Antepartum: Hemorrhage (APH) Exam practice Guide Questions with Approved Answers 2023/2024

Antepartum: Hemorrhage (APH) Exam practice Guide Questions with Approved Answers 2023/2024 Purpose and scope - correct answer ● Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby. ●The most important causes of APH are placenta praevia and placental abruption, although these are not the most common. ●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. ● In the 2006-08 report of the UK Confidential Enquiries into Maternal Deaths, haemorrhage was the sixth highest direct cause of maternal death. ●The causes of APH include: placenta praevia, placental abruption and local causes (for example bleeding from the vulva, vagina or cervix). It is not uncommon to fail to identify a cause for APH when it is then described as 'unexplained APH'. defenitions - correct answer ● It is important when estimating the blood loss, to assess for signs of clinical shock. The presence of fetal compromise or fetal demise is an important indicator of volume depletion. -Spotting - staining, streaking or blood spotting noted on underwear -Minor haemorrhage - blood loss 50 ml that has settled -Major hge - blood loss of 50-1000 ml, + no signs of clinical shock -Massive haemorrhage - blood loss 1000 ml and/or signs of shock. -Recurrent APH are episodes of APH on more than one occasion. What are the risk factors for placenta praevia? - correct answer ● Previous placenta praevia ● Previous caesarean sections -One previous caesarean section (OR 2.2) -Two previous caesarean sections (OR 4.1) -Three previous caesarean sections (OR 22.4) ● Previous termination of pregnancy ● Multiparity ● Advanced maternal age (40 years) ● Multiple pregnancy ● Smoking ● Assisted conception ● Deficient endometrium due to presence or history of: - uterine scar - endometritis - manual removal of placenta - curettage - submucous fibroid What are the risk factors for placental abruption? - correct answer ●The most predictive is abruption in a previous pregnancy, Abruption recurs in 19-25% of women who have had two previous pregnancies complicated by abruption. ● Other risk factors for placental abruption include: pre-eclampsia, 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. ●-First trimester bleeding increases the risk of abruption later in the pregnancy. A threatened miscarriage increases the risk of placental abruption from 1.0% to 1.4%. when an intrauterine haematoma is identified on ultrasound scan in the first trimester, the risk of subsequent placental abruption is increased. ● -Overall, thrombophilias were associated with an increased risk of placental abruption, but significant associations were only observed with heterozygous factor V Leiden and heterozygous prothrombin 20210A. Can APH be predicted / prevented? - correct answer ● APH has a heterogeneous pathophysiology and cannot be predicted. abruption is usually a sudden and unexpected obstetric emergency, not predictable by means of known reproductive risk factors.Approximately 70% of cases of placental abruption occur in low-risk pregnancies. ● Women should be advised, encouraged and helped to change modifiable risk factors (such as smoking and drug misuse). There is limited evidence to support interventions to prevent APH. ● There are no good data to support a role for antithrombotic therapy (low dose aspirin +/- LMWH) in the prevention of abruption in women with thrombophilia. ● It is considered good practice to avoid vaginal and rectal examinations in women with placenta praevia, and to advise these women to avoid penetrative sexual intercourse. ● there is no place for the use of prophylactic tocolytics in women with placenta praevia to prevent bleeding.