Antepartum haemorrhage

Question 1

What is APH?

Answer 1

Genital tract bleeding from 24w

Question 2

What are the common causes of APH?

Answer 2

Dangerous causes
-Placenta praevia
-Abruption
-Vasa praevia
Other uterine sources
-Circumvallate placenta
-Placental sinuses
Lower genital tract sources
-Cervical polyps, erosions, carcinoma
-Cervicitis
-Vaginitis
-Vulval varicosities
Fibroid complication e.g. torsion, rupture

Question 3

What is placenta praevia?

Answer 3

Placenta lying in lower uterine segment, encroaching on or obstructing the cervical os

Question 4

Does a low lying placenta in early gestation mean a normal birth is not possible?

Answer 4

As the uterus expands through gestation, the placenta may ‘move’ away from the os (uterine expansion causes this; not placental movement)

Question 5

How many low lying placentas are praevia at term?

Answer 5

1 in 10

Question 6

What are the post partum implications for mothers with placenta praevia?

Answer 6

Increased PPH risk

Lower segment of uterus less effective at contraction

Question 7

How is placenta praevia classified?

Answer 7

Grannum classification
Marginal (types I-II), lower segment but does not cover the os
Major (types III-IV), partial or complete coverage of os

Question 8

Is the bleeding always revealed in placenta praevia?

Answer 8

Yes (compared to abruption, which can be hidden)

Question 9

What should be avoided in suspected placenta praevia?

Answer 9

Vaginal exam (bimanual or speculum)
Penetrative intercourse

Question 10

What is placenta praevia associated with?

Answer 10

CS
Sharp curette TOP
Multiparity
Multiple pregnancy
>40y
Assistant contraception
Other (deficient endometrium-manual removal of placenta, fibroids, endometritis)

Question 11

What are the potential complications of placenta praevia?

Answer 11

Placenta praevia usually warrants CS due to obstruction of engagement
PPH
Development of placenta accreta or percreta (if not recognised, women in delivery may have major haemorrhage, necessitating hysterectomy)

Question 12

What is typically seen in the Hx of placenta praevia?

Answer 12

Intermittent painless bleeds (increasing in frequency and time over several weeks)

Question 13

What would be seen on examination?

Answer 13

If suspected - do not perform vaginal exam

Breech presentation/transverse foetal lie are common

Question 14

How can a placenta praevia be diagnosed?

Answer 14

USS (normally diagnosed at second trimester USS, but repeated at 32w if major, 36w if minor to see if placenta has moved)
If placenta <2cm from os on second scan, unlikely to move by delivery

Question 15

Which women with placenta praevia should be admitted?

Answer 15

All
Keep blood on standby and give anti-D to Rh-ve
Steroids should be given in <34w

Question 16

How should the baby be delivered in placenta praevia?

Answer 16

If major - Delivery by CS

If minor - aim for normal unless the placenta is within 2cm of os (esp if placenta posterior/thick)

Question 17

If CS is indicated for placenta praevia, when should it be performed?

Answer 17

CS with consultant attendance at 38w

If 36-37w give steroid cover and have crossmatched blood available, if accreta suspected

Question 18

What is placenta accreta?

Answer 18

Placentation into the myometrium of the uterus; causes difficulties in removal due to extreme adherence postpartum

Question 19

What is placenta percreta?

Answer 19

Placentation beyond myometrium, including into surrounding pelvic organs e.g. bladder, bowel etc. Managed in interventional radiology (coils used to clot off supportive vessels)

Question 20

What is vasa praevia?

Answer 20

Foetal blood vessel running in the membranes in front of presenting part (usually from umbilical cord being attached to membranes rather than placenta)
CS needed

Question 21

What is placental abruption?

Answer 21

Part or all of placenta separates before delivery of foetus

Question 22

How common is abruption?

Answer 22

1%

Question 23

Do abruptions present with bleeding?

Answer 23

Not always; some may enter the myometrium or liquor rather than being lost through the os (haemorrhage is absent in 20%)

Question 24

What are risk factors for placental abruption?

Answer 24

IUGR
Pre-eclampsia
HNT (pre-existing)
Smoking
Previous abruption
PROM
Multiple pregnancy
Polyhydramnios
Inc maternal age
Thrombophilia
Abdo trauma
Drug use (esp cocaine/amphetamine)
Infection

Question 25

What are the consequences of abruption?

Answer 25

Placental abruption (foetal anoxia/death)
DIC

Question 26

How would a pt present with abruption?

Answer 26

Painful bleeding
Blood often dark
May be backache if posterior bleed

Question 27

What would be found on examination?

Answer 27

Tachycardia (shock disproportionate to blood loss)
Hypotension
Tender uterus, frequently contracting, “woody”
Difficult to palpate foetus
Foetal heart sound abnormal/absent

Question 28

What may occur in maternal shock from concealed bleeding?

Answer 28

Renal failure and Sheehan syndrome

Question 29

What Ix should be performed?

Answer 29

CTG

FBC, Coagulation and clotting screen, U&E

Question 30

How can abruption and praevia be distinguished?

Answer 30

• Shock out of keeping with visible loss vs shock proportional to visible loss
• Constant pain vs no pain
• Woody, tense tender uterus vs non-tender uterus
• Normal foetal lie/presentation vs abnormal lie
• Foetal heart abnormal/absent vs normal
• Coagulation problems vs rare to have coagulation problems
• Beware pre-eclampsia, DIC, anuria vs Small bleeds before large

Question 31

How should abruption be managed?

Answer 31

Admission (fluids, steroids, opiate analgesia, anti-D if required, catheterise and monitor urine output
Delivery if foetal distress by CS
If no distress but >37w, induction by amniotomy
If foetus dead, blood products given and labour induced
If no distress and pregnancy preterm with minor abruption, give steroids (if <34w) and monitor on ward

Question 32

What should be considered postpartum?

Answer 32

PPH always risk with APH hx