Ante-Partum Haemorrhage

Question 1

What is Antepartum haemorrhage?

Answer 1

Bleeding of the genital tract from 24 weeks of gestation until birth

Question 2

What causes APH? (5)

Answer 2

1. Placental abruption
2. Placenta Privea
3. Uterine rupture
4. Vasa Privea
5. Other Gynacological reasons- cervical lesions, infection etc.

Question 3

What is placenta Privea?

Answer 3

When the placenta is partially of fully implanted into the lower uterine segment

Question 4

When is it normal to have the placenta in the lower uterine segment?

Answer 4

<20 weeks of gestation

Question 5

What causes placenta privea?

Answer 5

1. Twins
2. Multiparity
3. Increased maternal age

Question 6

How do we classify Placenta Privea?

Answer 6

1. Marginal (types 1+2) is when the placenta is in the lower segment however not over the OS
2. Major (types 3+4) is when the placenta is completely or partially covering the OS

Question 7

What are the complications of placenta privea? (4)

Answer 7

1. CS due to obstructed head engagement
2. Haemorrhage
3. Placenta accreta
4. Placenta precreta

Question 8

What is Placenta accrete?

Answer 8

Implantation into previous CS and myometrium

Question 9

What is Placenta Percreta?

Answer 9

Penetration of the placenta through the uterine wall into surrounding structures

Question 10

What are the clinical features of placenta privea?

Answer 10

1. Intermittent painless bleeding

2. Breech/transverse lie

Question 11

Should a VE be done in suspected placenta privea?

Answer 11

NO - can provoke massive bleed

Question 12

How do we investigate placenta privea?

Answer 12

1. US to locate the placenta.

IF the placenta is <2CM from the internal OS at term it is positive

2. FBS, 6 units crossmatch, clotting
3. CTG

Question 13

What would you do if an US shows placenta privea at 20 weeks?

Answer 13

Re-scan at 32 weeks

Question 14

How is Placenta accreta diagnosed?

Answer 14

1. On US - if placenta is anterior with pre LSCS order an MRI

Question 15

How is placenta privea managed?

Answer 15

1. Admission
2. IV access
3. Steroids if <34 weeks
4. Blood ready to be transfused
5. Anti-D if RH -ve

Question 16

How are babies with placenta privea delivered?

Answer 16

1. Elective C-Section by senior consultant
2. Intra-operative and post operative PPH lookout
3. Lower segment does not contract well due to placental insertion

Question 17

How are babies with placenta accreta managed?

Answer 17

1. Consultant care -OBGYN + ANAESTHATIST
2. blood available
3. MDT
4. Pre-delivery discussion about possible intervention (hysterectomy, cell salvage, leaving the placenta in and interventional radiology)

Question 18

What is placental abruption?

Answer 18

When the placenta separates before the delivery of the baby

Question 19

What foetal complications does placental abruption cause?

Answer 19

1. Foetal distress

2. Foetal death

Question 20

What are the symptoms associated with placental abruption? (6)

Answer 20

1. Vaginal bleeding
2. Abdominal pain
3. Uterine tenderness/contractions
4. Foetal distress
5. Intrauterine death
6. DIC

Question 21

What causes placental abruption? (10)

Answer 21

1. IUGR
2. Pre-eclampsia
3. Autoimmune disease
4. Smoking
5. Cocaine
6. Previous abruption
7. Multiple pregnancy
8. Multiparity
9. Trauma
10. Pre-existing HTN

Question 22

What are the clinical features of placental abruption?

Answer 22

1. Painful bleeding (due to blood behind the placenta)

can be concealed or revealed

Question 23

What do you see on examination of placental abruption? (5)

Answer 23

1. Tachy
2. Hypotension
3. Tender uterus
4. Foetal heart sound abnormal/absent
5. Hard woody uterus

Question 24

How is placental abruption investigated?

Answer 24

1. Clinical diagnosis
2. CTG
3. FBC, clotting, crossmatch, U+E
4. Catheter hourly UO

Question 25

How is placental abruption managed?

Answer 25

1. Admission 2. IV fluids/blood 3. Steroids if gestation <34 4. Analgesia 5. Anti D if indicated 6. Early delivery

Question 26

When do you deliver in a mum with placental abruption?

Answer 26

1. When the mother is stable | 2. Depends on foetal state and gestation

Question 27

When would you perform C-section in placental abruption?

Answer 27

Foetal distress

Question 28

How do you induce labour in placental abruption with no foetal distress?

Answer 28

Amniotomy

Question 29

How is placental abruption conservatively managed?

Answer 29

1. Steroids 2. Close monitoring 3. PPH lookout

Question 30

Difference between Placenta privea and placental abruption in terns of: Shock Pain Bleeding Tenderness Foetus US

Answer 30

Abruption: ``` Shock: Inconsistent with external loss Pain: Common severe Bleeding: can be concealed Tenderness: severe tenderness with woody uterus Foetus: can be dead/distressed US: Normal ``` Placenta Privea: ``` Shock: Consistent with external loss Pain: No pain Bleeding: Red and profuse Tenderness: Rare Foetus: Abnormal lie/head height US: Low placenta ```

Question 31

What is the most common cause of bleeding of undetermined origin and how is it managed?

Answer 31

Minor abruption Managed conservatively

Question 32

What is vasa privea

Answer 32

When the foetal blood vessels run in the membrane infant of the presenting part causing a massive bleed when membranes rupture