Antepartum haemorrhage

Question 1

What two conditions need to be distinguished in antepartum haemorrhage?

Answer 1

Placental abruption and placenta praevia

Question 2

What are features of placental abruption?

Answer 2

shock out of keeping with visible loss
pain constant
tender, tense uterus*
normal lie and presentation
fetal heart: absent/distressed
coagulation problems
beware pre-eclampsia, DIC, anuria

Question 3

What are features of placenta praevia?

Answer 3

shock in proportion to visible loss
no pain
uterus not tender*
lie and presentation may be abnormal
fetal heart usually normal
coagulation problems rare
small bleeds before large

Vaginal exam should not be performed in primary care because women with placenta praevia may haemorrhage

Question 4

What are causes of antepartum haemorrhage in the first trimester?

Answer 4

Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole

Question 5

What are causes of antepartum haemorrhage in the second trimester?

Answer 5

Spontaneous abortion
Hydatidiform mole
Placental abruption

Question 6

What are causes of antepartum haemorrhage in the third trimester?

Answer 6

Bloody show
Placental abruption
Placenta praevia
Vasa praevia

Question 7

What conditions other than pregnancy related causes need to be excluded?

Answer 7

Cervical polyps and STDs

Question 8

What are the types of spontaneous abortion?

Answer 8

Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks

Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear

Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled.

Incomplete miscarriage - heavy bleeding and crampy, lower abdo pain.

Complete miscarriage - little bleeding

Question 9

How would an ectopic pregnancy present?

Answer 9

Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present

Question 10

How would a hydatidiform mole present?

Answer 10

Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high

Question 11

How would vasa praevia present?

Answer 11

Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen