Antepartum haemorrhage Flashcards
Definition of antepartum haemorrhage
Bleeding from or into the genital tract during pregnancy that occurs AFTER the point of fatal viability (ie. after 24 weeks)
Causes of antepartum haemorrhage
Painless
- Placenta previa*
- Vasa previa
- Lower genital tract tumour/trauma/infection
Painful
- Placental abruption*
- Uterine rupture
What is associated with antepartum haemorrhage?
Postpartum haemorrhage
Definition of placenta previa
Implantation of placenta overlying completely/partially or proximate to the internal cervical os, at the lower uterine segment after viability
Risk factors of placenta previa
- Previous caesarean section
- Maternal age (extremes of ages)
- Prior abortion
- Multiparity (2-4)
- High risk if 5 or more
- Due to a change in shape and size of uterus = More space for placenta to implant in the LUS - Smoking
- Previous placental abruption/ placenta praevia/ uterine surgery
- Use of assisted reproductive technologies
Signs & symptoms of placenta previa
- PAINLESS VAGINAL BLEEDING***
- usually in 3rd trimester
- can be recurrent
- a/w irritable uterus (ie uterine contractions) or onset of labour - Malpresentation: transverse or breech
- Presenting part high - deviated from midline
- Asymptomatic
Diagnosis for placenta previa
Transvaginal U/S
- If low-lying placenta is diagnosed in FA scan, repeat scan is done at 32 and 36 weeks for confirmation
Complications of placenta previa
Maternal
- Mortality & morbidity
- Post partum haemorrhage
- Placenta accreta/percreta
- Caesarian complications -> high bleeding risk
- Blood transfusion
- Recurrence
Fetal
- Mortality & morbidity
- Pre-term delivery
- IUGR
Physical examinations for APH
Assess maternal and fetal well-being and determine the cause of APH
Maternal well-being:
Regular vitals assessment TRO hypovolemic shock
Presence of HTN warrants excluding pre-eclampsia
Fetal well-being:
Continuous CTG monitoring to trace foetal heart beat for signs of fetal distress
Abdomen:
SFH
Palpate for contractions and woody hard uterus for placenta abruptio
Determine fetal lie and presentation
Bedside U/S:
Exclude placenta and vasa previa, retroplacental haemorrhage and confirm fetal presentation
Speculum examination:
Amount of blood in vagina, presence of active bleeding, appearance of cervix to assess dilatation
Vaginal examination:
I will NOT perform a vaginal exam if placenta and vasa previa have NOT been excluded
Expected PE findings for placental previa
Non-tender uterus
Transverse lie or breech malposition
Presenting part high
Investigations for APH
Bloods
1. FBC
- Hb for anemia and platelets for thrombocytopenia
2. GXM (at least 4 units)
- Blood transfusion, anti-D immunoglobulin if RH-neg
3. DIC screen (PT/PTT, INR, Plt, Fibrinogen, D-dimers)
- Prolongation of PT/PTT and fibrinogen
- Fibrinogen < 2 is diagnostic of DIC in pregnancy
4. RP, LFT
- Pre-op bloods
*With every episode of bleed in APH, Rhesus -ve woman needs Kleihauer Betke test + Prophylactic RhoGAM (Anti-D Ig)
Imaging
TVUS
- Confirm location of placenta if unbooked case of placenta previa
- Retroplacental haemorrhage
- Confirm fetal presentation
Foetal
Continuous cardiotocography monitoring to trace foetal heart beat for signs of fetal distress
Management of ACUTE placenta previa
Emergent management
1. Activate obstetric code –consultant obstetrician, anesthetist, senior midwife and neonatologist
2. ABCs
3. Continuous maternal vital signs monitoring, Continuous cardiotocography monitoring to trace foetal heart beat for signs of fetal distress
4. Keep NBM
5. IDC for hourly I/O charting
6. Pad charting
7. Insert large bore IV line: give IV fluids - crystalloids and colloids as needed
8. Draw blood to send off for investigations
9. Call blood bank for packed red cell and blood product transfusion
10. Monitor bleeding
- If ongoing bleed, get informed consent and prep for CAESAREAN section
- If bleed settles and CTG normal, observe patient in labour ward (McAfee regimen) and aim to delay to term (37 weeks)
-> IM dexamethasone for fetal lung maturity if preterm and delivery not immediately required
11. Postpartum haemorrhage prophylaxis post delivery
Management of ‘placenta previa’
(Antenatal - low lying placenta)
- No intervention required
- Most placenta would ‘migrate’ upwards as lower uterine segment forms (it does not actually move upwards bc it is stuck to the wall, it is just that the LUS grows longer in a sense) - Advice given:
- Admit with any antepartum haemorrhage
- Avoid sexual intercourse - Avoid digital cervical examination
- Can still do speculum exam to assess cervical dilatation or lower genital tract cause of APH
Indications for immediate delivery (APH)
APH after 37 weeks
Major haemorrhage preterm posing threat to mother or fetus
Management of STABLE placenta previa
Expectant management following McAfee regimen to delay delivery until term (37 weeks)
1. Stay in fully equipped maternity unit from time of initial diagnosis till delivery
2. Regular maternal vital signs monitoring, regular cardiotocography monitoring to trace foetal heart beat for signs of fetal distress
3. Complete bedrest
4. Stool softeners + high fiber diets to prevent constipation and straining
5. Periodic assessment of maternal Hct
- Prophylactic transfusions to maintain maternal Hct >30% in anticipation of future blood loss
6. Ferrous gluconate + Vit C to improve intestinal Fe absorption
7. Pad chart - Monitor bleed
8. IM dexamethasone for fetal lung maturity if preterm and delivery not immediately required
9.Kleihauer-Betke test and prophylactic Anti-D Ig for Rh -ve women
- Only if they bled
- Readministration not needed if delivery or rebleeding occurs within 3 weeks
10. Serial U/S every 2-4 weeks to assess placental location, fetal growth, AFI
11. Tocolytics if contraction are present but delivery is not needed (mother + fetus safe)
12. Aim to deliver at 37 weeks GA
13. Delivery via elective lower segment caesarean section
