is approximately 12 times more likely in CS for placenta praevia
What is the success rate in controlling PPH for Intrauterine balloon tamponade in women with placenta praevia ?
75 - 88%
What are the surgical procedures should be used for women with placenta praevia to reduce blood loss & the risk of PPH?
1- J shaped uterine incision for anterior placentas instead of cutting through the placenta
2- intrauterine balloon tamponade
( Bakri balloon, BT cath ) 400ml / warm saline
3- endouterine sutures ( B-lynch)
4- radiological techniques: transarterial embolization of internal iliac artery
What is the incidence of placenta praevia after CS?
4,5 for one CS
7,4 for 2 CS
6,5 for 3 CS
44,9 for 4 CS or more
according to 2014 studies:
10 / 1000 with 1 CS
28 / 1000 with 3 CS or more
What is the prevalence of malpositions of the fetus occurring with placenta praevia?
35 % of cases the fetus is malpositioned ( transverse/ breech)
What is the definition of placenta accreta ?
A spectrum disorder ranging from abnormally adherent to deeply invasive tissue
If the woman with placenta praevia is asymptomatic & wish for vaginal birth, how to make a decision?
By TVS
If the placental edge less than 20 mm from the internal os in the 3rd trimester OR
placental edge is thicker than 10 mm
👉 CS
Women with placenta praevia having CS are at increased risk of blood loss, what are the risk factors for massive haemorrhage?
1- placenta covering the internal os
2- anterior placentation
3- pre delivery anaemia
4- thrombocytopenia
5- diabetes
6- magnesium use
Case : woman with placenta praevia + transverse fetal position < 28w
How to perform CS?
Vertical skin / uterine incision
Classical CS
What are the factors associated with the failure of Bakri balloon tamponade for placenta praevia?
1- previous CS
2- anterior placentation
3- thrombocytopenia at the time of insertion
4- coagulopathy at the time of insertion
5- PPH volume > 500 ml within the first hour of placement
Management Summary placenta praevia at 3rd trimester:
Asymptomatic / symptomatic?
Asymptomatic low lying placenta?
Asymptomatic 👉 steroids 34 - 36 w
Schedule CS 36 - 37 w
Symptomatic👉 steroids before 34w
Schedule CS 34 - 36 w
Asymptomatic low lying placenta 👉
Repeat scan at 36w if still 👉
Individualized decision offered
What are the risk factors for placenta accreta spectrum?
1- history of accreta in previous pregnancy
2- previous CS
3- uterine surgery
4- repeated endometrial curettage
5- placenta praevia
6- increased maternal age > 35
7- ART
8- uterine pathology: adenomyosis, submucous fibroids ،bicornuate uterus
9- cesarean scar pregnancy
10- postpartum endometriosis
What are the factors that should alert the antenatal team of the higher risk of placenta accreta?
Previous CS + Anterior low lying placenta /or placenta praevia
After one prior CS , how many times the risk of invasive placentation increases?
7 folds
What is the median estimated blood loss of placenta accreta? And the median number of blood transfused?
2000 - 7800 ml
5 blood units
How many of placenta accreta remains undiagnosed before delivery?
1/2 - 2/3 in population studies
What is the role of US imaging in diagnosing placenta accreta?
Highly accurate
With high sensitivity & specificity
Among US signs of placenta accreta
Which has the best predictive accuracy ?
Which has best specificity?
🚩Predictive accuracy:Abnormal vasculature on color doppler
🚩Specificity: Abnormality of the uterus bladder interface
What is the risk of placenta accreta in women presenting with placenta praevia and :
1-No previous CS
2-prior CS after : 1 /2 /3 /4 /5 CS?
No prior CS 3-4%
1 CS 3%
2 CS 11%
3 CS 40 %
4 CS 61 %
5 CS or more 67%
What is the definition of:
Accreta / increta / percreta ?
*Accreta: villus attach directly to the myometrium in the absence of decidua
* increta : villus invade deeper in the myometrium, don’t extend to serosa
* percreta : the villus reach the serosa
What are the most common US signs associated placenta accreta spectrum?
