Antepartum haemorrhage Flashcards
From what gestation is vaginal bleeding considered an antepartum haemorrhage? Why is this important?
20wks to term.
There are different differential diagnosis to consider for bleeding earlier in pregnancy - e.g. threatened/miscarriage is more common in the first and early second trimester
What are the differential diagnoses for bleeding in the first and second trimester?
Implantation of placenta (physiological)
Threatened or actual miscarriage
Abnormal pregnancy (e.g. ectopic, gestational trophoblastic disease)
Trauma (post-coital)
Cervical lesions, e.g. cervical polyp, cervical cancer or cervicitis, e.g. due to STIs
What are the differential diagnoses for antepartum haemorrhage?
Placenta previa
Placental abruption
Vasa previa
Cervical lesions (cervicitis, ectropion, cervical cancer)
Uterine rupture
Bloody ‘show’ - cervical mucus plus small amount of per-cervical bleeding, usually preceding the start of labour
What is a feature on history that can help distinguish between placenta praevia and placental abruption?
Bleeding associated with placenta previa is usually painless, whereas is painful for placental abruption
What are some fetal complications of placental abruption?
Perinatal mortality (25-60%)
Prematurity - spontaneous and iatrogenic
Fetal hypoxia
What are some maternal complications associated with placental abruption?
haemorrhagic shock & multi-system failure
DIC
Sheehan syndrome
What is the role of ultrasound in the diagnosis of placental abruption?
Placental abruption is a clinical diagnosis. U/S is not a sensitive investigation for the diagnosis of placental abruption.
What is essential before performing a vaginal examination in the presence of PV bleeding? How would you do this?
It is important to exclude placenta praevia before a VE is performed. This can be done by reviewing previous ultrasounds or via a scan before proceding
What are some risk factors associated with placental abruption?
- Previous abruption
- Maternal hypertension or vascular disease
- Smoking, cocaine use
- Multiparity
- Maternal age >35years
- PPROM
- Direct trauma to the uterus
What is a Kleihauer test and why is it important in management of antepartum haemorrhage?
Test that determines volume of feto-maternal haemorrhage. Used to guide the amount of Anti-D that should be given to a Rhesus negative mother in sensitizing events.
A positive result also confirms the diagnosis, although is not sensitive enough to be used as a primary test of abruption.
What is placenta previa, and how is it graded?
Insertion of placenta partially or wholly in the lower uterine segment
Grade 1 - Enters the lower segment
Grade 2 - Reaches in the internal os
Grade 3 – Partially covering the internal os
Grade 4 - completely covers the internal os
What are the maternal risks in placenta previa?
- APH, PPH and all the consequences of massive haemorrhage
- Need for caesarean section
- Possible need for hysterectomy and consquent risks
- Recurrence
- Placenta accreta
What are the fetal risks in placenta previa?
- Preterm birth
- IUGR
- Placental abruption
- Feto-maternal haemorrhage
- Fetal death
How might a placental abruption present clinically?
- PV Bleeding in 70 – 80%
- Constant abdominal pain
- Onset of labour
- Abdominal tenderness, and on palpation, a tense “woody hard” uterus
- Fetal distress or death
- Maternal shock
What is the significance on a low lying placenta seen on a morphology scan at 18 weeks?
20% of pregnancies will be noted as having a low lying placenta at the morphology scan.
90% are normally sited by term due to uterine growth and the formation/elongation of the lower uterine segment.
All women with a low placenta should have a rescan to assess position at 32 weeks
And again at 36 weeks if still low at 32/40
