Flashcards in APH Deck (36):
What is APH?
Bleeding from the genital tract >5mL occurring 20/40 - birth.
- placenta previa
- placental abruption
What is the leading cause of perinatal and maternal mortality worldwide?
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
What are the RFx for abruption?
- *Previous abruption*
- Non vertex presentation
- Polyhydramnios / multiparity
- Advanced maternal age
- Increased parity
- Poor nutrition
- Sudden reduction in uterine volume (e.g. after delivery of first twin).
What are the RFx for placenta praevia?
- Previous previa
- Previous LUSCS
- Previous termination
- 40yo +
- Deficient endometrium (scar, endometritis, curettage, fibroid)
What are the maternal complications of APH?
- Consumptive coagulopathy
- Prolonged hospital stay
- Psychological sequelae
What are the foetal complications of APH?
- Foetal hypoxia
- IUGR / SFDs
Why is it important to ascertain pain status on Hx in APH?
- Continous: ? abruption
- Intermittent: ? labour
Hx features APH?
- RFx: previa and abruption
- Foetal movements
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)
What are potential causes of local bleeding in APH presentation?
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
Components of initial APH assessment?
- Blood loss
- AFx: abdo pain, contractions
- Provoking factors: trauma, sexual intercourse
- Foetal movements
- 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.
What features on Hx may help diagnose cause of APH?
- RFx for abruption / previa
- Foetal movements
- Pap smear Hx
PEx features to diagnose cause of APH?
- Abdo palpation
- Spec examination
- VE: not until US excludes praevia
What is suggested by a tense or woody abdomen in the setting of APH?
What is the purpose of spec examination in APH?
- Identify cervical dilation
- visualise lower genital tract cause
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
Blood Ix in major APH?
- Group and crossmatch
- Coagulation profile
- ABG in severe cases
- Consider blood products if bleeding severe
Purpose abdo palp in APH?
- foetal presentation and lie
- assess uterine activity
- assess for pain, tenderness
Why is US NOT investigation to diagnose abruption?
Will either be substantive and therefore clinically apparent OR not seen on US
PEx features suggestive of abruption?
- Tense, tender uterus
- Large for dates
- Shock out of proportion with visible bleeding
PEx features suggestive of praevia?
- High presenting part
- Abnormal lie
- No contractions
- Soft, non-tender uterus
Mx of placenta praevia?
- 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
How is placenta praevia diagnosed?
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
What is placenta praevia?
Placenta attached to lower segment of uterus, may cover cervix.
Placental site usually >5cm from os.
What is placental abruption?
Haemorrhage from decidual detachment of a normally situated placenta.
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
Considerations for delivery in placental abruption in premature gestation?
PREMATURE (32-37) :
Conservative for minor abruption.
- susbstantive blood loss
- significant uterine tenderness
- coagulopathy or
- foetal compromise.
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.
Should women with abruption be admitted?
Nearly all abruption admitted. Will often remain in hospital until delivery.
Follow up following delivery in cases of abruption?
- Send placenta for path
- Maternal screening for thrombophilias
- Advise drug and smoking cessation
What are the serious complications of abruption?
- Maternal haemorrhage and shock
Amount of blood to cross match in major APH?
Should antenatal care be altered following APH?
- Cervical ectropion: no
- Abruption or unexplained APH: high risk; consultant led ANC