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Flashcards in APH Deck (25)
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1

Definition of APH

bleeding from or in to the genital tract, occurring from 24+0
weeks of pregnancy and prior to the birth of the baby

2

Causes of APH

'local':
Bleeding from vagina, cervix or vulva

Placental:
Abruption
Placenta praevia

Unexplained

3

Incidence of APH

APH complicates 3–5% of pregnancies and
is a leading cause of perinatal and maternal mortality worldwide.

Up to one-fifth of very preterm babies are
born in association with APH, and the known association of APH with cerebral palsy can be explained by preterm delivery.

4

APH RCOG guideline definitions:

Spotting
Minor haemorrhage
Major haemorrhage
Massive haemorrhage

Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection
Minor haemorrhage – blood loss less than 50 ml that has settled
Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock
Massive haemorrhage – blood loss greater than 1000 ml and/or signs of clinical shock.

5

Risk factors for abruption

- The most predictive is abruption in a previous pregnancy. 4% if 1 previous, 19-25% if 2 or more.

Other risk factors for placental abruption include:
-pre-eclampsia/HTN disorder
-fetal growth restriction,
-non-vertex presentations,
-polyhydramnios,
-advanced maternal age,
-multiparity,
-low body mass index (BMI),
-pregnancy following assisted reproductive techniques,
- intrauterine infection,
- premature rupture of membranes,
- abdominal trauma (both accidental and resulting from domestic violence),
- smoking and drug misuse (cocaine and amphetamines) during pregnancy.

70% of cases of placental abruption occur in low-risk pregnancies

6

Preventing abruption

Limited evidence to support interventions to reduce abruption but recommend:

- Modify lifestyle risk factors e.g. stop smoking/drug use
- May be some evidence to suggest folic acid and vitamins may reduce risk of abruption but large trials looking at folic acid alone failed to show benefit
- no evidence for antithrombotic therapy (e.g. LMWH) for women with thrombophilias
- Large study currently looking at giving LMWH to women with previous abruption to see if this reduces incidence of abruption, IUGR and PET.

7

Association between APH and maternal/perinatal outcomes

** May be presentation of domestic violence

- Maternal complications:
Anaemia
Infection
Maternal shock
Renal tubular necrosis
Consumptive coagulopathy
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Complications of blood transfusion

- Fetal complications:
Fetal hypoxia
SGR and FGR
Prematurity (iatrogenic and spontaneous)
Fetal death

8

Complications of unexplained APH

Increased risk of stillbirth, prematurity, fetal anomalies, SGA

9

Role of assessment in APH

- Triage- is urgent intervention required to manage maternal or fetal compromise?

- Hx: pain, risk factors, an assessment of the extent of vaginal bleeding, the cardiovascular condition of the mother, and an assessment of fetal wellbeing.

Examination:
- abdo exam, speculum, consider digital only if placenta praevia excluded

Consider steroids

10

Investigations for women presenting with an APH

FBC, coag (major haemorrhage or low plt), cross-match/G+H. U+Es, LFTs

Kleihauer: for rhesus negative women to quantify fetomaternal haemorrhage (FMH) in order to gauge the dose of anti-D immunoglobulin required. Not a sensitive test for diagnosing abruption.

Ultrasound- for placenta praevia but doesn't exclude abruption. (USS will miss 75% of abruptions but if it does suggest abruption then likely to be one)

Placental abruption is a clinical diagnosis and there are no sensitive or reliable diagnostic tests
available.

11

Who should be admitted due to APH?

Spotting and no longer bleeding- (if praevia excluded) can go home after a reassuring clinical assessment.

All women with APH heavier than spotting and women with ongoing bleeding should remain in hospital at least until the bleeding has stopped

12

Use of tocolysis in context of APH and uterine activity

Tocolysis should not be used to delay delivery in a woman presenting with a major APH, or who is haemodynamically unstable, or if there is evidence of fetal compromise.

A senior obstetrician should make any decision regarding the initiation of tocolysis in the event of an APH.

13

Antenatal care for women with APH

Cervical ectropion: No change

APH from placental abruption or unexplained APH:
- Obstetrician led care
- Serial growth scans
- Risks: FGR, oligohydramnios, PPROM, preterm labour and caesarean delivery

14

Delivery options for women with APH

IUD: vaginal birth recommended mode but caesarean if unstable.

