Antepartum Haemorrhage (APH)

Question 1

What is the definition of APH?

Answer 1

Bleeding from/into the genital tract from 24+0 to the birth of the baby

Question 2

What percentage of women have APH’s?

Answer 2

3-5%

Question 3

What percentage of global maternal deaths does it cause?

Answer 3

50%

Question 4

Name 4 causes of APH

Answer 4

Placenta praevia
placental abruption
ruptured vasa praevia
uterine scar rupture

Question 5

What minor things can cause an APH? (6)

Answer 5

Show
Cervicitis
Cervical Polyp
Cervical cancer
Cervical ectropion
Vaginal Trauma

Question 6

What is the definition of placental abruption?

Answer 6

When the placenta detaches from the uterus wall before delivery

Question 7

What are the signs of placental abruption? (8)

Answer 7

Vaginal bleeding (in a revealed) +/- clots 
Abdo pain 
Hypertonic uterus 
Couvelaire uterus (concealed) 
Backache
Fetal distress
Maternal shock

Question 8

Name some risk factors for placental abruption (11)

Answer 8

• Pre existing condition
• Previous placental abruption
• Pre-eclampsia
• Fetal growth restriction
• non vertex presentation
• polyhydramnios
• high mat age
• multiparity
• low bmi
• drug misuse
• domestic abuse

Question 9

What percentage of pregnancies have an abruption?

Answer 9

1%

Question 10

What is the recurrence rate of placental abruption?

Answer 10

19-25%

Question 11

What should you never do until placental site is confirmed?

Answer 11

vaginal examination

Question 12

Management of placental abruption (10 steps)

Answer 12

• prioritise mother
• call for help (bell/2222)
• left lateral
• ABC (oxygen, sats, BP, RR, pulse, temp)
• IV access + bloods
• indwelling catheter
• 3 Ps - pres part, position, progress
• stabilize mother
• then consider baby

Question 13

What additional blood tests should you do for an abruption?

Answer 13

Blood tests - fbc, clotting, group and save, cross match, kleihauer if RH -

Question 14

What other tests should you do for an abruption? (minus bloods)

Answer 14

MSU + urine
Speculum
USS - placental site

Question 15

What is the definition of placenta praevia?

Answer 15

Placenta praevia is when the placenta is inserted wholly or in part of the lower segment of the uterus

Question 16

How is placenta praevia diagnosed?

Answer 16

USS at 20 weeks, repeat follow ups

Question 17

What percentage of pregnancies does placenta praevia occur in?

Answer 17

0.5-1%

Question 18

What are the two classifications of placenta praevia?

Answer 18

Major- <2cm from or covering cervical os

Minor- >2cm from cervical os

Question 19

What are the 8 signs of placenta praevia?

Answer 19

• Painless bright red vaginal bleeding (may be precipitated by intercourse)
• hx of smaller pv bleeds
• uterus may or may not be contracting
• maternal shock/collapse
• fetal distress
• malpresentation/unstable lie (placenta in the way)
• high head
• check the scan

Question 20

What are the risk factors for placenta praevia? (10)

Answer 20

• prev CS
• prev uterine intrumentation
• high parity
• high mat age
• smoking
• multiple pregnancy
• maternal haemorrhage
• transfusion
• prematurity
• Placenta acreta, increta and percreta

Question 21

What is placenta accreta, increta and percreta?

Answer 21

Placenta attaches too deeply into the uterus so remains after birth 
Locations 
Accreta - low side 
Increta  - Side 
Percreta- top

Question 22

Causes of placenta praevia (3 sections)

Answer 22

Endometrial scarring, increased placental mass, impeded endometrial circulation

Question 23

What causes endometrial scarring? (3)

Answer 23

• prev lscs or myomectomy (fibroids)
• prev placenta praevia
• Multiparity - placenta likes to change site each pregnancy

Question 24

What causes placental mass? (2)

Answer 24

• placental anomolies (succenturiate lobe or bipartite)

- multiple pregnancy - usually join into one big mass and stay in lower segment

Question 25

What causes impeded endometrial circulation? (5)

Answer 25

``` Medical conditions (hypertension, diabetes) Increased maternal age Uterine tumours Smoking Drugs ```

Question 26

Management of placenta praevia (11 steps)

Answer 26

- prioritise mother - call for help (bell/2222) - left lateral - ABC (oxygen, sats, BP, RR, pulse, temp) - IV access and bloods- x matched should be available - Fluid resus - indwelling catheter - 3 P's- pres part, position, progress - USS - stabilise mother - then baby

Question 27

What percentage of 20/40 scans show low lying placenta?

Answer 27

50%

Question 28

How many placentas stay low after 20/40?

Answer 28

10%

Question 29

What are the 12 potential complications of a severe APH?

Answer 29

- severe anaemia - infection - pph - blood coagulation disorders - acute renal failure - sheehans syndrome - psychological distress/ptsd - hysterectomy - fetal hypoxia - neonatal anaemia/hypovolaemia - preterm delivery - intrauterine death

Question 30

Management of severe APH (7)

Answer 30

- catheterise (urometer) - strict fluid balance - involve haemotologist - may need blood products - EMCS - may need central line - uterine rupture - possible hysterectomy

Question 31

What is sheehans syndrome?

Answer 31

pituitary necrosis

Question 32

What is vasa praevia?

Answer 32

Fetal blood vessels within the membranes covers the cervical os ahead of the presenting prat - often with velamentous insertion of the cord or succenturiate lobe

Question 33

What causes rupture of vasa praevia?

Answer 33

membrane rupture- because they are unsupported by umbilical cord or placental tissue

Question 34

Does ruptured vasa praevia cause bleeding?

Answer 34

Can in the 3rd trimester but may present in labour or with ROM

Question 35

What are the possible poor outcomes with ruptured vasa praevia?

Answer 35

high fetal/perinatal mortality & can lead to fetal exsanguination

Question 36

What is fetal exsanguination?

Answer 36

baby drained of blood

Question 37

What is the definition of uterine rupture?

Answer 37

rupture of an unscarred uterus or dehiscence of a previous uterine scar

Question 38

What is the incidence of uterine rupture?

Answer 38

0. 2/1000 women | 2. 1/1000 with a uterine scar

Question 39

What are the 3 types of uterine rupture?

Answer 39

1. complete- rupture involves the full thickness of the uterine wall and pelvic peritoneum 2. Incomplete- involves the myometrium but not the pelvic peritoneum 3. Scar dehiscence- thinning or tearing of the uterine wall at old scar

Question 40

17 causes of uterine rupture

Answer 40

- prev surgery - too much oxytocin - high parity - more stretched - obstructed/prolonged labour - trauma - perv perforation (ERPC, hysteroscopy) - mid forceps delivery with cx tearing - shoulder dystocia - can occur pre-labour - manipulation in pregnancy/labour - congenital uterine abnormalities - uterine over-distension - vigorous external uterine pressure - difficult placental removal - morbidly adherent placenta - placental abruption due to distension and abruption of uterine wall - hypertonic uterus

Question 41

How do they diagnose uterine rupture? (11)

Answer 41

- fetal distress/no fh - complete rupture associated with sudden severe maternal collapse - abdo tenderness + pain - maternal tachycardia - vaginal bleeding - abdo girth may increase - cessation of uterine contractions - fetal parts easily visualised or palpated - haematuria - incomplete rupture - possible lack of symptoms - may be diagnosed retrospectively