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Midwifery Emergencies > APH: Week 1 > Flashcards

APH: Week 1 Flashcards

1
Q

What is APH?

A

bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby (RCOG 2014)

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2
Q

What are the most common causes of APH?

A

placenta praevia and placenta abruption, however they’e not the most common (RCOG 2014)

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3
Q

APH facts

A

APH complicates 3–5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide

Up to one-fifth of very preterm babies are born in association with APH, and the known association of APH with cerebral palsy can be explained by preterm delivery (RCOG 2014)

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4
Q

What is the incidence of APH?

A
  • Leading cause of maternal death worldwide
  • 50% of maternal deaths globally: –250 000 deaths from haemorrhage per yearUK deaths from haemorrhage are now rare:•Haemorrhage mortality rate total= 22(UK & Ireland)Which is 18.8% of direct deaths (0.88 per 100,000 maternities UK & Ireland) EMBRRACE-UK (2013-2015) Pg. 75.(Placental abruption 3; Placenta Praevia/Accreta 9 (5 post C/S); PPH 10) Pg.75
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5
Q

Areas for improvement in management of APH in the UK?

A

•‘Major substandard care’ in over 50% of all women who died (MBRRACE – UK 2012-2014)
–Lack of early senior multi-professional involvement
–Failure to act on signs and symptoms
–Inadequate use and interpretation of maternal obstetric early warning score charts

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6
Q

What are the causes of vaginal bleeding in pregnancy?

A

Placenta Praevia 0.5% - 1% (Hutcherson, 2017)
•Abruption
•Ruptured Vasa Praevia
•Uterine Scar Disruption
In addition:
•Show
•Cervicitis
•Cervical Polyp (polyp+ grape like growth of tissue- painless until begins to twist and can bleed)
•Cervical Cancer
•Cervical Ectropion (cells normally inside cervix come to surface, proliferate out and can cause bleeding)
•Vaginal Trauma

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7
Q

What are the different classifications of placenta praevia?

Hutcherson, 2017

A

–“Low Lying : Placenta mainly in the upper uterine segment but encroaching on the lower segment.
–Marginal : Placenta reaches to, but does not cover, the internal os
–Partial : Placenta covers the internal os when closed but not completely when it is dilated
–Total : placenta completely covers the internal os.”

RCOG (2011) Total = MAJOR

If the leading edge of the placenta is in the lower uterine segment but not covering the OS = MINOR or PARTIAL

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8
Q

What are the signs and symptoms of a placental abruption?

A
  • Vaginal bleeding may or may not be present- usually dark red or brown +/- clots
  • Abdominal pain + uterine tenderness (sometimes described as ‘knife-like’ or ‘tearing’
  • Uterine activity/ irritable uterus
  • Hypertonic uterus (feels very tight, maybe can’t hear FH with concealed abruption)
  • Couvelaire uterus (feels hard/ woody) common in concealed abruptions
  • Backache (more common in a posterior implanted placenta)
  • Fetal distress
  • Maternal shock (may be disproportionate to blood loss)
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9
Q

What are the risk factors for placental abruption? (RCOG 2011)

A 
1% of pregnancies 
Pre-existing maternal conditions:
–Recurrent abruption 19-25%
–Pre-eclampsia
–Fetal growth restriction
–Non vertex presentations
–Polyhydramnios
–Advanced Maternal Age
–Multiparity
–Low BMI
–Drug misuse (e.g. Cocaine and Amphetamines)
–Domestic abuse
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10
Q

What is the management of a placental abruption?

A 
NEVER DO A VE UNTIL IT HAS BEEN CONFIRMED THE PLACENTA IS NOT LOW 
•Your priority is always the mother
•Call for help (Emergency Bell/ 2222)
•Left Lateral Position
•ABC (Oxygen, Sats, Bp, RR, Pulse, Temp)
•I.V. access and bloods
•Fluid resuscitation
•Indwelling Catheter
•Presenting part, fetal position and progress in labour
•Stabilize the mother
•Only then consider the baby
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11
Q

What additional investigations are carried out?

A

Blood tests- FBC, Clotting, G&S/ X-match, Kleihauer if RH Negative
•MSU & urine dipstick
•Speculum examination
•NO digital examination unless placental site confirmed as not low
•Ultrasound

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12
Q

What is placenta praevia?

A

Placenta Praevia exists when the placenta is inserted wholly or in part into the lower segment of the uterus (RCOG 2011)

Diagnosed by Ultrasound (transvaginal USS at 20/40 – follow up if placenta lies anteriorly and reaches the os / implanted in CS scar)
Incidence:0.5% to 1% pregnancies at term (Hutcherson, 2017)

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13
Q

What are the different classifications of placenta praevia?

A

Major- < 2cm from or covering cervical os

Minor- > 2cm from cervical os (RCOG 2011)

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14
Q

What are the signs of placenta praevia?

A
  • Painless bright red vaginal bleeding ranging from mild to torrential (may be precipitated by intercourse)
  • History of previous smaller PV bleeds (sentinel bleeds)
  • Uterus may or may not be contracting
  • Maternal shock / collapse
  • Fetal distress
  • Malpresentation / unstable lie
  • High head
  • Check the scan
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15
Q

What are the risk factors for placenta praevia and associated morbidity?

