antepartum haemorrhage - GM

Question 1

define APH

Answer 1

genital tract bleeding from 24 weeks gestation and complicates 3-5% of pregnancies

Question 2

three most important causes of APH

Answer 2

placenta praevia, placental abruption and vasa preavia

Question 3

less serious causes of APH

Answer 3

lower genital tract sources eg. cervical polyps, vaginitis and cervicitis

Question 4

why does placenta previa increase the likelihood of APH

Answer 4

poor attachment of the placenta to the uterine wall

Question 5

marginal placenta praevia

Answer 5

less than 2cm from the os

Question 6

complete placenta praevia

Answer 6

complete coverage of the cervical os

Question 7

placental abruption define

Answer 7

complete or partial detachment of the placenta before delivery

Question 8

risk factors for placental abruption

Answer 8

maternal age greater than 35
multiparity
current pre-eclampsia, HELLP
Hx of hypertension
Hx of previous abruptions
Hx of anti-phospholipid syndrome
Hx of thrombophilia
smoking during pregnancy
use of cocaine during pregnancy
tramua
over distension of the uterus - polyhydramnios, twins

Question 9

History of placental abruption

Answer 9

abdo pain - posterior placental abruptions may present with back pain
vaginal bleeding
uterine contractions
dizziness and/or loss of consciousness

Question 10

revealed vs. concealed placental abruption

Answer 10

amount of blood loss often correlates poorly with the degree of abruption
abruption may be revealed where blood tracks between membranes and out of the vagina
may however be concealed where the blood accumulates with no obvious external bleeding

Question 11

clinical findings of placental abruption include

Answer 11

woody, tense uterus
fetal heart absent or distressed

Question 12

imaging for placental abruption

Answer 12

US required to identify location of the bleed

Question 13

lab investigations of placental abruption

Answer 13

FBC, U&Es, LFTs, helps exclude hypertensive conditions such as HELLP or pre-eclampsia
clotting profile
kleihauer test
group and save
crossmatch

Question 14

differential diagnoses for placental abruption

Answer 14

placenta praevia
vasa praevia
marginal placental bleed: partial abruption
uterine rupture
local causes: polyps, carcinoma, cervical ectropion, infection

Question 15

initial management for APH

Answer 15

call for help
AA-E
replace fluids
2 large bore cannulas
left lateral position
prepare for theatre if severe
IV fluids
FHR
rin relief, anti-D if negative blood group
consider corticosteroids

Question 16

management of placental abruption if the fetus is alive

Answer 16

if there is no signs of fetal distress: observe closely and induce and deliver vaginally if over 36 weeks
if there is signs of fetal distress: immediate C-section

Question 17

management of placental abruption if the fetus is dead

Answer 17

induce vaginal delivery
if the mother is haemodynamically compromised and/or ongoing massive haemorrhage, delivery should be expadited by c-section to arrest bleeding

Question 18

complications of placental abruption for the mother

Answer 18

major haemorrhage: if suspected, the major haemorrhage protocol should be activated
shock: can result in sheehan syndrome
compression of uterine muscles prevents good contraction of muscles during labour
Release of thromboplastin from placental haematoma: can lead to DIC
post partum haemorrhage

Question 19

complications of placental abruption for the fetus include

Answer 19

placental insufficiency: results in hypoxia and intrauterine growth restriction (IUGR) due to lack of nutrients
premature birth
stillburth

Question 20

vasa praevia define

Answer 20

occurs when foetal blood vessels (the two umbilical arteries and single umbilical vein) are within the fetal membranes and run across the internal cervical os

Question 21

aetiology of vasa praevia

Answer 21

normally, the fetal vessels are protected within the umbilical cord or placenta
in vasa praevia, the vessels are exposed which increases the risk of the vessels rupturing following the rupture of supporting membranes

Question 22

types of vasa praevia

Answer 22

vasa praevia with velamentous umbilical cord insertion: the fetal vessels insert into the membranes and travel around to the placenta, rather than inserting directly into the placenta
vasa praevia with multi- lobed placenta: the fetal vessels are exposed as they travel to an accessory placental lobe

Question 23

risk factors for vasa praevia

Answer 23

IVF pregnancy
multiple pregnancy
low lying placeta

Question 24

Hx of vasa praevia

Answer 24

painless vaginal bleeding
rupture of membranes
fetal bradycardia

Question 25

clinical examination of vasapraevia

Answer 25

soft non tender uterus fetal bradycardia

Question 26

differential diagnosis of vasa praevia

Answer 26

placenta praevia placental abruption uterine rupture local causes: polyps, carcinoma, cervical ectropian, infection

Question 27

bedside investigations for vasa praevia

Answer 27

vital signs: RR, BP, oxygen saturations, pulse and temperature

Question 28

laboritory investigations for vasa praevia

Answer 28

FBC, U&Es, LFTs, helps to exclude hypertensive conditions such as HELLP or pre-eclampsia clotting profile kleihauer test group and save crossmatch

Question 29

imaging for vasa praevia

Answer 29

ultrasound scan cardiotocography is used to monitor the foetus

Question 30

management of vasa praevia

Answer 30

if a woman is found to have vasa praevia on US, an elective c-section at 34-36 weeks is required corticosteroids are given from 32 weeks to promote fetal lung maturity

Question 31

vasa praevia in the event of APH

Answer 31

emergency caesarean section is required to deliver the foetus

Question 32

main complication for vasa praevia is

Answer 32

major haemorrhage

Question 33

vasa praevia presents usually as

Answer 33

painless vaginal bleeding but may also coincide with rupture of membranes

Question 34

other uterine causes of APH

Answer 34

circumvallate placenta placental sinuses

Question 35

lower genital tract sources of APH include

Answer 35

cervical polyps cervical erosions and carcinoma carvicitis vaginitis vulval varicosities

Question 36

which presentation is painful

Answer 36

placental abruption is painful not vasa praevia or placenta praevia

Question 37

which presentation causes a tender uterus

Answer 37

placental abruption causes a tender uterus not vasa praevia or placenta praevia

Question 38

which presentation includes an abnormal lie and/or presentation

Answer 38

placenta praevia may cause abnormal lie and/or presentation vasa praaevia and placental abruption present with normal lie

Question 39

how is fetal heart affected by these presentations

Answer 39

fetal heart rate is normal in placenta praeviaa fetal heart rate is absent or distressed is placental abruption fetal heart rate is bradycardic in vasa praevia

Question 40

which presentations cause coagulation problems

Answer 40

coagulation problems are rare in placenta praevia and vasa praevia coagulation problems will be present in placental abruption