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A - ObsNGynae > obs - Antepartum haemorrhage > Flashcards

obs - Antepartum haemorrhage Flashcards

1
Q

define antepartum haemorrhage

A

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

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2
Q

list the most important and other causes of APH?

A

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

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3
Q

How can the known association of APH with cerebral palsy be explained?

A

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)

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4
Q

How does vasa praevia present?

A

Classic triad:
rupture of membranes - flow of liqour followed by
painless vaginal bleeding
and fetal bradycardia

In 3rd trimester

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5
Q

What are the maternal/fetal risks of vasa praevia and placenta praevia?

A

unlike placenta praevia, vasa praevia carries no major maternal risk but fetal mortality rates are significant.

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6
Q

what are the differentials for bleeding in pregnancy in order of likelihood?

A

1st trimester
Miscarriage
Ectopic pregnancy
Hydatidiform mole

2nd trimester
Miscarriage
Hydatidiform mole
Placental abruption

3rd trimester
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
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7
Q

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?

A

Hydatidiform mole

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8
Q

define placenta praevia

what are teh diifferent types?

A

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

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9
Q

why can a p praevia spontaeenously resolve?

A

lower uterine segment growths in 3rd trimester

placenta moves up

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10
Q

what are the risk factors for p praevia?

A

Slightly more common with twins, . parity, . age and if uterus is scarred

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11
Q

what are somee complicaitions of p praevia?

A

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

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12
Q

how does p praevia present?

A

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

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13
Q

how would you ivx?

A

Diagnosis via US

Anterior pravia - 3D US
posterior p - TVUS

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14
Q

how is praveia managed?

A

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

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15
Q

deifn abruption

A

When all or part of the placenta separates before delivery of fetus

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16
Q

what is the aetiology of abruption?

A 
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
17
Q

how does abruption present?

what would be found on examination?

A

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
18
Q

how would you ivx praevia?

A

 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
19
Q

what tests would we do on mother to assess and prepare for management of haemorrhage?

A 
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&amp;Es
o CVP monitoring
20
Q

what aree the features of major abruption?

A 
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 failure
21
Q

how would you manage abruption?

A

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

22
Q

what are the complications of APH?

A

MATERNAL:
Anaemia, postpartum haemorrhagee
Materenal shock, infectoin, psychological imapct

Fetal:
Hypoxia , IUGR, Death, peamturity

23
Q

what happens in event of major haemorrhage (EBL >1000ml)?

A

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

24
Q

what is the difference between APH and PPH?

A

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.

25
Q

what causes vasa praevia?

A

velamentous insertion of umbilical cord:

attached to membranes rather than the placenta

26
Q

how is vasa praevia ivx?

A

exclude other causes eeg do speculum, swab etc

US: usually misses it though - usually realised in vaginal delivery

27
Q

what are the cut of ml for APH?

A

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.

28
Q

define PPH?

A

> 500-mL vaginal bleeding 24 hours after delivery, within 6 weeks

29
Q

What is the care bundle for PPH?

A

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

30
Q

Cause of PPH and MDT involved in mc + mnemonics?

A

TTTT
Tone - atony 70%
trauma (eg large episiotomy), Tissue, thrombin

SOAP
Senior midwife, obstetrician, a scribe, porter

A - ObsNGynae (37 decks)

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