Case 6 - Antepartum Haemorrhage Flashcards
History Exam Investigations Differential diagnosis definitive diagnosis
Pain, bleeding, maternal shock, uterine tenderness, fetal lie, fetal heart, US
- What are the main causes of APH?
Placenta (abruption, previa, placental edge bleed)
Lower genital tract - cervical polyp, ectropoin, genetial infection, cervical carcinoma
Vasa previa
Uterine rupture
- What clinical features in the history and examination might be helpful in guiding you to a diagnosis
of 1) placenta praevia or 2) placental abruption?
Pain, bleeding, maternal shock, uterine tenderness, fetal lie, fetal heart, US
Abruption
- sever, constant pain
- bleeding may or may not be present
- maternal shock more common and early, and may be inconsistant w external bleeding
- uterine tenderness can be severe, and uterine tone may be hard
- Fetal lie - normal
- Fetal heart - may be distressed or absent
- US - placenta normally located
Praevia
- No pain
- heavy bleeding or small recurrent bleeds
- maternal shock less common, unless large blood loss
- uterine tenderness rare and tone normal, full uterine relaxating between contractions
- fetal lie - often abnormal or high presenting aprt
- fetal heart - nromal
- placenta -low
- What are the risk factors for placenta praevia and placental abruption?
Risk factors for abruption
- previous abrupion
- preeclampsia, HTN
- trauma to abdo
- smoking
- high pariety
- mutliple pregnancies
- polyhydraminos
- advanced maternal age
- thrombophilia
RF for preavia
- older women
- multiple pregnancies
- multiparous womn
- following caesarean birth or other uterine surgery
- What initial steps would you take in managing a patient who presents with an antepartum
haemorrhage?
- History, exam, examination, investigations - urgent (differentiate between abruption and praevia) (also assess for signs of shock - pallor, cool peripheires, delayed cap refil time, restlessness, agitation) (palpate uterus - tenderness, pain, uterine tone, contractions) Speculum exam - amount of bleeding, dilation of cervix, exclude local causes of APH)
- US - establish position of placenta (if has not already had 18-20 week US to determine placental position)
- Blood group
- What initial steps would you take in managing a patient who presents with an antepartum
haemorrhage?
- Drs ABCs, IV access, History, exam, examination, investigations - urgent (differentiate between abruption and praevia) (also assess for signs of shock - pallor, cool peripheires, delayed cap refil time, restlessness, agitation) (palpate uterus - tenderness, pain, uterine tone, contractions) Speculum exam - amount of bleeding, dilation of cervix, exclude local causes of APH)
- US - establish position of placenta (if has not already had 18-20 week US to determine placental position)
- Blood group
- Investigations
- analgesia
Emergency management
- resusciatate and restore blood volume (crystalloid fluid replacement)
- correct anaemia and coagulopathy (may need FFP, platelet transfusion if DIC)
- provide pain relief
- monitor fetal condition
- monitor fluid balance and urine output
- transfer
- deliver baby and placenta - immediate c section
- anticipate postpartum haemorhage
Management of abruption - depends on condition of mother and baby, gestation age and weather mother in in labor. Admit to hospital, Give analgesia.
Resus negative - antiD prophylaxis.
Placenta previa management
Emergency - resuscitate, urgent delivery by c section
at 37-38 weeks - women w complete previa required planned c sections
-women with partial - vaginal delviery posible if plcenta >2cm from OS
Small recurrent bleeds - admission
- repeat US for fetal growth if concerns
- corticosteroids if <34 weeks and early delivery likely
- check blood count to avoid anemia
- if rhesus negative give anti-d
- What are the major complications (for mother and baby) of placental abruption?
Placental abruption
- Shock
- DIC/coagulopathy
- renal failure
- fetal death
- postpartum haemorrhage
- maternal death
Placental praveia
- haemoraheg
- transfusion bloods
- preterm delviery
- c section
- placenta creta
- hysterectomy
- maternal death
- What investigations may be indicated when a woman presents with APH?
FBC Blood group + antibody screen group and hold Resus negative women - kleihauer test to quantify fetomaternal haemorrhage and guide amount of anti-D prophylaxis -coagulation studies -renal studies
Investigate fetal wellbeing 0 <24 weeks -doopler
CTG >26 weeks
Dont need US if major haemorhage as it may delay treatment
- Why is the woman’s rhesus status important and how would you explain the need for Anti-D to a
rhesus-negative patient?
Look this up again
Rhesus status important - if mother is anti Rh negative and baby is rh positive, then mother will make antibodies against baby and this can cause fetal haemolytic anaemia.
Fetal red cells are destroyed by maternal igG antibodies that cross the placenta.
-need to give this if having to give birth so baby does not develop this
- What factors might influence mode of delivery for a woman with APH?
Major abruption with maternal compromise - if fetus is alive, then immediate c section
If the mother has a rapid labour and are midway through labour then normal vaginal delivery, or instrumental.
dead baby - vaginal delivery preferred.
Praevia - depending on where placenta is
-if it is more than 2 cem away form os then can have vaginal deliveyr,
