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Flashcards in APH Deck (36):
1

What is APH?

Bleeding from the genital tract >5mL occurring 20/40 - birth.
Important causes:
- placenta previa
- placental abruption

2

What is the leading cause of perinatal and maternal mortality worldwide?

APH

3

How is APH classified?

Spotting / minor / major / massive.

- Spotting: staining, streaking or spotting on underwear or sanitary protection.
- Minor: less than 50mL that has settled
- Major: 50 - 1000mL with no signs of clinical shock
- Massive: more than 1000mL +/- clinical signs of shock

4

What are the RFx for abruption?

- *Previous abruption*
- PEt
- IUGR
- Non vertex presentation
- Polyhydramnios / multiparity
- Advanced maternal age
- Trauma
- HTN
- Increased parity
- Poor nutrition
- ECV
- Sudden reduction in uterine volume (e.g. after delivery of first twin).
- Chorioamnionitis

5

What are the RFx for placenta praevia?

- Previous previa
- Previous LUSCS
- Previous termination
- Multiparity
- 40yo +
- Smoking
- Deficient endometrium (scar, endometritis, curettage, fibroid)

6

What are the maternal complications of APH?

- Anaemia
- Infection
- Shock
- ATN
- Consumptive coagulopathy
- PPH
- Prolonged hospital stay
- Psychological sequelae

7

What are the foetal complications of APH?

- Foetal hypoxia
- IUGR / SFDs
- Prematurity
- FDIU

8

Why is it important to ascertain pain status on Hx in APH?

- Continous: ? abruption
- Intermittent: ? labour

9

Hx features APH?

- Pain
- RFx: previa and abruption
- Foetal movements
- ROM

10

What are the causes of APH?

- Placenta praevia (30% APH)
- Placental abruption (25% APH)
- Marginal bleed
- Vasa praevia (rare condition; + ROM)
- Uterine rupture
- Local causes: cervix, vagina (45% APH)

11

What are potential causes of local bleeding in APH presentation?

- Ectropion
- Dysplasia
- Cervicitis
- Polyps
- Carcinoma

12

What is the first aim of APH assessment?

Categorise into two groups:
1) Major haemorrhage from APH
2) APH where resuscitative measures are not required

13

Components of initial APH assessment?

HOPC
- Timing
- Blood loss
- AFx: abdo pain, contractions
- Provoking factors: trauma, sexual intercourse
- Foetal movements

Current Pregnancy:
- Previous episodes of bleeding
- Review of US scans performed earlier esp for placental site on 20w scan or later
- Complete past obstetric, gynaecological, medical and surgical history.

14

What features on Hx may help diagnose cause of APH?

- Pain
- RFx for abruption / previa
- Foetal movements
- ROM
- Pap smear Hx

15

PEx features to diagnose cause of APH?

- Abdo palpation
- Spec examination
- VE: not until US excludes praevia

16

What is suggested by a tense or woody abdomen in the setting of APH?

Abruption

17

What is the purpose of spec examination in APH?

- Identify cervical dilation
- visualise lower genital tract cause

18

Emergency mx of major APH?

- Call for help
- Basic life support: ABCs
- IV access, bloods, fluid replacement: 16g, crystalloid or colloid
- Insert IDC and record output
- Abdo PEx and spec
- CTG and US
- Medications (if time permits)
- Consider delivery
- Document
- Communicate

19

Blood Ix in major APH?

- FBE
- Group and crossmatch
- Coagulation profile
- Kleihauer
- ABG in severe cases
- Consider blood products if bleeding severe

20

Purpose abdo palp in APH?

- foetal presentation and lie
- assess uterine activity
- assess for pain, tenderness

21

Why is US NOT investigation to diagnose abruption?

Will either be substantive and therefore clinically apparent OR not seen on US

22

PEx features suggestive of abruption?

- Tense, tender uterus
- Large for dates
- Shock out of proportion with visible bleeding

23

PEx features suggestive of praevia?

- High presenting part
- Abnormal lie
- No contractions
- Soft, non-tender uterus

24

Mx of placenta praevia?

- Resuscitation
- Foetal assessment and delivery (Major APH)
- Insert IV and crossmatch
- Confirm diagnosis on US
- Expectant Mx if preterm and blood loss small
- Serial growth scans to exclude IUGR
- Admit and plan for ongoing hospital admission until C section if major grade
- Steroid prophylaxis for lung maturity if premature
- Anti D if Rh -ve
- C section if large bleed, continuing
- Watch for PPH,
- counsel re possible hysterectomy
- Avoid digital examination and intercourse in T3

25

How is placenta praevia diagnosed?

Diagnosis
by US: inferior edge of placenta and os measured
- asymptomatic minor: f/u scan 32-36w
- asymptomatic major: f/u scan 30-32w
- symptomatic: individual Mx

26

What is placenta praevia?

Placenta attached to lower segment of uterus, may cover cervix.
Placental site usually >5cm from os.

27

What is placental abruption?

Haemorrhage from decidual detachment of a normally situated placenta.

28

Mx placental abruption?

- Resuscitate and restore volume
- IV access with 2x 16g
- Cross match, (+ platelets and FFP if MTP ?required).
- Ix: FBE, coags, UEC, LFTs, Kleihauer test
- Monitor urine output
- Anti D
- ASAP foetal assessment and continuous monitoring
- Rx: steroids, MgSO4 (if under 30w and delivery planned)
- Consider delivery

29

Considerations for delivery in placental abruption in premature gestation?

PREMATURE (32-37) :
Conservative for minor abruption.
Delivery if
- susbstantive blood loss
- significant uterine tenderness
- coagulopathy or
- foetal compromise.

30

Considerations for delivery in very and extreme prem APH due to abruption?

VERY PREM (28-32) and EXTREME preterm (<28)
- Conservative management even if susbstantive bleeding but only if both maternal and foetal conditions stable. Weigh risks of early delivery and continuing pregnancy.
- C section if mother / foetus unstable. Stabilise both.

31

Should women with abruption be admitted?

Nearly all abruption admitted. Will often remain in hospital until delivery.

32

Follow up following delivery in cases of abruption?

- Send placenta for path
- Maternal screening for thrombophilias
- Advise drug and smoking cessation

33

What are the serious complications of abruption?

- FDIU
- Maternal haemorrhage and shock
- PPH
- DIC

34

Amount of blood to cross match in major APH?

4U

35

Should antenatal care be altered following APH?

- Cervical ectropion: no
- Abruption or unexplained APH: high risk; consultant led ANC

36

What is appropriate management of third stage of labour in women with APH?

- PPH should be anticipated
- Counsel need for active management
- Consider Syntometrine (ergometrine + oxytocinon) if no HTN