Antepartum Haemorrhage

Question 1

What is anteparteum Haemorrhage?

Answer 1

Definition:

• bleeding from the genital tract between 20weeks gestation until labour
• minor haemorrhage <50mls
• major 50-100
• massive 1L or signs of clinical shock.

Show (3rd trimester mucus plug - darkened) is not the same as APH.

Question 2

What are some of the general causes of APH?

Answer 2

• Placental abruption (30%)
• placenta praevia (20%)
• ‘marginal’ placental bleeding
• local (vaginal tract) causes: cervical, vaginal, uterine
• rare but catastrophic
  
  • uterine rupture
  • vasa praevia
• idiopathic
• domestic violence

Question 3

What is placental abruption? What is its clinical presentation?

Answer 3

• premature seperation of a normally implanted placenta prior to delivery
• Presentation: 20-30mls quick to call partial abruption if you have pain.
  
  • vaginal bleeding
  • uterine tenderness/contractions
  • back pain
  • non-reassuring fetal status
  • haemodynamic compromise (blood loss)
• RFs:
  
  • had before
  • chorioamnionitis
  • sudden reduction in size of overdistended (e.g. twins)
  • trauma
  • smoking/cocaine
  • chronic hypertensive (pre-eclampsia, thrombophiias, chronic HTN)
• Diagnosis:
  
  • clinical but US - anti-D test for occult fetal haemorrhage

Question 4

What is placenta praevia? What is a DDx you should consider? What investigations should you do/not do?

Answer 4

• partially or completely implanted in lower uterine segment, <2cm away do a CS (1.8cm we do another scan, hopeful).
  
  • major - covers internal cervical os
  • minor - does not cover os
• distinct from placental adhesive disorders (although coexist) - difficult to treat.
  
  • placental accreta
  • placental increta
  • placental percreta
• incidence is higher in CS

Investigations:

• do a TVUS for PP, abdo miss quite a bit:
  
  • asymptomatic minor 32-36weeks, major do it earlier 30-32.
• Suspect do not do digital vaginal examination
  
  • cause catastrophic haemorrhage
  • speculum exam is safe

Presentation:

• painless bleeding (mostly in 3rd trimester)
• mlpresentation - presenting part high (later in pregnancy)/malpresentation at term.
• bleeding in labour.

Question 5

What are some rare causes of APH? Why are they important.

Answer 5

Both these conditions are important because they can be catastrophic.

• Uterine rupture
  
  • occurs in labour generally
  • RF EDS (ehlers danlos)
  • sudden abdominal pain, distension, hypovolaemic collapse
  • management is aggressive with maternal resus
  • fetal demise is likely if not delivered within minutes
• Vasa Praevia
  
  • fetal vessels come through membranes from below the presenting part over the internal cervical os. No placental tissue or cervical cord where vessels are. Residual vessels from not forming.
  • associated with:
    
    • bipartite placenta, velamentous cord insertion, succenturiate lobe
  • minimal risk to mother, major risk to fetus (smaller blood volume)
  • Presentation: TVUS - transvaginal scans. 20weeks. Rarely APH bleeding. Can feel of VE/Pulsating (babies die within 1 minute)
    
    • usually iatrogenic causes of death, ROM usually along the vessel.
  • Management:
    
    • deliver a bit earlier. 36-38weeks.

Question 6

What is the management for APH?

Answer 6

1. Resus - haemodynamic compromise is a obstetric emergency
   
   • stable - history obtained
   • examination - vitals, abdo palpatition and speculum exam
     
     • NO VE until praevia excluded.
2. Assess
   
   • FBE, Coags, G+H, FMH (Kleihaur), UECs, LFTs
   • CTG
   • USS (placenta, presentation, estimated fetal weight, AFI, dopplers)
3. General (optimise Hb and avoid intercourse/strenous activity)
4. Admission
   
   • if symptomatic at any gestation
   • outpatient if (<34weeks, close to hospital)
5. Delivery
   
   • prep with steroids (<34weeks and delivery)
   • MgSO4 considered if <30weeks
   • tocolysis if safe + <34weeks
   • timing - major 37wks, minor 38wks, earlier if heavy
   • mode - CS (give oxytocin + ergometrine to reduce bleeding, consider classifcal CS).
   • minor - may repeat scan at 36weeks to assess VD

Question 7

A pregnancy women at 28 weeks has a PV bleed of 200ml. CTG shows no problems. What is the best management option?

1. discharge
2. immediate delivery and hysterectomy
3. administer dexamethasone and nifedipine
4. monitor closely with CTG for 24 hours
5. review in 6 weeks

Answer 7

d - monitor:

• admit at any GA if bleeding
• resuscitate if necessary
• DO NOT perform a vaginal exam until the Dx excluded.
  
  • abruption - no tocolysis (worsen bleeding)
  • vasa praevia - no digital exams

Other choices:

• resuscitate if necessary
  
  • admit for - volume of loss, or foetal fundal height, CTG, USS.
• steroids if delivery is indicated and gestation is <34 weeks.
• MgSO4 considered if <30 weeks
• oxytocin and ergometrine is standard to reduce risk of bleeding, may require a CS to minimise bleeding.

Question 8

What advice can you give for someone who has placenta privia?

Answer 8

• avoid strenous exercise
• avoid sexual intercourse (orgasm can cause cervical excitation)
• do not allow VE
• another TVUS at 32 (major), 34 (minor)
• timing/mode of delivery:
  
  • plan for CS -
  • short term - maternal haemodynamic (deliver), fetal CTG (deliver)
  • long term - progressive IUGR (non well vascularised segment, higher chance), porous membranes PROM (rupture - agar plate for bacteria/porous), vasa praevia, gestation is adequate

Question 9

Management of placental abruption?

Answer 9

Term:

• easy - just deliver

Not near term:

• Resus
• Kelihaur test - how much anti-D?
• corticosteroids in <34weeks gestation
• Magnesium sulphate if <30weeks (CP protection)
• consider:
  
  • CTG
  • gestational age
  • co-existent conditions (PET/placental insufficiency of unknown origin)

Near term:

• very premature (28-32 weeks)
  
  • conservative management - only if stable
  • deliver if either are unwell

VD if both are stable

Question 10

What are some causes of lower genital tract bleeding in APH?

Answer 10

45% of APH

• clean up the cervix - dysplasia, ectropion
• polyp
• varices
• trauma! (lacerations)