1-Placental lacunae give the placenta a MOTH EATEN appearance on grayscale imaging
2- increased vascularity of placental bed with large feeder vessels entering the lacunae
What is the role of MRI in diagnosing placenta accreta?
⚠️Diagnostic value of MRI & US in detecting placenta accreta is similar
* help to assess the invasion of myometrium especially with: -posterior placentation
-US suggestive parametrial invasion
What is the role of MRI with IV gadolinium injection in diagnosing placenta accreta?
Increase the sensitivity of MRI
But safety is limited
When should delivery be planned for women with placenta accreta?
MDT
35 - 37 w
What is the likelihood of emergency delivery in cases of placenta accreta after 34w of pregnancy?
20%
What is massive blood transfusion?
8 units or more
What are the risks associated with the delivery of placenta accreta?
1- massive haemorrhage 👉coagulopathy
2- multisystem organ failure
3- death
What are the 6 elements considered to be reflective of good care in delivering placenta accreta?
1- consultant obstetrician
2- consultant anaesthetist
3- blood products available
4- MDT
5- discuss possible interventions:
Hysterectomy, leaving the placenta in situ ..)
6- local availability of level 2 critical care bed
What surgical approach should be used for women with placenta accreta spectrum?
1-planned preterm CS hysterectomy with placenta left in situ is preferable
2- uterus preserving surgery: partial myometrial resection, in case of the extend of placenta accreta is limited
What is the role of ureteric stents in the surgery for placenta accreta?
Insufficient data to recommend the routine use
* may have a role when the bladder is invaded by placental tissue
In cases of placenta accreta what is the risk of hysterectomy during attempting placental remove?
100 % of the cases
What is triple P procedure as a surgical approach for placenta accreta?
*perioperative placental localization
* pelvic devascularization
*placental non separation
Transverse uterine incision + myometrial excision & reconstruction of the uterine wall
What surgical approach should be used for women with placenta percreta?
1- primary hysterectomy following delivery
2- delivery of the fetus + repair the incision + leave the placenta in situ
3- delivery of the fetus without disturbing the placenta then partial excision of the uterus wall
4- delivery of the fetus without disturbing the placenta & leave the placenta then elective hysterectomy 3-7 days later
What is the role of ureteric stents in the surgery for placenta percreta ?
It is recommended to pre operative cystoscopy and placement of ureteric stents
In a case of placenta percreta if the bladder is involved what surgical approach should be considered?
Planned cystotomy
What are the risks of expectant management of placenta accreta ( leaving the placenta in situ?
Bleeding & infection
What is the role of MTX adjutant therapy in the expectant management of placenta accreta( leaving the placenta in situ)?
Should not be used
Unproven benefit and has significant side effects
If at the time of elective CS find out presence of placenta accreta and the mother & baby are stable, what is the management?
CS should be delayed until appropriate staff and adequate blood products are available
In case of unsuspected placenta accreta spectrum diagnosed after the birth of the baby , what is the best approach?
Placenta should be left in situ and perform emergency hysterectomy
What is the prevalence of vasa praevia?
1/ 1200 - 1/ 5000
How is vasa praevia usually diagnosed?
1- during early labour detecting pulsating fetal vessels by vaginal examination
2- presence of dark red bleeding & acute fetal compromise after spontaneous or artificial rupture of membranes
How is vasa praevia classified?
Type 1( 90 %) : when the vessel is connected to a velamentous umbilical cord
Type 2 (10%) : when the vessel connects the placenta with succenturiate or accessory lobe
What is the fetal mortality associated with vasa praevia?
60 %
What is the average fetal blood loss in case of vasa praevia bleeding in labour?
80 - 100 ml / kg
If stillbirth has occurred in a case of vasa praevia, how to confirm the diagnosis?
Placental pathological examination
What is the association between vasa praevia & placenta praevia?
60 % of women with vasa praevia at delivery have placenta praevia or low lying placenta identified during the 2nd trimester
If vasa praevia is diagnosed in the 2nd trimester, what is the percentage that will be resolved before delivery?
