APH Flashcards
What is APH?
PV bleeding from 24 weeks to onset of labour
What are the causes/ddx of APH?
Placental Causes:
Previa 30%, Abruption 20%, Morbidly adherent
Fetal Causes:
Vasa Previa
Local Causes 5%
e.g. lesions, trauma etc
Unclassified (45%)
What is the clinical presentation of Placenta previa?
- often asymptomatic/ found incidentally on US
- If PV bleeding - painless, bright red
- Uterus is non tender & Smooth
- Might have a high fetal presentation
- Normal foetal heart sounds
What is the clinical presentation of placental abruption?
- can be revealed or concealed - if revealed blood tends to be dark red
- Painful - abdomen and back pain
- Hard wood like uterus and abdomen
- Difficult to palpate and difficult to auscultate fetal heart sounds
- Tends to be haemodynamically unstable - emergency situation
What are the risk factors for Placenta previa?
- multi-parity
- advanced maternal age
Other:
smoking, prior uterine surgery, prior CS, multiple pregnancy
What are the risk factors of placental abruption?
- Chronic HTN/ PET
- Drugs - cocaine
- MVA/ deceleration accident/ trauma
- PPROM
- chronic chorioamniotitis
- multiparity
- smoking
- past uterine surgery
- past hx abruption
- maternal thrombophilia
What is the diagnosis of placenta previa?
TVUS to locate placenta
how do you diagnose placental abruption?
clinical diagnosis
confirmed by delivery of retroplacental clot
What are the complications of placenta previa?
maternal:
1. haemorrhage
2. accreta
3. abruption
4. hysterectomy
5. death
fetal:
1. Preterm delivery
2. IUGR
3. Death
What are the complications of placental abruption?
coagulopathy
DIC
PPH
Management of APH?
- Immediate:
- History ans examination
- IMEWS/ABCD
- IV line
- FBC/Coag/X-match 4 units
- IV Fluids
- Prepare O negative blood
- Continuous CTG
- Call for senior help
- Delivery:
- Elective CS 34 weeks if severe placenta previa
- Emergency CS –severe bleeding abruption
- Vaginal delivery –fetus already dead
- Expectant:
- Antenatal Corticosteroids <36 weeks
- Admission from viability or as outpatient
- US at 36 weeks
- Aim for elective CS at 37 weeks
Examination in APH
- IMEWS –specifically pulse and BP
- Signs of anemia
- CS scar –must rule out morbidly adherent placenta previa
- SFH -<dates? IUGR due to recurrent abruption
- Uterine tenderness –abruption (wood-like)
- Lie/presentation –unstable, breech (placenta previa)
- Vaginal exam is contraindicated in APH unless prior scan excluded placenta previa
Investigations in APH?
- Transvaginal ultrasound + empty bladder to locate placenta (TVUS>TAUS in diagnosis of placenta previa)
Points of note in an APH history?
- Nature of bleeding
- Amount, more than a period?
- Flooding
- Clots
- Color (bright or dark red, pink/watery, show)
- Pain (abruption)
- Abdominal trauma
- Post coital
- Setting
- Recurrent
Smoking, blood pressure (abruption), previous CS (placenta previa)
cervical smear?
* Rhesus status, anti-D
* Position of placenta in anatomy
scan
* Presentation of baby
* Speculum done?
* Antenatal corticosteroids given?
* On iron tablets?
* CTG? Reactive? Location of FH
* Management plan?
What are the indications for immediate delivery in placenta previa?
- life threatening maternal haemorrhage
- non reassuring fetal testing
- if at advanced gestational age 34-36 weeks
Ok to hold off till 36-37 if only minor bleed, not recurrent and steroids had not been given
