Antepartum Haemorrhage

Question 1

Define Antepartum Haemorrhage

Answer 1

Uterine bleeding that occurs >20weeks gestation.

Question 2

What are the possible causes of antepartum bleeding?

Answer 2

1. Placental cause:
   - Placenta previae
   - Placental abruption.
2. Cord causes
   - Vasa previa
3. Structural

Cervical: polyps, cervicitis, carcinoma of the cervix.

Vulvovaginal: varicosities, tumours (malignant or benign), infections.

4. Trauma - ie, sexual intercourse.
5. Haematuria.

Question 3

What is placenta previae? What are the different categories?

How does it present? How is it managed?

What are the risk factors involved?

Answer 3

D - Presence of placental tissue extending (completely or partially) over the cervical os.

P- classic = painless vaginal bleeding + fetal malpresentation (presenting part remains high, increased risk of transverse lie).

Categories:

Complete: placenta covers entire internal os

Partial: Covers a portion of the internal os.

Marginal: edge lies within 2cm of the internal os

Low lying placenta: edge lies 2-3.5cm from the internal os.

Resolved: low lying placenta in early pregnancy has migrated away from internal os.

Exam

• absence of cx/vaginal causes on speculum exam
• absence of uterine tenderness
• low BP + tachycardia (blood loss).

Invx

• US: transabdo/transvag: assess placental position.

Mx

• as per antepartum haemorrhage protocol if acute.
• If <37-38 weeks:
  1. Administer tocolytics (if in labour) - to cease labor
  2. Corticosteroids (24-34 weeks gestation).
• If >37 weeks: LSCS.

RF -

• multiparity, previous PP, IVF, endometrial scarring (previous LSCS)
• impeded endometrial vascularisation (HTN, diabetes, uterine tumour, drugs - cocaine, advanced maternal age).
• Increased placental mass: multi-gestation.

Question 4

What is placental abruption?

How does it present? How is it managed?

What are the risk factors involved?

Answer 4

D - premature separation of a normal implanted placenta from the decidual lining of the uterus after 20 weeks gestation.

P - Triad - painful bleeding + tender uterus + increased uterine tone.

M -

Non-severe, <36 weeks, no foetal distress:

• expectant management
• corticosteroids, Rh immunology
• foetal surveillance.

Severe, or non-severe >36 weeks:

• Correct hypovolemia + coagulation (if DIC)
• Expedite delivery: normal vaginal / LSCS.

RF:

• previous placental abruption (increased risk after 2)
• vasoconstrictive causes:

smoking

cocaine use

HTN

• Trauma (causing draining of polyhydramnios + decompression of the uterus).
• Uterine abnormality (eg, bicornuate uterus).

Question 5

What are the important investigative and management principles of antepartum bleeding?

Answer 5

1. Identify type of bleeding: consistency, time, heaviness.
2. Examine uterus: tenderness/bogginess.

Examine for changes in fundal height.

3. Vitals
4. Foetal monitoring.
5. Bloods: FBC, coags, UECs, RH serology, G+H.
6. Speculum exam (NOT PV EXAM!!).

Question 6

Compare and contrast Placenta Previae, Placental Abruption + Placenta Accreta.

Answer 6

See One Note