20 % of cases
At what gestation should elective delivery occur in a case of diagnosed vasa praevia?
Planned CS at 34 - 36 in asymptomatic women
Case : woman in labour+ abnormal CTG ( HR 90) after rupture of membranes, what to suspct, what is the management?
Vasa praevia
Category 1 CS ( emergency)
What is the painless vaginal bleeding caused by vasa praevia called?
Benckeiser’s haemorrhage
Can vasa praevia be diagnosed during fetal anomaly scan?
High diagnostic accuracy
With low false positive rate
What is the investigation that has the best diagnostic accuracy for vasa praevia?
Combination of both trans abdominal & transvaginal color doppler imaging CDI
What is the definition of vasa praevia?
Vessel running in the free placental membranes within 2 cm of the cervix
What are the risk factors for vasa praevia that indicate midpregnancy US assessment to screen for vasa praevia?
1- placenta praevia
2- bilobed placenta
3- succenturiate lobes
4- ART
5- velamentous cord insertion
How should women with vasa praevia be managed?
1- prophylactic hospitalization
30 - 32 w
2- antenatal steroids 32 w
3- planned CS 34-36 w
What is the percentage of pregnancies complicated by APH ?
3- 5 % of pregnancies
What is the proportion of preterm deliveries caused by APH ?
1 / 5 of the preterm babies
What is the recurrence rate of placental abruption after 1 abruption & 2 abruptions?
After 1 abruption 👉 4.4 %
After 2 abruptions 👉 19 - 25 %
What is the proportion of abruption cases the USG fails to detect?
3 / 4
What is the percentage of placental abruption abnormal CTG detected with?
69 %
What is the prevalence of placental abruption?
3-6 / 1000 of pregnancies
What is the perinatal mortality rate for placental abruption?
Up to 48 %
What is the lower limit of gestational age to define placental abruption?
As low as 20 weeks
How many of placental abruption cases found to be in low risk pregnancies?
70 % of the cases of placental abruption in low risk pregnancies
What are the clinical features of placental abruption?
1- vaginal bleeding 70 -80 %
2- abdominal pain 50 %
3- uterine tenderness 70 %
4- fetal distress 65 %
5- fetal death 15 %
6- DIC
7- maternal shock
What is the definition of APH ?
Bleeding from genital tract occurring from 24 w of pregnancy and before the birth of the baby
What is the definition of : minor / major/ massive haemorrhage regarding APH ?
*Minor: < 50 ml % settled
*Major: 50 - 1000 ml with no signs of clinical shock
*Massive: > 1000 ml &/or signs of clinical shock
What are the risk factors for placental abruption?
1- PET 2- FGR
3- non vertex presentation
4- advanced maternal age
5- low BMI
6- pregnancy following ART
7- PROM 8- smoking
9- abdominal trauma
10 - intrauterine infection
11- drug misuse ( cocaine/ amphetamines)
12 - multiparty
13 - polyhydramnios
⚠️ first trimester bleeding increases the risk of placental abruption
What is the association between thrombophilia & placental abruption?
Significant associated with:
-Heterozygous factor v leiden
-Heterozygous prothrombin gene mutation
Can APH be predicted?
APH has heterozygous pathophysiology & CANNOT be predicted
Can APH be prevented?
Change modifiable risk factors
Smoking/ drug misuse
⚠️ folic acid supplements has no conclusive evidence of benefit
⚠️ no good data to support the use of aspirin/ LMWH in women with thrombophilia to prevent placental abruption
What are the maternal complications of APH?
Anaemia / infection / shock
Postpartum hemorrhage
Renal tubular necrosis
What are the fetal complications of APH?
Hypoxia / SGA / prematurity/ death
What is the incidence of cervical cancer in delivery ?
7.5 / 100,000 delivery
Half of them had previous abnormal cervical smear
How to make an assessment for women with APH ?
