Antepartum bleeding

Question 1

What are the classifications for antepartum bleeding volume

Answer 1

Spotting (staining, streaking or blood spotting noted on underwear or sanitary protection)
Minor haemorrhage (<50ml blood loss that has settled)
Major haemorrhage (50-1000ml blood loss, with no signs of clinical shock)
Massive haemorrhage (blood loss >1000ml and/or signs of clinical shock)

Question 2

Define antepartum haemorrhage

Answer 2

Bleeding from the genital tract after 24 weeks of pregnancy up to completion of the second stage of labour

Question 3

What is the epidemiology of antepartum bleeding

Answer 3

APH complicates 3–5% of pregnancies and is a major cause of perinatal and maternal mortality worldwide (50%).
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.

Question 4

What are the classes of haemorrhagic shock

Answer 4

I: <750ml blood loss, HR <100, normal BP and RR
II: 750-1500ml blood loss, HR 100-120, normal BP, RR 20-30
III: 1500-2000ml loss, HR 120-140, BP decreased, RR 30-40
IV: >2000ml blood loss, HR >140, BP decreased, RR >35

Question 5

What are the causes of antepartum bleeding in the first trimester

Answer 5

Miscarriage
Ectopic pregnancy
Implantation bleeding
Hydatidiform mole
Cervical ectropion
Vaginitis
Trauma
Polyps
STIs

Question 6

What are the causes of antepartum bleeding/haemorrhage in the second trimester

Answer 6

Abortion / miscarriage
Hydatidiform mole / choriocarcinoma
Vaginal infection
Cancer of the cervix
Cervicitis

Question 7

What are the causes of antepartum bleeding/haemorrhage in the third trimester

Answer 7

Placental abruption
Placenta praevia
Vasa praevia
Vaginal infection
Cancer of the cervix
Cervicitis
Bloody show

Question 8

What is a bloody show

Answer 8

Cervical changes, effacement in the early labour may cause a mucous plug which can be blood-stained
May have occurred after a membrane sweep
Associated tightening/contractions

Question 9

What investigations should be done for antepartum bleeding

Answer 9

A-E assessment
Bedside: urine pregnancy, bimanual and speculum
Bloods: beta-hCG, FBC, G&S, cross-match, rhesus status, CRP
Imaging: TVUSS, CTG

Question 10

What necessitates referral to an early pregnancy unit

Answer 10

Positive pregnancy test +
- pain and abdominal tenderness
- pelvic tenderness
- cervical motion tenderness

> 6 weeks gestation + bleeding

Question 11

What should be done if a pregnancy is < 6 weeks, with bleeding but no pain or RF for ectopic pregnancies

Answer 11

Advice:
Return if bleeding continues or pain develops
Repeat a urine pregnancy test after 7–10 days and to return if it is positive
A negative pregnancy test means that the pregnancy has miscarried