Antepartum haemorrhage Flashcards
Definition of antepartum haemorrhage
Bleeding from the genital tract after 24 weeks gestation until the end of the 2nd stage of labour
What percentage of pregnancies are affected by APH?
3-5%
5 Main causes of APH
Placental problems
Local causes
Uterine problems
Vasa praevia
Indeterminate
Placental causes of APH
Placental abruption
Placenta praevia
Local causes of APH
Ectropion
Polyp
Infection
Carcinoma
Uterine cause of APH
Rupture
What are the 4 classifications of APH bleeding?
- Spotting - Staining, streaking, wiping
- Minor - <50ml
- Major - 50-1000ml
- Massive - >1000ml +/- Shock
Minor APH volume
<50ml
Major APH volume
50-1000ml
Massive APH volume
> 1000ml + shock
Management of APH
- ABCDE approach, resuscitating mother first, then assessing baby
- Deliver (Emergency or planned)
- Steroids and MgSO4
- Cell salvage
- MDT
- Tranexamic acid, IV crystalloid and calcium replacement may all also be given
Maternal complications of APH
- Hypovolaemic shock
- Anaemia
- PPH (25%)
- Renal failure
- Coagulopathy/DIC
- Infection
- Psychological issues (Mother and partner)
Foetal complications of APH
- Foetal death (14%)
- Hypoxia
- Prematurity
- Small for gestational age and foetal growth restriction
What is placental abruption?
the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates.
Risk factors for placental abruption
- Previous placental abruption
- Pre-eclampsia
- Bleeding early in pregnancy
- Trauma (consider domestic violence)
- Multiple pregnancy
- Fetal growth restriction
- Multigravida
- Increased maternal age
- Smoking
- Cocaine or amphetamine use
Describe th pathophysiology of placental abruption
Vasospasm followed by arteriole rupture into the decidua
Blood therefore escapes into the amniotic sac or further under the placenta and into the myometrium
This causes tonic contraction and interrupts placental circulation which causes hypoxia
This results in Couvelaire uterus (Blood penetrates into the peritoneal cavity, uterus becomes tense and rigid and myometrium becomes weakened
Presentation of placental abruption
- Sudden onset severe abdominal pain that iscontinuous
- Vaginal bleeding (antepartum haemorrhage)
- Shock (hypotension and tachycardia)
- Abnormalities on the CTG indicating fetal distress
- Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
What is a concealed abruption
where thecervical osremains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated with concealed haemorrhage.
Management of placental abruption
Obstetric emergency
- Urgent involvement of a senior obstetrician, midwife and anaesthetist
- 2 x grey cannula
- Bloods include FBC, UE, LFT and coagulation studies
- Crossmatch 4 units of blood
- Fluid and blood resuscitation as required
- CTG monitoring of the fetus
- Close monitoring of the mother
What is the use of antenatal steroids?
Causes acceleration of maturation of the lungs
When are antenatal steroids offered?
24 - 34+6 weeks in anticipation of pre-term delivery
What is placenta praevia?
where the placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus.Praeviadirectly translates from Latin as “going before”.
Definition of low-lying placenta
Placenta within 20mm of the internal cervical os
Definition of placenta praevia
Placenta covering the internal cervical os
Risks of placenta praevia?
- Antepartum haemorrhage
- Emergency caesarean section
- Emergency hysterectomy
- Maternal anaemia and transfusions
- Preterm birth and low birth weight
- Stillbirth
- Smoking
- Any previous surgery to the uterus
Risk factors for placenta praevia?
- Previous caesarean sections
- Previous placenta praevia
- Older maternal age
- Maternal smoking
- Structural uterine abnormalities (e.g. fibroids)
- Assisted reproduction (e.g. IVF)
How is placenta praevia diagnosed?
Usually diagnosed on 20-week anomaly scan
How does placenta praevia usually present?
APH after or around 36 weeks
Management of placenta praevia on 20-week anomaly scan
Repeat TVUS at:
- 32 weeks gestation
- 36 weeks gestation
Steroids between 34 and 36 weeks
Planned delivery between 36 and 37 weeks to reduce risk of spontaneous labour
May require emergency C-sectoio
Management of haemorrhage with placenta praevia
- Emergency caesarean section
- Blood transfusions
- Intrauterine balloon tamponade
- Uterine artery occlusion
- Emergency hysterectomy
What is placenta accreta?
when the placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby
What are the 3 stages of placenta accreta?
Superficial placenta accerta - Surface of myometrium
Placenta increta - Deeply into myometrium
Placenta percreta - Beyond the myometrium
Risk factors for placenta accreta
- Previous placenta accreta
- Previous endometrial curettage procedures (e.g. for miscarriage or abortion)
- Previous caesarean section
- Multigravida
- Increased maternal age
- Low-lying placenta or placenta praevia
How is placenta accreta diagnosed?
USS - Usually during antenatal scans
Management of placenta accreta
- Complex uterine surgery
- Blood transfusions
- Intensive care for the mother
- Neonatal intensive care
When should delivery be performed in placenta accreta?
35 - 36+6 weeks to reduce risk of spontaneous labour
(Give antenatal steroids)
Options for placenta accreta during C-section
Hysterectomy
Uterus preserving surgery
Expectant management
What is the risk of uterine rupture in C-section
0.5% (1 in 200)
Definition of uterine rupture
full thickness opening of the uterus including the serosa
What is a partial thickness (Serosa intact) tear in the uterus known as?
Dehinscence
Risk factors for uterine rupture
- Previous C-section
- Previous uterine surgery
- Multparity
- Use of prostaglandins or syntocinon
- Obstructed labour
Symptoms of uterine rupture
- Severe abdominal pain
- Shoulder-tip pain
- Maternal collapse
- PV bleeding
Signs of uterine rupture
- Loss of contractions
- Acute abdomen
- Presenting part rises
- Peritonism
- Foetal distress or IUD
What is vasa praevia?
A condition where the foetal vessels travel outwith the umbilical cord and into the foetal membranes, travelling across the internal cervical os
What is velamentous umbilical cord?
where the umbilical cord inserts into thechorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta.
What is a succenturiate lobe?
An extra lobe of the placenta, which causes foetal vessels to travel from the placenta to it, unprotected by the umbilical cord
How can vasa praevia cause APH
When the membranes rupture it can cause the exposed foetal vessels to bleed, leading to foetal blood loss and possibly death
What are the 2 types of vasa praevia
- Type I vasa praevia– the fetal vessels are exposed as a velamentous umbilical cord
- Type II vasa praevia– the fetal vessels are exposed as they travel to an accessory placental lobe
Risk factors for vasa praevia
- Low lying placenta
- IVF pregnancy
- Multiple pregnancy
Presentation of vasa praevia
On USS during antenatal scans
APH
On vaginal exam during labour
Foetal distress and dark-red bloody liquor
Management of vasa praevia
Corticosteroids from 32 weeks
Elective C-section for 34-36 weeks
Emergency section if APH
