APH

Question 1

define APH (antepartum haemorrhage)

Answer 1

Any bleeding from the genital tract after the 20th week of gestation but before the onset of labour

Question 2

causes of APH

Answer 2

• cervical or lower genital tract bleeding (45%)
• placenta praevia (35%)
• placental abruption (25%)

other:
- uterine rupture
- vasa praevia
- unclassified bleeding

Question 3

On first assessment of the woman, what should be determined?

Answer 3

if she is haemodynamically stable
Check with airway, breathing circulation approach. (ABC)

Question 4

If haemodynamically UNstable what are the next steps?

Answer 4

1. call for help
2. establish airway, give O2
3. 2x 16g I.V. cannulas
4. take bloods
5. 2000mls of crystalloid infusion
6. activate massive transfusion protocol
7. early involvement of obstetrician, neonatologist, and haematologist

Question 5

Is she is stable what are the next steps?

Answer 5

History
blood loss
abdomen
fetus
vaginal examination

Question 6

considerations for history

Answer 6

• medical
• surgical
• obstetric
• gynaecological
• this pregnancy (any bleeding?)
• any provoking incident such as sexual intercourse, motor vehicle accident
• review latest USS to determine placental location or request bedside scan.

Question 7

considerations when assessing blood loss

Answer 7

• colour
• volume
• consistency
• weigh sanitary pads

Question 8

considerations for assessing the abdomen?

Answer 8

is there pain? or tenderness?
is it hard / woody?
irritable / contracting?
palpate tone, fetal lie and parts, fundal height

Question 9

considerations for assessing the fetus?

Answer 9

• continuous fetal monitoring on ctg (if > 28/40)
• otherwise use doppler
• enquire about fetal movements

Question 10

Considerations for vaginal examination

Answer 10

• digital examination is contraindicated unless placenta and vasa praevia is ruled out
• speculum examination to assess site and nature of bleeding if possible.

Question 11

timing of birth

Answer 11

if 36 weeks or more gestation and any APH - expedite birth.
if severe maternal or fetal compromise - expedite birth irrespective of gestation
if earlier than 36 weeks - and mother and baby are well - conservative management is ok

Question 12

mode of birth

Answer 12

If mother and baby are stable, CTG is normal and placenta / vasa praevia is ruled out, then it is possible to achieve a vaginal birth.
Otherwise if there is maternal or fetal compromise - it is category one caesarean section

Question 13

minor APH managment

Answer 13

admit for ongoing assessment and observation
consider discharge after cessation of bleeding if stable
education about monitoring fetal movements
serial growth scans fortnightly
maintain Hb

Question 14

fetal considerations

Answer 14

• corticosteroids antenatally before 34 weeks for pulmonary maturation
• magnesium sulphate if birth imminent and less than 30 weeks gestation for neonatal neuroprotection.

Question 15

Maternal considerations:

Answer 15

• consultation category in referral guidelines
• debrief woman and whanau
• if Rh- kleihauer and anti-d