obsteric haemorrhage : APH

What are the causes of obstetric haemorrhage? (5) in the past

1. Patient deltas in seeking medical care

2. Lack of blood + blood products

3. Lack os stuff / overburdened services

4. Delayed treatment due to inaccurate estimation of blood loss

5. Substandard care with inadequate resuscitation

What are the causes of OH in this triennum? (5)

1. Bleeding at C/S or after

2. PPH after vaginal delivery

3. APH- Abruptio placenta

4. Placenta praevia

5. Ruptured uterus (both scarred and unscarred)

Define obstetric haemorrhage

Any kind of abnormal bleeding that is related to pregnancy can can occur antepartum, during delivery of postpartum

What are some causes of bleeding antepartum? (6)

1. Placenta praevia

2. Abruptio

3. Coagulopathy

4. Uterine rupture

5. Cervical lesions

6. APHUO (after 20 wks)

What is a cause of bleeding intrapartum?

Lacerations during vaginal delivery

What are some causes of bleeding postpartum? (4)

1. Bleeding from a morbidly adherent placenta

2. Uterine atony

3. Retained placenta

4. Cervical tear

Define antepartum haemorrhage (aph)

Bleeding from / into the genital tract occurring from 20 weeks or after the gestation age of viability (26-28) and prior to delivery

What are some signs of significant volume depletion shock in APH ? (3)

1. Fetal distress

2. Fetal demise (death in the womb)

3. Clinical shock

How does the RCOG define APH severity?

Spotting > staining / streaks of blood on underwear

Minor haemorrhage > blood less <50 mls

Major haemorrhage > blood loss of 50 - 1000 mls with no signs of clinical shock

Massive haemorrhage > blood loss > 1000 mls and/ signs of clinical shock

Define recurrent APH

More than 1 episode of APH

What are the placental causes of APH ? (3)

1. Placenta praevia

2. Abruptio placentae (placenta separates from uterine wall before baby is born cutting of its oxygen & nutritional supply)

3. Vasa praevia (unprotected vessels from the umbilical cord / placenta cross the opening of the cervix)

What are the genital tract causes of APH? (4)

1. Cervicitis

2. Trauma

3. Cervical tumour

4. Sexual intercourse

What is an unexplained caused of APH?

Antepartum haemorrhage of unknown origin

Define Abruptio placentae

Premature separation of a normally implanted placenta from the uterus prior to delivery of foetus

• could be minor / major associated complications with fetal death and maternal morbidity

How often does abruptio plancentae occur?

In 0.6 - 1.2% with more causes happening at term causing more than 10% preterm babies

What is abruptio placentae strongly associated with?

Premature rupture of membrane (PROM) in both a caudal and consequential manner

What is strongest risk factor for abruptio placentae?

Previous abruptio placentae (10-15% recurrence risk)

Risk factors for maternal substance use for abruptio placentae? (2)

1. Cigarette smoking

2. Cocaine and other drug use

Risk factors of maternal diseases associated with abruptio placentae? (4)

1. Pre-eclampsia & eclampsia

2. Chronic hypertension

3. Pregestational diabetes mellitus

4. Iron-deficiency anemia

Risk factors of uterine factors associated with abruptio placentae? (3)

1. Fibroids

2. Uterine synechiae

3. Previous uterine surgery

What are the other risk factors for abruptio placentae? (4)

1. Trauma

2. Rapid uterine decompression associated with multiple pregnancies & polyhydraminos

3. Oligohydramnios (low amniotic fluid in the baby)

4. Chorioamniontis (bacterial infection of amniotic fluid e.g Step B / E. Coli)

Define acute abruptio placentae

Sudden onset of bleeding which occurs from centrally located and larger deciduous arteries

What are some associations of acute abruptio placentae? (4)

1. Abdominal plain and uterine tenderness with tachysystole (more then 5 contractions in 10 minutes)

2. Abnormal fetal heart rate patterns

3. Maternal hypotension and coagulopathy

4. Fetal death

Define chronic abruptio placentae

Light to moderate vaginal bleeding which occurs from peripherally located smaller deciduous veins

What are some associations of chronic abruptio placentae?

Signs of chronic placental inflammation and dysfunction like oligohydramnios, FGR, pPROM

What are the clinical presentations of abruptio placentae caused by? (3)

1. Whether it’s an acute / chronic abruptio

2. Is it an overt / concealed abruptio

3. Severity of bleeding > abdominal plain better predictor of poor maternal & fetal outcome

How do we diagnose an abruptio?

Clinical diagnosis that is supported by radiological, laboratory and pathological studies

What are the 3 locations radiology can identify to support the diagnoses of abruptio placentae?

