APH Flashcards
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.
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.
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.
4% sensitivity for diagnosing abruption, but should be sent as highly specific and positive result suggests significant FMH.
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.
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
Antenatal care for women with APH
Cervical / vaginal causes: No change
APH from placental abruption or unexplained APH:
- Obstetrician led care
- Serial growth scans
- Risks: FGR, oligohydramnios, PPROM, preterm labour and caesarean delivery
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.
How should the woman presenting with an APH who develops a coagulopathy be managed?
Assess for cause of bleeding
Monitor for the development of DIC -
- clotting studies (raised INR, PT and APTT)
- low fibrinogen (<2g/l highly predictive DIC and massive haemorrhage)
- low platelets
- thromboelastography (TEG) in theatres
- Hb (assess degree blood loss)
- LFTS (liver pathology and reduced septic production of clotting factors contributing)
- U&E and creatinine - high risk for AKI
- ABG (metabolic acidosis, electrolytes, hypoxia)
Rx:
- Call haematology and blood bank
MTP (initially):
- 4 x Red cells
- 2 x FFP
- 1 x Platelets
- cryoprecipitate (3-4g if <1g/L) - commence early in obstetric haemorrhage as higher risk DIC than other causes major haemorrhage
- 1g TXA IV over 10 mins
Supportive
- Avoid hypothermia
- Avoid excessive crystalloid - causes dilution of clotting factors
- Tolerate relative hypotension SBP 80-100
- Reverse anticoagulation
What are the postnatal issues that need to be addressed in women whose pregnancies
are complicated by APH?
Thromboprophylaxis
Ongoing monitoring in appropriate setting e.g. ICU
Careful documentation
Clinical incident reporting
Debriefing
Good postnatal support - recognition PTSD
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
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
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
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.
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
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
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
