What is APH?
bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby (RCOG 2014)
What are the most common causes of APH?
placenta praevia and placenta abruption, however they’e not the most common (RCOG 2014)
APH facts
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 (RCOG 2014)
What is the incidence of APH?
- Leading cause of maternal death worldwide
- 50% of maternal deaths globally: –250 000 deaths from haemorrhage per yearUK deaths from haemorrhage are now rare:•Haemorrhage mortality rate total= 22(UK & Ireland)Which is 18.8% of direct deaths (0.88 per 100,000 maternities UK & Ireland) EMBRRACE-UK (2013-2015) Pg. 75.(Placental abruption 3; Placenta Praevia/Accreta 9 (5 post C/S); PPH 10) Pg.75
Areas for improvement in management of APH in the UK?
•‘Major substandard care’ in over 50% of all women who died (MBRRACE – UK 2012-2014)
–Lack of early senior multi-professional involvement
–Failure to act on signs and symptoms
–Inadequate use and interpretation of maternal obstetric early warning score charts
What are the causes of vaginal bleeding in pregnancy?
Placenta Praevia 0.5% - 1% (Hutcherson, 2017)
•Abruption
•Ruptured Vasa Praevia
•Uterine Scar Disruption
In addition:
•Show
•Cervicitis
•Cervical Polyp (polyp+ grape like growth of tissue- painless until begins to twist and can bleed)
•Cervical Cancer
•Cervical Ectropion (cells normally inside cervix come to surface, proliferate out and can cause bleeding)
•Vaginal Trauma
What are the different classifications of placenta praevia?
Hutcherson, 2017
–“Low Lying : Placenta mainly in the upper uterine segment but encroaching on the lower segment.
–Marginal : Placenta reaches to, but does not cover, the internal os
–Partial : Placenta covers the internal os when closed but not completely when it is dilated
–Total : placenta completely covers the internal os.”
RCOG (2011) Total = MAJOR
If the leading edge of the placenta is in the lower uterine segment but not covering the OS = MINOR or PARTIAL
What are the signs and symptoms of a placental abruption?
- Vaginal bleeding may or may not be present- usually dark red or brown +/- clots
- Abdominal pain + uterine tenderness (sometimes described as ‘knife-like’ or ‘tearing’
- Uterine activity/ irritable uterus
- Hypertonic uterus (feels very tight, maybe can’t hear FH with concealed abruption)
- Couvelaire uterus (feels hard/ woody) common in concealed abruptions
- Backache (more common in a posterior implanted placenta)
- Fetal distress
- Maternal shock (may be disproportionate to blood loss)
What are the risk factors for placental abruption? (RCOG 2011)
1% of pregnancies Pre-existing maternal conditions: –Recurrent abruption 19-25% –Pre-eclampsia –Fetal growth restriction –Non vertex presentations –Polyhydramnios –Advanced Maternal Age –Multiparity –Low BMI –Drug misuse (e.g. Cocaine and Amphetamines) –Domestic abuse
What is the management of a placental abruption?
NEVER DO A VE UNTIL IT HAS BEEN CONFIRMED THE PLACENTA IS NOT LOW •Your priority is always the mother •Call for help (Emergency Bell/ 2222) •Left Lateral Position •ABC (Oxygen, Sats, Bp, RR, Pulse, Temp) •I.V. access and bloods •Fluid resuscitation •Indwelling Catheter •Presenting part, fetal position and progress in labour •Stabilize the mother •Only then consider the baby
What additional investigations are carried out?
Blood tests- FBC, Clotting, G&S/ X-match, Kleihauer if RH Negative
•MSU & urine dipstick
•Speculum examination
•NO digital examination unless placental site confirmed as not low
•Ultrasound
What is placenta praevia?
Placenta Praevia exists when the placenta is inserted wholly or in part into the lower segment of the uterus (RCOG 2011)
Diagnosed by Ultrasound (transvaginal USS at 20/40 – follow up if placenta lies anteriorly and reaches the os / implanted in CS scar)
Incidence:0.5% to 1% pregnancies at term (Hutcherson, 2017)
What are the different classifications of placenta praevia?
Major- < 2cm from or covering cervical os
Minor- > 2cm from cervical os (RCOG 2011)
What are the signs of placenta praevia?
- Painless bright red vaginal bleeding ranging from mild to torrential (may be precipitated by intercourse)
- History of previous smaller PV bleeds (sentinel bleeds)
- Uterus may or may not be contracting
- Maternal shock / collapse
- Fetal distress
- Malpresentation / unstable lie
- High head
- Check the scan
What are the risk factors for placenta praevia and associated morbidity?
- Previous CS
- Previous Uterine Instrumentation
- High Parity
- Advanced Maternal Age
- Smoking
- Multiple Pregnancy
- Maternal Haemorrhage
- Operative delivery complications
- Transfusion
- Prematurity
- Placenta accreta, increta, percreta
What are the different causes of placenta praevia?
Endometrial scarring
Increased placental mass
Impeded endometrial circulation
What causes endometrial scarring?
previous LSCS or myomectomy
previous placenta praevia
multiparity
What causes an increase in placental mass?
placental anomalies e.g. succenturiate lobe or bipartite placenta
multiple pregnancy
What causes an impeded endometrial circulation?
- medical conditions
- (hypertension, diabetes)
- increasing maternal age
- uterine tumours
- Smoking
- drugs
What is the management of placenta praevia?
NEVER DO A VE our priority is always the mother •Call for help (Emergency Bell/ 2222) •Left Lateral Position •ABC (Oxygen, Sats, BP, RR, Pulse, temp) •I.V. access and bloods (Cross matched blood should be readily available. Cell salvage) •Fluid resuscitation •Indwelling Catheter •Presenting part and fetal position •USS •Stabilize the mother •Only then consider the baby
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What are the potential complications of severe APH?
- Severe anaemia
- Infection
- PPH
- Blood coagulation disorders/ DIC
- Acute renal failure
- Sheehan’s syndrome (pituitary necrosis)
- Psychological distress/ post traumatic stress
- Hysterectomy
- Fetal hypoxia
- Neonatal anaemia/ hypovolaemia
- Preterm delivery
- Intrauterine death
What is the management of severe APH?
- Catheterise (urometer)
- Strict fluid balance
- Involvement of Haematologist
- May need blood products
- Emergency LSCS when stable
- May need a central line (CVP)
- In the case of uterine rupture or morbidly adherent placenta Possible Hysterectomy
- DOCUMENTATION
What is vasa previa? (RCOG 2011)
•Occurs when a fetal blood vessel within the membranes covers the cervical os ahead of the presenting part. Often associated with a velamentous insertion of the cord or succenturiate lobe
.•Rarely causes bleeding in the 3rd trimester but may present in labour or with rupture of the membranes
•Associated with high fetal/ perinatal mortality & can rapidly lead to fetal exsanguination-Reported incidence - 1:2000 to 1:6000 pregnancies
