What is the definition of an APH?
Bleeding from or into the genital tract, occuring from 24+0 weeks - prior to birth of the baby.
(RCOG)
There are no consistent definitions of the severity of an APH, but in what 4 catergories is it typically broken down into?
Spotting- staining/streaking of blood in underwear or on pad
Minor haemorrhage- blood loss >50mls and settles
Major haemorrhage- blood loss of 50-1000mls with no signs of clinical shock
Massive haemorrhage- Blood loss >1000mls with signs of clinical shock
What are the two most important causes of APH?
Placenta praevia and Placental Abruption
(Although not the most common causes)
(RCOG)
What are the risk factors for placental abruption?
- previous abruption (reoccurs in 19-25% of those who have had 2x previous)
- pre-eclampsia
- FGR
- Low BMI
- Abdominal trauma (Accident/Dom Violence)
- Polyhydramnios
- FGR
- PROM
- Advanced maternal age and multiparity
- Smoking and drug use (amphetamines/cocaine) during pregnancy
What are the risk factors for placenta praevia?
- previous praevia
- previous LSCS
- previous TOP
- multiparity
- advanced maternal age >40
- smoking
- assisted conception
- deficient endometrium due to: uterine scars, fibroids, prev manual removal of placenta or previous endometrisis (inflammation of endometrium/inner lining of uterus)
What are the maternal complications of an APH?
- Anaemia
- infection
- Maternal Shock
- Renal Tubular necrosis
- PPH
- complications of a blood transfusion
- Risk of DIC
What are the fetal complications of an APH?
- Hypoxia
- SGA and FGR
- Premature delivery
- Fetal Death
How is placenta praevia clinically presented?
-Signs of hypovolaemia (pale, sweating, tachycardia, increased RR, decreased BP and urine output)
- Painless bleeding
- Soft Uterus
- Often no fetal compromise
How is placental abruption clinically presented?
- signs of hypovolaemia
- concealed or revealed bleeding
- severe, constant abdominal pain
- tender, rigid uterus
- fetal compromise
- risk of DIC
How is a uterine rupture clinically presented?
- signs of hypovolaemia
- sudden onset of constant pain
- presenting part is high
- bleeding, which may be concealed
- pathological CTG
- contractions may cease
- haematuria
How is vasa praevia clinically presented?
- PV bleeding following ROM
- Acute fetal compromise
- Sinusoidal CTG trace
- Fetal Bradycardia
- No change in maternal condition
(Fetal blood- catastrophic to fetus)
Management of Massive APH?
- Obstetric emergency- call for soaps. 2222 for neonatologist (may need to transfuse baby) and haematoligist.
- Lay mother on left lateral positon
- Give high flow oxygen 15L/min
- Gain IV access x2
- take bloods: FBC, clotting, g&s, Xmatch 4 units and check Rh status.
- Rapid fluid replacement x2 of crystalloid, haartmans or 0.9% saline
- Assess fetal wellbeing via continuous CTG
- Maternal obs (resps, BP, pulse and sats)
- find source of bleed, clinical history
- examine abdomen for tone/pain
- measure blood loss
- fluid balance
- consider expediting birth and mode of birth
- advise active management of 3rd stage followed by IV syntocinon infusion for 4 hours (40iu of synt to 46ml of saline)
- hourly fluid balance assessment following birth
