Antepartum Haemorrhage

Question 1

Definition of antepartum haemorrhage?

Answer 1

Bleeding during pregnancy from genital tract > 20 weeks gestation

Question 2

What proportion of pregnancies are affected by APH?

Answer 2

2-5%

Question 3

What are the 4 main causes of APH?

Answer 3

Placenta praevia
Placental abruption
Vasa praevia
Unclassified

Question 4

What is the definition of placenta praevia?

Answer 4

Placenta inserted in lower uterine segment

Question 5

Name 5 risk factors of placenta praevia

Answer 5

Age
PMx of placenta praevia
Smoking
Parity
Previous C/S

Question 6

By how much does 1, 2 and 4 C/S increase your risk of placenta praevia?

Answer 6

1 - 0.65%
2 - 2.2%
4 - 10%

Question 7

What is the usual presentation of placenta praevia? At what gestational age do they usually present?

Answer 7

Unprovoked, acute, painless vaginal bleeding

Usually presents around 32-34 weeks, 50% under 36 weeks

Question 8

What test is necessary to diagnose placenta praevia?

Answer 8

U/S (transabdo or transvaginal)

Question 9

What are the 4 grades of placenta praevia? What is a resolved praevia? Which grades of praevia are capable of resolving? Which grades are classified as minor and major praevia?

Answer 9

Grade 1 (low-lying) - edge of placenta within 2.5-3cm of internal cervical os
Grade 2 (marginal) - edge within 2cm of internal os
Grade 3 (partial) - covers a portion of internal os
Grade 4 (complete) - covers entire internal os

Resolved = praevia that has migrated away from internal os. Grade 1-3 capable of resolving

Minor praevia = Grade 1 and 2
Major praevia = Grade 3 and 4

Question 10

Name 5 complications/risks of placenta praevia to the mother

Answer 10

Death - 20% of maternal deaths in developing world
PPH
Anaesthetic and surgical complications (increased C/S rate)
Post-partum sepsis
Placenta accreta more likely in next pregnancy
10% recurrence risk in next pregnancy

Question 11

Name 5 complications/risks of placenta praevia to the foetus

Answer 11

Prematurity
Small for gestational age
FDIU
Malpresentation
Umbilical cord accidents
Congenital malformation

Question 12

What is the definition of placental abruption?

Answer 12

Premature separation of a normally located placenta from uterine wall, before delivery of foetus

Question 13

Name 5 risk factors for placental abruption

Answer 13

HTN
Blunt trauma
PHx
Age
Multiparity
Smoking
Cocaine

Question 14

Name 5 risks/complications of placental abruption to mother

Answer 14

Hypovolaemic shock
Acute renal failure
DIC
PPH
Death
Feto-maternal haemorrhage

Question 15

Name 5 risks/complications of placental abruption to foetus

Answer 15

Small for gestational age
Congenital malformation
Anaemia
Coagulation abnormalities
Death

Question 16

What is the usual presentation of placental abruption? How is it diagnosed?

Answer 16

Sudden onset abdominal/back pain + PV bleeding. Clinical diagnosis based on signs and symptoms (pain + bleeding + uterine contractions)

Question 17

What is a concealed placental abruption? How common is it?

Answer 17

Bleeding only occurs behind placenta = pelvic pain but no PV bleeding. Occurs in 20% of abruptions

Question 18

Name differences of presentation and clinical findings between placental praevia and placental abruption

Answer 18

Praevia - painless, soft abdomen on examination, foetus should be normal
Abruption - painful (abdo/back pain), uterine tenderness and rigid ‘board-like’ abdo on examination, foetal parts may be hard to palpate and non-reassuring CTG

Question 19

What examination should you not perform on someone with undiagnosed APH and why?

Answer 19

Vaginal examination - might cause more bleeding if they have a placenta praevia

Question 20

Go through standard immediate management of anyone with APH

Answer 20

Want to stabilise maternal condition:

• 16G IV access and fluid replacement
• Take blood for FBC, group and hold +/- crossmatch, coagulation screen and Kleihauer test (for possible feto-maternal haemorrhage)
• Give Anti-D if Rhesus-negative
• Insert urinary catheter (for fluid monitoring)

Question 21

What are the two principles of management for placenta praevia? What are the indications to use one over the other and why?

Answer 21

Expectant management - indicated if bleeding is controlled and mother and foetus are stable. Aim is to wait until foetus is term before delivery at 37-38 weeks. Admit to hospital and monitor until asymptomatic. Consider tocolytics, corticosteroids, mag sulf if preterm. Avoid sexual intercourse. Follow up U/S at 32-34 weeks. Admit to hospital at 34 weeks if a major (partial or complete) placenta praevia.

Immediate delivery (via C/S) - indicated if bleeding uncontrolled, or maternal or fetal condition is compromised.

Question 22

What are the two principles of management for placenta abruption? What are the indications to use one over the other and why?

Answer 22

Expectant management - indicated if bleeding is controlled and mother and foetus are stable. Observe via continuous CTG and serial haematocrit until 38 weeks, then deliver with induction of labour

Immediate delivery - indicated if bleeding uncontrolled, or maternal or fetal condition is compromised. If foetus already dead, aim for vaginal delivery. If foetus alive and mother deteriorating, perform emergency LUSCS (unless patient already fully dilated)

Question 23

What is a vasa praevia? Who is more at risk from a vasa praevia - the mother or fetus? How is the diagnosis made antenatally? What two medical procedures can cause fetal death from vasa praevia? What is the management of it (briefly)?

Answer 23

Foetal vessels that traverse within the membranes over internal cervical os. Fetus at risk, not mother - fetal blood flow can be compromised. Can diagnose w U/S. Amniocentesis or AROM = fetal death
Management - elective C/S at 36 weeks

Question 24

Name 5 Ddx of APH that are lumped under the ‘unclassified bleeding’ category

Answer 24

Marginal sinus rupture
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Trauma
Infection
Cervical polyp
Cervical Ca
Unexplained