Antepartum Haemorrhage

Question 1

DEFINITION

Answer 1

Bleeding >24w gestation.

Question 2

PLACENTA PRAEVIA

EPIDEMIOLOGY

Answer 2

• 5% low-lying placenta at 16-20w USS
• 10% low-lying placentas will be praevia at term.
• 0.5% pregnancies at term

Question 3

CLASSIFICATION(PP)

CLASSICAL GRADING(I-IV)

Answer 3

1. Marginal: not over os
2. Major: Completely/partially covering os.

Type I: placenta reaches lower segment, not internal os.
Type II: placenta reaches internal os but X cover it.
Type III: Placenta covers internal os before dilation but not after dilation.
Type IV: Placenta completely covers internal os.

Question 4

AETIOLOGY(PP)

Answer 4

More common in: twins, multiparity, aged, uterus scarred

Question 5

COMPLICATIONS(PP)

Answer 5

1. Obstructs engagement of head
   - necessitates C-section
   - may cause transverse lie
2. Increase haemorrhage drg delivery
   - lower segment can’t contract as well.
3. Placenta accreta
   - 10% of women w placenta praevia and prev Cesarean scar
   - Massive haemorrhage at delivery, may need hysterectomy
4. Placenta percreta

Question 6

CLINICAL FEATURES(PP)

Answer 6

1. Intermittent, painless bleeding
2. Abnormal lie, breech presentation
   * never do vaginal examination on bleeding patient unless placenta praevia has been excluded.

Question 7

INVESTIGATIONS(PP)

Answer 7

1. US
2. If low-lying placenta and posterior, TVUS @32w:
   - if <2cm from internal os, likely praevia at term
   - no need to limit activity/intercourse unless bleed.
   - if @32w, grade I/II, scan every 2w. @37w, if high presenting part/abnormal lie, C-section.
3. If placenta ant. and underneath C-section scar, 3D power US
   - assess for placenta accreta
4. CTG, FBC, coag, cross-match

Question 8

MANAGEMENT(PP)

Answer 8

1. Admit all bleeding cases usually until delivery.
2. If asymptomatic, can delay admission until 37w.
3. Anti-D if Rh -ve, keep blood available
4. Steroids if <34w
5. Elective C-section for grades III/IV btw 37-38w. btw 36-37 w if placenta accreta. Emergency if before that. If grade I, vaginal delivery
6. Intraoperative and PPH may req. Rusch balloon/hysterectomy

Question 9

PLACENTAL ABRUPTION

EPIDEMIOLOGY

Answer 9

about 1 in 200 pregnancies

Question 10

COMPLICATIONS(PA)

Answer 10

1. Acute fetal distress
2. Fetal death(30%)
3. Massive haemorrhage req blood transfusion
4. DIC, renal failure, maternal death

Question 11

AETIOLOGY(PA)

Answer 11

Major risk f:

1. Pre-eclampsia, pre-existing hypert.
2. IUGR
3. Previous abruption(risk 6%)
4. Maternal smoking

Other risk f;

1. Cocaine use
2. Multiparity
3. Multiple pregnancy
4. Age
5. Maternal trauma

Question 12

CLINICAL FEATURES(PA)

Answer 12

1. Severe abdominal pain
   - Constant w exacerbations
2. Vaginal bleeding
   - usually dark blood
   - if no bleed but abdominal pain, concealed abruption.
3. Tachycardia
4. Hypot. if severe
5. Tender uterus on palpation, can be woody hard.
6. Abn./absent fetal heart sounds
7. widespread bleeding w coag failure
8. Poor urine output/renal failure

Question 13

INVESTIGATIONS(PA)

Answer 13

1. CTG
2. US to estimate fetal W and exclude placenta praevia
3. FBC, U&E, coag, cross-match
4. Urinary catheterization and monitor urine output hourly
5. CVP monitoring in severe cases

Question 14

MANAGEMENT(PA)

1. Assessment and resus
2. Conservative Mx.
3. Delivery
4. Postpartum

Answer 14

1. Admit even all pts with pain and uterine tenderness even if no bleeding
   - IV fluids
   - Steroids if <34w
   - Anti-D to Rh-ve
   - Consider blood transfusion
   - May req opiate analgesia
2. If minor abruption, no fetal distress, preterm pregnancy
   - steroids if <34w
   - monitor closely on ward
   - D/C when Sx. settle but tx as high-risk
   - USS to monitor fetal growth.
3. Urgent C-section if fetal distress
   - if no fetal distress, gestation ≥37w, IOL w amniotomy; continuous fetal heart monitoring; monitor maternal health; C-section if fetal distress
   - if fetus death, coagulopathy likely. Blood products transfusion and IOL
4. PPH likely

Question 15

VASA PRAEVIA

Answer 15

• fetal blood vessels run in membranes in front of presenting part
• can be detected on US but seldom.
• may rupture in 1 in 5000 pregnancies.
• painless, moderate vaginal bleeding at amniotomy or SRM + severe fetal distress
• C-section usually X fast enough to save fetus.
• fetal bradycardia is classic sign

Question 16

OTHER CAUSES

Answer 16

Uterine rupture, cervical lesions(<5%) ie cervicitis, cervical erosion, cervical carcinoma; genital infection; vulval and vaginal lesions.

Question 17

ABRUPTION VS PRAEVIA

1. Shock
2. Pain
3. Bleeding
4. Tenderness
5. Fetus
6. USS

Answer 17

1. A: inconsistent w external loss.
   P: Consistent w external loss.
2. A: common, often severe, constant w exacerbations.
   P: None, occassional contractions.
3. A: can be absent, often dark.
   P: Red and often profuse.
4. A: common, can be woody hard.
   P: Rare
5. A: Normal lie, may be dead/distressed
   P: Often abn. lie
6. A: Placenta not low
   P: low-lying placenta