Antepartum haemorrhage Flashcards
If there is antepartum hemorrhage what Ix must be done?
Speculum examination
- Local lesions
- Status of cervix (closed / dilated)
- Bleeding through cervical os
- Amount of bleeding
- Mass protruding
- Cord prolapse?
What are the 4 most common causes of antepartum hemorrhage?
- APH of unknown origin
- Placenta previa
- Placental abruption (revealed type –> peripheral placental detachment)
- Local lesions (separate local lesions from blood coming above)
What are less common causes of antepartum hemorrhage?
- Vasa previa (common sign is rupture of membrane which causes sudden fetal compromise (UA pulsatility index, fetal heart rate monitoring)
- Vilamentous cord insertion (when within 2cm from cervical os can cause vas a previa) which can tear and cause blood loss
- Uterine rupture (if previous C-seciton): sudden pain due to intraperitoneal bleeding
Compare bloody show and antepartum hemorrhage in appearance?
Bloody show happens during 1st stage of labor as there is effacement and dilatation of the cervix. The cervix is prone to bleeding –> the blood mixes with mucus –> forming bloody show. Can also be paired with uterine contractions (which comes with pain and are intermittent)
Antepartum hemorhage is more fluid like.
Define the severity of antepartum hemorrhage?
Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection
Minor Haemorrhage – blood loss less than 50 mL that has settled
Major Haemorrhage – blood loss of 50 – 1000 mL, with no signs of clinical shock
Massive Haemorrhage – blood loss greater than 1000 mL and/or signs of clinical shock
What is the classification of placental abruption
What is the presentation of placenta abruption?
Can be concealed (less common –> retroplacental bleeding –> central placental detachment) or revealed bleeding (peripheral placental detachment –> bleeding from cervical os).
Retroplacental bleeding: blood can irritate the uterus causing low amplitude uterine contractions (not genuine –> used in CTG to differentiate from labor uterine contractions)
What are the types of hemorrhage in placental abruption?
- Subchorionic: bleeding between myometrium and placental membranes
- Retroplacental: bleeding between myometrium and placenta
- Preplacental: bleeding between placenta and amniotic fluid
- Intraplacental: bleeding within or inside the placenta
What is the cause of couvelaire uterus?
What is the symptoms and signs?
Couvelaire uterus: caused by placental abruption concealed type causing retroplacental bleeding which penetrates into the myometrium forcing its way into the peritoneal cavity.
Symptoms: pain secondary to uterine contractions (caused by irritation of blood –> but low amplitude contractions)
Signs:
uterus very tense and rigid (wood like)
Signs can be due to uterine hypertonus, fetal distress, fetal death
Uterus may adopt a bluish/purplish appearance due to extravasation of blood into uterine muscle.
What drug is contraindicated in APH?
Tocolytics (causes uterine relaxation)
Uterine contraction causes decreased blood loss
What is the Mx of placental abruption?
Unstable mother/non reassuring fetal status –> C-section
Stable mother and reassuring fetal status –> depends on gestation
* <34 weeks: consider corticosteroid to promote fetal lung maturity if <34 weeks and tocolysis if indicated to allow administration of full course of steroid. Also MgSO4 (for neuroprotection)
* >34 weeks: deliver and vaginal delivery is preferred (only if signs of labor and cervical is dilated can do vaginal delivery. If not do C-section)
What is the mode of delivery for placentia previa?
C-section for all grades of placenta previa except for those with placental edges >2cm away from internval cervical os under TVS examination and fetal head is well engaged.
* Chance of APH is much less while the chance of successful vaginal delivery is acceptably good
What is history taking in antepartum hemorrhage?
- How much bleeding was there and when did is start?
- Was it fresh red or old brown blood, or was it mixed with mucus?
- Could the waters have broken (membranes ruptured?)
- Was it provoked (post-coital) or not?
- Is there any abdominal pain?
- Are the fetal movements normal?
- Are there any risk factors for abruption? e.g. smoking/drug use/trauma – domestic violence is an important cause.
What is done in general exam for APH?
- Pallor, distress, check capillary refill, are peripheries cool?
- Is the abdomen tender?
- Does the uterus feel ‘woody’ or ‘tense’ (which may indicate placental abruption)?
- Are there palpable contractions?
- Check the lie and presentation of the fetus/fetuses. Ultrasound can be used to help.
- Check fetal wellbeing with a cardiotocograph (CTG) at 26 weeks gestation or above: (otherwise auscultate the fetal heart only).
How to assess the bleeding in PE for antepartum hemorrhage?
- Externally
- Cusco speculum examination: avoid this until placenta previa has been excluded by USG (transabd is normally sufficient. If borderline than do TVS). If not excluded doing any vaginal examination can cause massive bleeding.
- Take triple genital swabs to exclude infection if bleeding is minimal
- Digital vaginal examination: in minor bleed when placenta previa is excluded it can help to establish whether the cervix is beginning to dilate (signs of labor)
- Avoid digital VE if the membranes have ruptured
What is the classical triad of vasa previa?
- Vaginal bleeding
- Rupture of membranes
- Fetal compromise
The bleeding occurs following membrane rupture when there is a rupturre of the umbilical cord vessels, leading to loss of fetal blood and rapid deterioration in fetal condition.
