Antepartum Haemorrhage

Question 1

What is APH?

Answer 1

• bleeding from the genital tract after the 24th week of pregnancy and before the birth of the baby

Question 2

What are some of the causes of APH?

Answer 2

• undetermined origin
• placenta praevia
• placental abruption
• cervix
• vasa praevia
• uterine rupture

Question 3

What is placenta praevia?

Answer 3

• normally the chorionic villi surround the whole embryo but later degenerate under the decidua capsularis to form the chorionic laeve
• if the chorionic villi near the lower pole fail to degenerate as the decidua capsularis fuses with the decidua Vera the area will become part of the placenta, encroaching on the lower segment
• more common in multiples, older others and if the uterus is scarred
• marginal —> placenta in lower segment, not over os
• major —> placenta completely covers os

Question 4

How is placenta praevia diagnosed?

Answer 4

• USS
• malpresentation
• non-engagement of pp
• loud maternal pulse in placental bed below umbilicus
• bleeding due to stretching of lower segment

Question 5

How is placenta praevia managed?

Answer 5

• VE can provoke massive bleeding
• bleeding is maternal
• can occur at any time or at start of labour
• may become torrential
• foetus may be compromised if uterus blood flow is reduced
• massive haemorrhage - EM c/s

Question 6

What are the different types of adherent placentae?

Answer 6

• accreta —> decidua basalis is deficient and chorionic villi have attached to the myometrium
• increta —> where the villi penetrate deeply into the myometrium
• percreta —> where the villi have penetrated into the serous external coat

Question 7

What is placental abruption?

Answer 7

• the premature separation of a normally-sited placenta
• maternal blood loss
• haematoma forms which separates the placenta from the maternal circulation

Question 8

What are some of the clinical signs of placental abruption?

Answer 8

• pallor
• hypotension
• tender, hard uterus
• fetal distress or no FH
• tachycardia
• abdominal pain
• vaginal bleeding

Question 9

Describe the different types of blood loss that can occur with placental abruption

Answer 9

• some believe the magnitude is determined at the outset (conception), others believe abruption causes progressive placental separation
• revealed —> detachment is at the margin, all blood is seen, condition of the woman is directly related to the loss
• partially revealed —> some of the blood remains in the uterus, degree of shock may be greater than expected
• concealed —> central to placenta, blood cannot escape so retroplacental clot forms, extravasated blood may infiltrate the full thickness myometrium (couvelaire uterus) pain and shock usually severe

Question 10

What are some of the pre-disposing factors for placental abruption?

Answer 10

• advanced maternal age
• previous abruption
• smoking
• cocaine/amphetamine use
• trauma
• hypertensive disorders
• thrombophilia (increased risk of clotting)
• pre-term, pre-labour ROM
• infection
• polyhydramnios

Question 11

How can placental abruption be categorised?

Answer 11

• mild —> slight blood loss
  —> uterus soft non-tender
  —> no/mild pain
  —> no signs of shock
  —> FH normal
• moderate —> more than 1000ml blood loss
  —> uterus firm and tender
  —> quite severe pain
  —> tachycardia/hypotension
  —> signs of fetal distress
• severe —> more than 2000 ml
  —> hard, woody uterus, backache if posterior placenta
  —> couvelaire uterus
  —> severe pain
  —> extreme shock
  —> fetal heart absent-fetal demise

Question 12

How should a suspected abruption be managed?

Answer 12

• good communication
• contemporaneous record keeping
• palpation
• estimate blood loss
• assess causes
• ctg
• analgesia
• IV access x2
• bloods - FBC, U+E, clotting, x-match, 4 units
• resuscitation with crystalloids until blood available
• assess ABC
• monitor sa o2 and administer o2 if necessary
• AVPU
• strict fluid balance

Question 13

What are the complications of placental abruption?

Answer 13

• fetal death
• massive haemorrhage causing DIC
• renal failure
• HELLP syndrome
• maternal death

Question 14

What is DIC (Disseminated Intravascular Coagulopathy)?

Answer 14

• tissue damage causes release of thromboplastins - greater damage in abruption
• widespread clotting occurs within the vascular tree leading to ischaemic organ damage
• further damaged tissue leads to release of more thromboplastins
• platelets depleted so no further clotting can occur
• spontaneous bleeding from puncture sites, mucous membrane and uterus
• may lead to anuria, jaundice, dyspnoea, cyanosis due to organ damage

Question 15

What is the treatment for DIC?

Answer 15

• managed by MDT - anaesthetist, haematology
• HDU care
• FFP
• packed cells
• platelets - given carefully so as not to stimulate more clotting factor being released

Question 16

What is vasa praevia?

Answer 16

• fetal blood
• velamentous insertion of the cord
• may be diagnosed on USS
• often found at ROM
• associated with sudden fetal distress
• immediate delivery