1. Subchorionic - between placentae + membranes

2. Retroplacental - between placenta + myometrium (worst prognosis)

3. Preplacental - between placenta + amino

Define placenta praevia

Abnormal placental location occurs when the placenta covers the internal cervical os completely/ extends close enough to the cervix to cause bleeding when the cervix dilates / lower uterine segment effaces (thins & stretches) after 20 weeks

Define low-lying placenta

Occurs if the placental edge is <2cm from internal os but does not cover it

When should a low-lying placenta and placenta praevia be followed up?

At 32 weeks and 36 weeks

Define placental migration

Resolution of the placenta praevia that occurs near term as the pregnancy advances to the stationary lower placental edge from the development of the lower segment

Define trophotropism

The growth of trophoblastic tissue away from the cervical os towards the fundus

What are the risk factors of placenta praevia? (8)

1. Previous placenta praevia

2. Previous C/S increases with number

3. Previous TOP

4. Multipartity

5. AMA (>40)

6. Smoking

7. Deficient endometrium due to uterine scar, endometritis, submucous fibriods, MROP

8. Assited reproductive therapy (IVF)

What are clinical features of placenta praevia on history? (3)

1. Vaginal bleeding is painless

2. Blood is bright red

3. Fetal movement are well felt

What are clinical features of placenta praevia on examination ? (3)

1. Normal vitals with no signs of shock + normal fetal heart rate

2. Uterus is soft, not tender / irritable

3. Presenting part is high + abnormal

Different between placenta praevia and abruptio (7)

Define vasa praevia

Fetal vessels run via the free placental membrane and are more likely to rupture in active labour / amniotomy is preformed to induce / augment labour , located near or over the cervix

What are the classifications of vasa praevia

1. Type 1 - vessels connect to a velamentous umbilical cord

2. Type 2 - vessels connect the placenta with a succenturiate / accessory lobe

Define uterine rupture

It’s a complete separation of all uterine layers including the serosa resulting in rapid massive maternal haemorrhage

What can a uterine rupture lead to? (6)

1. Hysterectomy

2. Urological injury

3. Haemodynamic instability

4. Coagulopathy

5. Massive blood transfusion

6. Maternal death

How do we confirm placenta praevia?

Transvaginal ultrasound (NO VAGINAL EXAMINATION)

Define uterine dehiscence

Incomplete separation of the uterine scar, often with disruption of the endometrium and myometrium with intact serosa resulting in a uterine window that may be seen during c/s with no adverse perinatal outcome

what are the risk factors of a uterine rupture? (5)

1. Previous C/S (higher with previous classical C/S)

2. Previous uterine rupture

3. Previous uterine surgery (eg. Myomectomy)

4. Induction of labour / augmentation

5. Interpregnancy interval <18 months

How do we diagnose uterine rupture? (7)

1. Sudden onset of fetal distress on CTG

2. Loss of fetal station

3. Acute vaginal bleeding

4. Severe abdominal pain

5. Loss of contractions

6. Haematuria

7. Haemodynamic instability

How do we approach a patient with antepartum haemorrhage?

• If patient is unable to give Hx, resuscitation should be started immediately and mother is main priority

• If patient it is stable, a full history should be taken

What are the 6 main questions to ask a patient with APH during history taking?

1. Is there pain associated with haemorrhage

2. Identity RFs

3. Is the fetus moving well

4. When was the last cervical smear done

5. Has the pt have history of c/s or underground induction of labour

6. Did the bleeding start after artificial rupture of membrane (AROM) / spontaneous rupture of membrane (SROM)

During an abdominal palpation for APH investigation, if I feel a tender or soft abdomen what does that mean?

Tender, hard - significant abruptio

Soft, nontender - bleeding from genital tract / placenta praevia / vasa praevia

What is a speculum exam useful in?

cervical dilation / lower genital tract lesion

When is a CTG performed during investigation of APH?

After mother is stable and resuscitated

For how long should patients with a past history of IUFD from an abruptio be hospitalised?

Until bleeding has stopped an continues admission for at least 24 hours

Which patients should be administered steroids?

At risk of iatrogenic/ spontaneous preterm birth <34 weeks to reduce the risk of neonatal deaths

True /False :Tocolytic therapy should be given to patients with major haemorrhage, clinical abruptio, haemodynamically unstable

False > decision should be made by senior obstetrician

Which medications should be avoided because they can cause maternal hypotension?

Calcium chanel blockers

How should we manage patients with APH throughout their pregnancy ?

Should be classified as high-risk and have Incressed fetal surveillance during ANC

Approach on delivery of placenta praevia

Approach on delivery of abruptio

Approach on delivery of vasa praevia

What are the 4 main components of the approach to maternal resuscitation?

1. Communication > midwife, anaesthetic, obstetrician, neonatologist

2. Resuscitation > ABCDE

3. Monitoring and investigations > Continuous check ups

4. Arrest the bleeding > 4Ts

When should a single dose of steroids be given to mothers and why?

When there’s a risk of iatrogenic / spontaneous PTB <34 weeks to reduce the risk of respiratory distress syndrome & neonatal deaths