A
  • Previous CS
  • Previous Uterine Instrumentation
  • High Parity
  • Advanced Maternal Age
  • Smoking
  • Multiple Pregnancy
  • Maternal Haemorrhage
  • Operative delivery complications
  • Transfusion
  • Prematurity
  • Placenta accreta, increta, percreta
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16
Q

What are the different causes of placenta praevia?

A

Endometrial scarring
Increased placental mass
Impeded endometrial circulation

17
Q

What causes endometrial scarring?

A

previous LSCS or myomectomy
previous placenta praevia
multiparity

18
Q

What causes an increase in placental mass?

A

placental anomalies e.g. succenturiate lobe or bipartite placenta
multiple pregnancy

19
Q

What causes an impeded endometrial circulation?

A
  • medical conditions
  • (hypertension, diabetes)
  • increasing maternal age
  • uterine tumours
  • Smoking
  • drugs
20
Q

What is the management of placenta praevia?

A 
NEVER DO A VE 
our priority is always the mother
•Call for help (Emergency Bell/ 2222)
•Left Lateral Position
•ABC (Oxygen, Sats, BP, RR, Pulse, temp)
•I.V. access and bloods
(Cross matched blood should be readily available. Cell salvage)
•Fluid resuscitation
•Indwelling Catheter
•Presenting part and fetal position
•USS
•Stabilize the mother
•Only then consider the baby
21
Q

h

A

h

22
Q

What are the potential complications of severe APH?

A
  • Severe anaemia
  • Infection
  • PPH
  • Blood coagulation disorders/ DIC
  • Acute renal failure
  • Sheehan’s syndrome (pituitary necrosis)
  • Psychological distress/ post traumatic stress
  • Hysterectomy
  • Fetal hypoxia
  • Neonatal anaemia/ hypovolaemia
  • Preterm delivery
  • Intrauterine death
23
Q

What is the management of severe APH?

A
  • Catheterise (urometer)
  • Strict fluid balance
  • Involvement of Haematologist
  • May need blood products
  • Emergency LSCS when stable
  • May need a central line (CVP)
  • In the case of uterine rupture or morbidly adherent placenta Possible Hysterectomy
  • DOCUMENTATION
24
Q

What is vasa previa? (RCOG 2011)

A

•Occurs when a fetal blood vessel within the membranes covers the cervical os ahead of the presenting part. Often associated with a velamentous insertion of the cord or succenturiate lobe

.•Rarely causes bleeding in the 3rd trimester but may present in labour or with rupture of the membranes

•Associated with high fetal/ perinatal mortality & can rapidly lead to fetal exsanguination-Reported incidence - 1:2000 to 1:6000 pregnancies

25
Q

What is a uterine rupture?

A

Rupture of an unscarred uterus or dehiscence of a previous uterine scar

Incidence:
0.2 / 10002.1 / 1000 women with a uterine scar (Fitzpatrick et al 2012)

26
Q

What are the different types of a uterine rupture?

A

Complete: rupture involves the full thickness of the uterine wall and pelvic peritoneum

Incomplete (silent): involves the myometrium but not the pelvic peritoneum

Scar dehiscence: thinning or tearing of the uterine wall along an old scar

27
Q

What are the possible causes of a uterine rupture?

A
  • Previous uterine surgery (LSCS, myomectomy)
  • Excessive oxytocin usage
  • High parity
  • Obstructed/ prolonged labour
  • Trauma
  • Previous perforation (ERPC, hysteroscopy)
  • Mid-forceps delivery with cervical tearing
  • Shoulder dystocia
  • Can occur pre labour
  • Manipulation in pregnancy/ labour
  • Congenital uterine abnormalities
  • Uterine over-distension
  • Vigorous external uterine pressure
  • Difficult placental removal
  • Morbidly adherent placenta
  • Placental abruption due to distension and abruption of uterine wall
  • Hypertonic uterus
28
Q

How is a uterine rupture diagnosed?

A
  • Fetal distress/ no FH
  • Complete rupture associated with sudden and severe maternal collapse
  • Abdominal tenderness
  • Severe abdominal pain (will break through an epidural)
  • Maternal tachycardia
  • Vaginal bleeding
  • Abdominal girth may increase
  • Cessation of uterine contractions
  • Fetal parts easily visualised or palpated
  • Haematuria
  • Incomplete rupture- possible lack of signs and symptoms - maybe gradual onset
  • May be diagnosed retrospectively
29
Q

What is a cervical ectropion? What are the symptoms? What are the causes? How can it be treated?

A

The soft cells on the inside of the cervix are known as glandular cells- columnar epithelium. The hard cells on the outside of the cervix are known as squamous epithelial cells.
CE is when the glandular cells appear on the outside of the cervix
Symptoms:
pain during sex
bleeding during or after sex
light discharge of mucus
spotting between periods

Causes:
Hormonal changes: fluctuations in hormone levels and is most common in women who are of reproductive age.

Taking the contraceptive pill: birth control pills affects a person’s hormone levels

Pregnancy: due to the changes in hormone levels.

Treatment:
Diathermy: This uses heat to cauterize the affected area.
Cryotherapy: This uses very cold carbon dioxide to freeze the affected area. A 2016 study found this to be an effective treatment for women with cervical ectropion who were experiencing a lot of discharge.
Silver nitrate: This is another way to cauterize the glandular cells.

Midwifery Emergencies (6 decks)

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