Antepartum Haemorrhage and Obstetric Emergencies

Question 1

What is antepartum haemorrhage? (1)

Answer 1

Bleeding from genital tract after 24 weeks gestation.

Question 2

Name 3 causes of APH. (3)

Answer 2

Undetermined
Placental abruption
Placenta praevia
Vasa praevia
Uterine rupture

Question 3

What is placenta praevia? (1)

What are the 2 types of placenta praevia? (2)

Answer 3

Placenta implanted in lower segment of the uterus at term.
Major: completely or partially covering os.
Marginal: placenta in lower segment not covering os.

Question 4

Name 3 complications of placenta praevia. (3)

Answer 4

Transverse lie
Obstruction of engagement of fetus: c/s
Haemorrhage: lower segment less able to contract to constrict blood flow.
Placental accreta (if implants in previous uterine scar)
Hysterectomy if massive haemorrhage

Question 5

Julie has a low lying placenta on her 20 week ultrasound.
When should she be checked for placenta praevia? (1)
If she remains asymptomatic when should she be admitted? (1)
When should she be delivered? (1)

Answer 5

32 weeks
37 weeks
39 weeks

Question 6

What symptoms are suggestive of placenta praevia? (2)

Answer 6

Painless antepartum haemorrhage, often multiple, and increasing in frequency and severity.

Question 7

Define a placental abruption. (2)

Answer 7

When part or all of placenta separates from uterine wall before delivery of the fetus. Occurs in 1% of pregnancies.

Question 8

How can palcental abruption and placenta praevia be distinguished? (3)

Answer 8

Pain is common in abruption, and not in PP.
Bleeding may be absent or dark in abruption but red and profuse in PP.
Uterine tenderness is common in abruption and rare in PP
Fetus has normal lie and often engaged in abruption, abnormal lie in PP
Fetus will be distressed in abruption but hr normal in PP
USS can diagnosed PP

Question 9

Name 3 complications of placental abruption. (3)

Answer 9

Fetal death
Haemorrhage
Blood transfusion
Renal failure
Disseminated intravascular coagulation
Maternal death

Question 10

Name 3 major risk factors for placental abruption. (3)

Answer 10

IUGR
Pre-eclampsia
Pre-existing hypertension
Maternal smoking
Previous abruption

Question 11

How is placental abruption managed? (2)

Answer 11

Admit, if severe resuscitate with blood
Fetal distress: emergency c/s
Fetus OK: >37 weeks, induce labour
Fetus dead: induce labour

Question 12

What is shoulder dystocia? (2)

Answer 12

Difficulty in delivering the shoulders after delivery of the fetal head.

Question 13

name 3 risk factors for shoulder dystocia. (3)

Answer 13

Macrosomic baby, maternal diabetes, maternal obesity, previous shoulder dystocia, induced labour, instrumental delivery

Question 14

In shoulder dystocia, the obstruction is at the pelvic inlet. Why is excessive traction not appropriate? (2)

Answer 14

excessive traction can damage brachial plexus and cause Erb’s palsy, 50% of which are permanent.

Question 15

How should shoulder dystocia be managed? (2)

Answer 15

Gentle downwards traction
Call for senior help
Hyperflex legs towards the abdomen (increase pelvic dimensions- McRoberts manouevre)
Suprapubic pressure (90% should have delivered by this point)
Internal manouevres

Question 16

What is a cord prolapse and why is it an emergency? (3)

Answer 16

After rupture of membranes, the umbilical cord decends below the presenting part.
If untreated this can cause compression of the cord or spasm, resulting in fetal hypoxia.

Question 17

Name 3 risk factors for cord prolapse. (3)

Answer 17

Preterm labour, polyhydramnios, breech presentation, abnormal lie, multiple pregnancy, artificial amniotomy.

Question 18

What is a amniotic fluid embolism? (2)

Answer 18

Amniotic fluid enters the maternal circulation and causes anaphylactoid response and cardiorespiratory collapse. Mortality is 37%.

Question 19

Name 1 risk factor for a uterine rupture? (1)

Answer 19

VBAC (especially after classical caesarean), congenital uterine abnormalities.

Question 20

What is a uterine rupture? (2)

Answer 20

Primary tear or tear of a uterine from scar, causes extrusion of the fetus and contraction of the uterus causing maternal haemorrhage and fetal hypoxia.

Question 21

What can cause uterine inversion? (1)

Answer 21

Excessive traction in the third stage of labour.