Compromised mother or fetus: caesarean section is the appropriate method of delivery with concurrent resuscitation of the mother.

Timing of delivery of women presenting with unexplained APH and no associated maternal and/or fetal compromise is not established.

15

Fetal monitoring for women with APH in labour

Continuous CTG unless they have experienced one episode of minor APH, in which there have been no subsequent concerns regarding maternal or fetal wellbeing.

16

How should the woman presenting with an APH who develops a coagulopathy be managed?

Call haematology
Monitor for the development of DIC

Need:
- Clotting studies
- platelet count
- Consider given cryo/FFP as well as blood if developing DIC

17

What are the postnatal issues that need to be addressed in women whose pregnancies
are complicated by APH?

thromboprophylaxis, debriefing and clinical incident reporting.

18

A healthy 34 year old at 35 weeks gestation reports 2 hours of back pain followed by heavy vaginal bleeding. On examination she is pale, distressed and in pain. Pulse 130bpm, BP 70/40, the uterus is tender, the fundal height is 39cm above the symphysis pubis, longitudinal lie, cephalic presentation mobile at the pelvic brim. No fetal heart can be heard on auscultation, an ultrasound shows no activity of the fetal heart. The cervix is felt to be long and closed. Your provisional diagnosis is a placental abruption.

a. List in order of priority how you manage the initial presentation and subsequent delivery (5 marks)

• Arrange help – call emergency code for senior obstetrics/anaesthetics/midwifery +/- blood bank/haematology/OT/ICU
• Maternal ABC
• A and B – ensure airway patent and spont breathing especially if losing consciousness, consider high flow O2 and intubation/ventilation as appropriate
• C – IVL x2 large, take blood for FBC, G&S, X-match, Kleihauer, coag
• Rapid infusion with fluids e.g. crystalloid up to 3.5L
• Blood transfusion once available if still unstable after above, ideally matched but O neg if delayed
• If heavy bleeding/still unstable – will need delivery via hysterotomy, prepare for MTP/coagulopathy and PPH – needs specialist obstetrician and anaethetist
• If stabilises – confirm IUFD with formal USS, arrange IOL at a time to suit woman if stable (unlikely given the above)
• Anti D if Rh negative
• High dependency unit - ?need for ICU
• Document
• Debrief

19

b. After delivery the couple asks if you can determine why this occurred. What possible causes should be considered? (3 marks)

- Strongest predictor- hx of previous abruption
Other RF:
- Smoking or drug use (e.g. cocaine/methamphetamine use)
- PET or HTN disorder
- PPROM
- Polyhydramnios
- Non-vertex presentation
- AMA
- IVF/assisted reproductive techniques
- Intrauterine infection
- Fall/DV/other trauma

70% of cases occur in low risk pregnancies

20

c. What investigations would you organize? (3 marks) (Abruption q with IUFD)

- FBC, U+E, Coag, G+H - PET screen
- ANA, ESR, LAC, ACL -Thrombophilia screen postnatally
- BP monitoring
- Offer PM of baby and examination of placenta
- Other IUFD bloods – HbA1c, TORCH screen, karyotype

21

d. Justify the management options and advice you would consider for her next pregnancy (4 marks)

- Debrief postnatally and ensure psychological support next pregnancy

• Increased risk of recurrence but absolute risk still small (approx 4%)
• Cessation of smoking/drug use pre-pregnancy – reduce risk recurrence
• Early booking with LMC and obstetric input – early planning of co-ordinated care
• Consider aspirin and heparin In early pregnancy if APLS/SLE – reduced chance of IUGR/abruption/PET, miscarriage
• Routine care – folate/iodine, USS for dating/morphology, 1st trimester anuepolidy screeing and DM screening
• PET vigilance – check BP and urine – early identification to treat BP/timely delivery/reduce complications
• Monthly growth USS – IUGR is a RF for abruption
• Present early if any pain/bleeding – early identification to reduce complications
• Delivery – reasonable to offer at 38-39/40 – no evidence to back, but considerate of feelings if anxious. Mode dependent on previous delivery/maternal preference.