1- collapse 👉 ABC
2- pulse + BP
3- abdominal palpitation
4- speculum examination
5- digital vaginal examination
What maternal investigations should be performed in women presenting with APH?
⚠️ kleinhauer test for rhesus D negative women
2- US to diagnose placenta praevia
3- placental abruption is a clinical diagnosis
4- blood tests:
* minor: full blood count & group
* massive: CBC,coagulation screen, 4 units cross matched, urea ,electrolytes, LFTs
What fetal investigations should be performed in women presenting with APH ?
CTG ( abnormal CTG in 69 % of placental abruption cases)
US if viability cannot be detected using auscultation
Should women with APH be hospitalized ?
*Spotting + no longer bleeding + placenta praevia excluded 👉home
* heavier than spotting or ongoing bleeding 👉 hospitalize until the bleeding has stopped
* history of IUFD resulting from placental abruption 👉 hospitalization
Should steroids be administered to women who present with APH before term?
24 - 34 w 👉 offer single dose of steroids
Even if spotting & imminent delivery is unlikely
Should tocolytic therapy be used in women presenting with APH who have uterine activity?
Contraindicated in placenta praevia
Contraindicated in placental abruption
ONLY in those needing transverse to other hospital
If tocolytic drugs is indicated in a woman with APH , what are the considerations about them?
Calcium antagonist(nifedipine ) best avoided ( maternal hypertension)
Should the antenatal care of a woman be altered following APH?
1- pregnancy should be classified as High risk pregnancy
2- antenatal care should be consultant led
3- serial US for fetal growth
If the woman has unexplained APH ,she is at increased risk of pregnancy complications, which has the highest risk?
🏅 oligohydramnios
- IUGR
- PROM
- Preterm labour
- CS
When should women with APH be ddelivered?
🚩< 37w & no fetal or maternal compromise & bleeding has settled
👉 conservative management
🚩 > 37w or major APH 👉 induction of labour
What intrapartum fetal monitoring should be employed for women whose pregnancies were complicated by APH ?
📢 Continuous CTG:
1- active vaginal bleeding
2- preterm delivery with major APH or recurrent minor APH
3- clinical suspicion of an abruption
4- minor APH with placental insufficiency ( IUGR / oligohydramnios)
📢 Minor episodes with no other concerns 👉 intermittent auscultation
What is the appropriate management of the 3rd stage of labour in women with APH ?
*Placental abruption or placenta praevia 👉 STRONGLY RECOMMEND
Active management 3rd stage
*Consideration of ergomethrin- oxytocin
Should women presenting with APH who are RhD negative be given anti - D Ig?
⚠️ Anti- D should be given after any presentation with APH independent of routine prophylactic anti-D
⛔ recurrent APH after 20w 👉 anti-D at least 500 iu every 6 weeks
Then test FMH
If FMH > 4 ml 👉 additional anti -D
How should women presenting with APH who develop coagulopathy be managed?
Clotting studies
+ 4 units FFP + 10 units cryoprecipitate whilst waiting the results ( 2 packs)
What is the initial management for women with APH [ ABCD]?
*A airway
*B breathing ( 10 - 15 l / min ) via facemask
*C circulation ( 14 gauge IV access) + 20 ml blood for tests
*D assess the fetus & mode of delivery
What is the full protocol for massive haemorrhage of APH > 1000 ml or clinical shock?
Airway, breathing, circulation
Facemask 10 - 15 l/ min
2 IV access
Left lateral position tilt
Keep the woman warm
3.5 L crystalloid
Transfuse blood as soon as possible
ℹ special blood filters SHOULD NOT be used ( slow infusions)
About blood products transfusion:
When to give: FFP,PLT,cryoprecipitate?
FFP :4 units for every 6 units of RBCs
If Pt or Ptt > 1.5 mean control
Plt : if plt count < 50
Cryoprecipitate: if fibrinogen < 1 g/L
What is the main therapeutic goal of the management of massive blood loss?
1- Hb > 8
2- plt > 75
3- Pt < 1.5
4- Ptt < 1.5
5- fibrinogen > 1 g/ L
