Antepartum Haemorrhage Flashcards
Definition of Antepartum Haemorrhage
Bleeding from the genital tract after 24 weeks gestation
Causes of APH
Common
Undetermined origin
Placental abruption
Placenta praevia
Rarer
Incidental genital tract pathology
Uterine rupture
Vasa praevia
Classification of Placenta Praevia
Marginal: placenta in lower segment not covering os
Major: placenta completely or partially covering os
Apparently low lying placenta
At 20 weeks an apparent low lying placenta is common
Only 1 in 10 praevia by term
Myometrium where the placenta implants move away from the os as pregnancy progresses
Complications of Placenta Praevia
Obstructs engagement of head –> cesarean section necessary
May cause transverse lie
Haemorrhage can be severe and may continue during and after delivery as lower segment of uterus is less able to contract and control bleeding
If it implants in uterine scar can cause acrete (into full wifth of myometrium) or percreta (through the uterus into surrounding structure e.g. bladder)
Placenta acreta can prevent placental separation
Placenta acreta occurs in 10% of women who have both placenta praevia and previous cesarean section scar
–> massive haemorhage –> hysterectomy
Clinical Features of Placenta Praevia
Intermittent painless bleeding which increases in frequency and intensity over several weeks
Bleeding may be severe
1/3 do not experience bleeding before delivery
Breech presentation and transverse lie are common
High, non-engaged fetal head
NEVER perform a VE on someone who has had vaginal bleeding has not had a placenta praevia excluded
Investigations for a Placenta Praevia
USS: diagnosis
If low-lying at 20 week scan
Repeat USS but vaginally if the placenta is posterior at 32 weeks to exclude praevia
<2cm form os is likely to be praevia at term
If placenta is anterior, use 3D USS to determine if placenta acreta
Prepare for haemorrhage at delivery if so
Management of Placenta Praevia
Admission: necessary for all pregnant women with vaginal bleeding
If praevia confirmed –> keep in hospital until delivery as risk of massive haemorrhage
Keep blood available
Administer Anti-D if Rh neg
Steroids if <34 weeks
If asymptomatic, delay admission until 37 weeks with safety netting
Delivery
By elective CS at 39 weeks by most senior consultant
Intraoperative and PP haemorrhage are common
Emergency delivery required if bleeding is severe before this time
Placenta acreta and percreta should be anticipated and incision should be made away from placenta
Partial separation or transection –> massive haemorrhage
Compression of inside of the scar after removal with inflatable balloon
Or hysterectomy
Definition of Placental Abruption
When all, or part of, the placenta separates before delivery of the fetus
Complications of Placental Abruption
30% fetal death
Blood transfusion
DIC
Renal failure
Maternal death
Risk Factors for Pacental Abruption
IUGR PET Autoimmuen disease Maternal smoking Cocaine use Previous abruption (6%) Multiple pregnancy High parity Trauma Sudden reduction in uterine volume e.g. polyhydramnios with ROM
Clinical Features of Placental Abruption
Painful bleeding (praevia is painless)
Pain due to blood behind placenta and in myometrium
Dark blood
Degree of vaginal bleeding does not reflect severity - 20% don’t have vaginal bleeding
Pain or bleeding may present alone (concealed or revealed abruption)
Examination Tachycardia = profound blood loss Hypotension = massive blood loss Tender, contracting uterus Woody hard uterus and difficult to palpate fetus Fetal heart tones abnormal or absent
Investigations for Placental Abruption
Diagnosis usually clinical
Fetal Well-being Fetal monitoring CTG Fetal distress USS to estimate fetal weight at preterm and to exclude praevia Abruption not always visible on USS
Maternal Well-being FBC Coagulation screen Cross match Catheterisation and hourly urine output Regular FBC, coag, U&Es CVP monitoring
Features of major placental abruption Maternal collapse Coagulopathy Fetal distress Woody hard uterus Poor urine output or renal failure
Management of Placental Abruption
Admission if pain and uterine tenderness +/- vaginal bleeding
IV fluids Steroids if <34 weeks Transfusion considered Opiate analgesia Anti-D if Rh neg
Delivery
Depends on fetal state and gestation
Stabilise mother first
Fetal distress –> emergency cesarean section
No fetal distress >37 weeks –> IOL with amniotomy (artifical rupture of membrane)
Close CTG
C-section if fetal distress
If fetus has died, coagulopathy more likely
Conservative management
No fetal distress, minor abruption and preterm pregnancy
Give steroids and monitor on antenatal ward (not labour ward)
If symptoms settle –> discharge
Now high risk pregnancy
US for fetal growth
Vasa Praevia
Rare 1 in 5,000
fetal blood vessels runs in membranes in front of presenting part of fetus
Typically occur when umbilical cord is attached to membranes rather than the placenta (velamentous insertion)
Can be detected on USS but usually missed
ROM –> Vessel rupture –> massive fetal bleeding
Painless, moderate vaginal bleeding at amniotomy/SROM accompanied by severe fetal distress
C-section often not fast enough to save fetus