22

a. List four (4) serious adverse outcomes that are more commonly associated with placental abruption than with placenta praevia. (2 marks)

Maternal
• Coagulopathy- 10%
• Acute renal failure, acute tubular necrosis
• Stroke
Association with PET/HTN disorders

Fetal
• Feto-maternal haemorrhage
o Anaemia
o Coagulopathy
o Stillbirth
o NICU admission
• Fetal growth restriction

23

A 36 year old primigravid patient at 34 weeks gestation presents to the Delivery Ward with sudden onset of fresh vaginal bleeding (100 mL) and abdominal pain. On admission she is distressed, pulse rate 130 bpm, blood pressure 80/50 mmHg. Her uterus is tender, hard and difficult to palpate. The fetal heart beat cannot be heard. A bedside ultrasound scan confirms the absence of fetal heart activity and a cephalic presentation. Her cervix is tightly closed.
b. Outline step-by-step (giving at least 16 steps) your protocol for management of this woman. (8 marks)

Immediate management
• Airway, breathing and circulation assessment- results as above
o Give supplemental O2
o Place in L lateral tilt to allow better venous return
• Call an obstetric code: SMO, help from senior midwives, anaesthetists, theatre on standby
• IV access: 2x 14-16 gauge IV lines each arm
• Send as urgent:
o Full blood count
o Urea, electrolytes, creatinine
o Liver functions
o Coagulation screen: APTT, PR, fibrinogen
o Kleihauer: quantify the amount of anti-D needed if Rh negative
o Blood group and hold
 Call blood bank- cross match 4 units urgently, advise further requests may come
• Resuscitate: warmed IV fluids 2L (blood loss from an abruption with a fetal demise usually >1.5L)
o Continuous monitoring of maternal HR and SaO2
o Q15 minute BPs until rising, then Q30 minutes
o Empiric management with massive ongoing haemorrahage: 1 unit colloid, 4 FFP, 10 cryoprecipitate, O- blood
• Correct:
o Anaemia- packed RBCs
o Coagulopathy- fibrinogen, FFP, platelets
o Activate massive transfusion protocol with severe anaemia and coagulopathy
o Early involvement of haematologist in administration of products
• Insert IDC
o Carefully monitor output given risk of acute renal failure and ATN

Concurrently:
• Explain to the mother what is happening and offer condolences
• Offer support and counselling
• Offer to call family and friends to be with her

Planning for delivery
• Once the mother stable- confirm fetal demise with formal USS
• Advise regarding mode of delivery- vaginal delivery preferred with fetal demise if mother stable
o IOL with misoprostol protocol recommended by NICE guidelines for fetal demise
o High risk of spontaneous labour with abruption
o Close monitoring during labour- ideally labour in an obstetric HDU, may need an ART line for continuous monitoring
• If mother remains unstable then CS indicated on maternal grounds, but this would be high risk with coagulopathy, blood loss, and potential for emergency hysterectomy
o GA needed with coagulopathy/unstable mother
• If transfer to another unit for management necessary, ensure that mother stabilised before this
• Anticipate PPH and have a plan in place for steps to proceed:
o Active 3rd stage management with syntocinon
o Stepwise administration of further ecbolics
o Bakri balloon
o Consider IR for uterine artery embolisation
o Laparotomy last resort

Post-partum
• Placenta + cord for histology, discuss PM
• Admit to HDU post-operatively if unstable
• Hourly obs and urine output
• Debrief
• Give anti-D after Kleihauer back if Rh negative mother

24

c. Discuss five (5) risk factors which are associated with recurrence of placental abruption in this patient’s next pregnancy. Where appropriate, include how each risk factor may be managed or modified to try to avoid placental abruption. (5 marks)

Previous abruption Biggest risk factor and not modifiable
Smoking Smoking cessation
Cocaine and amphetamine use Cessation
Pre-eclampsia Aspirin and calcium in the next pregnancy
Hypertension Anti-hypertensives, weight loss, smoking cessation
Low BMI Weight gain to a healthy BMI

25

'Four pillars' of management of abruption?

1. Communication between all members of the multidisciplinary team
2. resuscitation
3. Monitoring and investigation
4. Arrest bleeding by arranging delivery of the fetus