obs - Antepartum haemorrhage Flashcards
define antepartum haemorrhage
bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby.
list the most important and other causes of APH?
The most important causes of APH are:
Placenta praevia & Placental abruption
(although these are not the most common)
o Idiopathic
o Incidental genital tract pathology
o Uterine rupture
o Vasa praevia
How can the known association of APH with cerebral palsy be explained?
APH can lead to PTD thats why
my theory - Hypoxic ischaemic encephalopathy/ injury
(remember 28 weeek PTD on the ward who had a praevia followed by abruption)
How does vasa praevia present?
Classic triad:
rupture of membranes - flow of liqour followed by
painless vaginal bleeding
and fetal bradycardia
In 3rd trimester
What are the maternal/fetal risks of vasa praevia and placenta praevia?
unlike placenta praevia, vasa praevia carries no major maternal risk but fetal mortality rates are significant.
what are the differentials for bleeding in pregnancy in order of likelihood?
1st trimester
Miscarriage
Ectopic pregnancy
Hydatidiform mole
2nd trimester
Miscarriage
Hydatidiform mole
Placental abruption
3rd trimester Bloody show Placental abruption Placenta praevia Vasa praevia
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis.
The uterus may be large for dates and serum hCG is very
This is indicative of which condition?
Hydatidiform mole
define placenta praevia
what are teh diifferent types?
Occurs when the placenta is implanted in the lower segment of the uterus
types:
o Marginal: placenta in lower segment, not over os
o Major: placenta completely or partially covering os
why can a p praevia spontaeenously resolve?
lower uterine segment growths in 3rd trimester
placenta moves up
what are the risk factors for p praevia?
Slightly more common with twins, . parity, . age and if uterus is scarred
what are somee complicaitions of p praevia?
If implanted in old CS scar -> placenta accreta / percreta -> Massive haemorrhage at delivery hysterectomy
Necessitates c-section: have to modify incision if anterior praevia
transverse lie
obstructs engagement of fetal head
how does p praevia present?
Intermittent painless bleedings which increases in frequency and intensity over several weeks
Bleeding may be severe
1/3 do not experience bleeding before delivery
Breech presentation and transverse lie are common
High, non-engaged fetal head
NEVER perform a VE
how would you ivx?
Diagnosis via US
Anterior pravia - 3D US
posterior p - TVUS
how is praveia managed?
Admission
blood; cross match group and save, anti-D if Rh –ve
Steroids if <34 weeks
Delivery By elective CS at 39 weeks by the most senior person available
Emergency delivery required if bleeding is severe before this time
o Compression of inside of scar after removal with inflatable balloon (balloon tamponade) or hysterectomy
deifn abruption
When all or part of the placenta separates before delivery of fetus
what is the aetiology of abruption?
IUGR PET Autoimmune disease Maternal smoking Cocaine use Previous abruption (6%) Multiple pregnancy High parity Trauma Sudden reduction in uterine volume e.g. ROM in polyhydramnios
how does abruption present?
what would be found on examination?
Painful bleeding
Pain due to blood behind placenta and in myometrium
Dark blood
Degree of vaginal bleeding does not reflect the severity of the abruption
Pain or bleeding may occur alone
o Concealed or revealed abruption
Examination o Tachycardia = profound blood loss o Hypotension = massive blood loss o Tender, contracting uterus o “Woody” hard placenta and difficult to palpate fetus o Fetal heart tones abnormal or absent
how would you ivx praevia?
Usually clinical diagnosis
Establish fetal wellbeing
o CTG
o USS to estimate fetal weight at preterm gestations and exclude praevia
o Abruption not always visible on USS
- dead card - see Lazs
what tests would we do on mother to assess and prepare for management of haemorrhage?
Maternal wellbeing and prep for APH: o FBC o Coagulation screen o Cross match o Catheterisation with hourly urine output o Regular FBC, coag, U&Es o CVP monitoring
what aree the features of major abruption?
o Maternal collapse
o Coagulopathy - DIC: low fibrinogen, prolonged PT (also
occurs when baby is dead)
o Fetal distress or demise
o Woody hard uterus
o Poor urine output or renal failurehow would you manage abruption?
minor abruptoin no fetal distress;
Give steroids and monitor on antenatal ward
If symptoms settle -> discharge
serious:
initiially same as praevia… admit
See APH guidelines ABCDE approach etc
opiates - for pain
Stabilise MOTHER first
Delivery:
Fetal distress: urgent EMCS
No fetal distress but >37 weeks: IOL with amniotomy
If fetus dead coagulopathy also likely
o Blood products given and labour induced
what are the complications of APH?
MATERNAL:
Anaemia, postpartum haemorrhagee
Materenal shock, infectoin, psychological imapct
Fetal:
Hypoxia , IUGR, Death, peamturity
what happens in event of major haemorrhage (EBL >1000ml)?
ABCD approach
Basic measures for haemorrhage up to 1000 ml with no clinical shock:
● intravenous access (14-gauge cannula x 1)
● commence crystalloid infusion - Hartmans
Full protocol for massive haemorrhage (blood loss > 1000 ml or clinical shock):
● assess airway
● assess breathing
● evaluate circulation
● oxygen by mask at 10–15 litres/minute
● intravenous access (14-gauge cannula x 2)
● position left lateral tilt - to prevent aortocaval comp
● keep the woman warm using appropriate available measures
● transfuse blood as soon as possible
● until blood is available, infuse up to 3.5 litres of warmed crystalloid Hartmann’s solution (2 litres) and/or
colloid (1–2 litres) as rapidly as required
● the best equipment available should be used to achieve rapid warmed infusion of fluids
what is the difference between APH and PPH?
APH - you have 2 people to care for. will resolve with delivery of fetus and placenta. so have to monitor fetus closely epsecially before deciding on delivery.
management protocols are otherwise the same.
what causes vasa praevia?
velamentous insertion of umbilical cord:
attached to membranes rather than the placenta
how is vasa praevia ivx?
exclude other causes eeg do speculum, swab etc
US: usually misses it though - usually realised in vaginal delivery
what are the cut of ml for APH?
Minor haemorrhage – blood loss less than 50 ml that has settled
Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock
Massive haemorrhage – blood loss greater than 1000 ml and/or signs of clinical shock.
define PPH?
> 500-mL vaginal bleeding 24 hours after delivery, within 6 weeks
What is the care bundle for PPH?
E MOTIVE
E - early detection M - massage of uterus O - oxytocin type drug T - tranexamic acid IV- IV fluids E - examine the genital tract and escalation (treatment of refractory PPH)
see Laz notes -> Slightly different
Oxytocin for prophylaxis eg straight after normal delivery.
ABCDE - call for help etc
IV syntocinon for PPH. in IM Carboprost. Ballon tamponade.
Highest escalation - hysterectomy
Cause of PPH and MDT involved in mc + mnemonics?
TTTT
Tone - atony 70%
trauma (eg large episiotomy), Tissue, thrombin
SOAP
Senior midwife, obstetrician, a scribe, porter
