Antepartum Haemorrhage

Question 1

What is antepartum haemorrhage?

Answer 1

Bleeding from the genital tract after 24 weeks gestation

Question 2

What is placenta praevia?

Answer 2

when the placenta is implanted in the lower segment of the uterus

Question 3

How does placenta praaevia differ from ‘low lying placenta’

Answer 3

Low-lying placenta is used when the placenta is within 20mm of the internal cervical os
Placenta praevia is used only when the placenta is over the internal cervical os

Question 4

How is placenta praevia classified?

Answer 4

Minor - placenta in lower segment (not over os)

Major - placental completely or partially covering os

Question 5

In what circumstances is placenta praevia more common in?

Answer 5

Previous caesarean sections
Previous placenta praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities (e.g. fibroids)
Assisted reproduction (e.g. IVF)

Question 6

What are the effects of placenta praevia?

Answer 6

Antepartum haemorrhage
Emergency caesarean section
Emergency hysterectomy
Maternal anaemia and transfusions
Preterm birth and low birth weight
Stillbirth

Question 7

What is the effect of placenta implanting in a previous C-section scar?

Answer 7

it may b so deep as to prevent placental separation (placenta accreta) or penetrate through the uterine wall into surrounding structures such as the bladder (placenta percreta)

Question 8

Who does placenta accreta occur in?

Answer 8

Previous placenta accreta
Previous endometrial curettage procedures (e.g. for miscarriage or abortion)
Previous caesarean section
Multigravida
Increased maternal age
Low-lying placenta or placenta praevia

Question 9

What is the effect of placenta accreta?

Answer 9

PPH

Question 10

What is the presentation of placenta praevia?

Answer 10

The 20-week anomaly scan is used to assess the position of the placenta and diagnose placenta praevia.

Many women with placenta praevia are asymptomatic. It may present with painless vaginal bleeding in pregnancy (antepartum haemorrhage). Bleeding usually occurs later in pregnancy (around or after 36 weeks).

Question 11

What lies and engagements are common with placenta praevia?

Answer 11

Breech position and transverse lie are common

the foetal head is not engaged and high

Question 12

How is diagnosis of placenta praevia done?

Answer 12

For women with a low-lying placenta or placenta praevia diagnosed in 20 week scan

32 weeks gestation
36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)

Question 13

What is the management of placenta praevia?

Answer 13

Corticosteroids are given between 34 and 35 + 6 weeks gestation to mature the fetal lungs, given the risk of preterm delivery.

Planned delivery is considered between 36 and 37 weeks gestation. It is planned early to reduce the risk of spontaneous labour and bleeding. Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os).

Emergency caesarean section may be required with premature labour or antenatal bleeding.

Question 14

What is the management if there is placenta accreta or percreta?

Answer 14

Anticipated and a clear plan made for elective delivery with interventional radiology and expert surgical and anaesthetic support

uterine incsion is made away from the placenta which can be left in situ or removed with the entire uterus

Partial separation or transection during uterine incision may lead to massive haemorrhage - treatment involves compression of the inside of the scar after removal of the placenta with an inflatable balloon; excision of the affected uterine segment or frequently total hysterectomy

Question 15

What is placental abruption?

Answer 15

Placental abruption refers to when the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates. Placental abruption is a significant cause of antepartum haemorrhage.

Question 16

What are the outcomes of placenta separating?

Answer 16

Considerable maternal bleeding may occur behind it - this ca have several consequences:

1. Further placental separation - acute foetal distress
2. Antepartum haemorrhage - tracks down between membranes and myometrium
3. Blood enter the liquor or myometrium

Foetal death is common

Question 17

What are the associated factors of placental abruptions

Answer 17

Previous placental abruption
Pre-eclampsia
Bleeding early in pregnancy
Trauma (consider domestic violence)
Multiple pregnancy
Fetal growth restriction
Multigravida
Increased maternal age
Smoking
Cocaine or amphetamine use

Question 18

What is the presentation of placental abruption?

Answer 18

Sudden onset severe abdominal pain that is continuous
Vaginal bleeding (antepartum haemorrhage)
Shock (hypotension and tachycardia)
Abnormalities on the CTG indicating fetal distress
Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage

Question 19

How is diagnosis of placental abruption done?

Answer 19

Clinical judgement - foetus monitored using CTG and uterine activity

USS used to exclude praevia and estimate foetal weight

Question 20

What is the management of placental abruption?

Answer 20

Admission is required, as resuscitation may be required

Delivery depends on foetal state and gestation - if foetal distress then emergency C-section, but if not then labour is induced with amniotomy

If no foetal distress the pregnancy is preterm and the degree of abruption is minor, then steroids can be given and the patient closely monitored and if all symptoms settle - discharge

(but pregnancy is now high risk)

Question 21

What is the major risk with placental abruption?

Answer 21

PPH

Question 22

Abruption vs praevia - shock?

Answer 22

Abruption - inconsistent with external loss

Praevia - consistent with external loss

Question 23

Abruption vs praevia - pain?

Answer 23

Abruption - common, often severe, constant with exacerbations

Praevia - no - contractions occasionally

Question 24

Abruption vs praevia bleeding?

Answer 24

Praevia - may be absent, often dark

Abruption - red and often profuse
often smaller previous antepartum haemorrhage

Question 25

Abruption vs praevia tenderness?

Answer 25

Abruption - usual, often severe, uterus may be hard

praevia - rare

Question 26

Abruption vs praevia fetus

Answer 26

abruption - lie normal, often engaged, may be dead or distressed

praevia - lie ofte abnormal/head high

Question 27

Abruption vs praevia ultrasound

Answer 27

abruption - often normal, placenta not low

praevia - low

Question 28

What are the other causes of antepartum haemorrhage?

Answer 28

Bleeding of undetermined origin

Ruptured vasa praevia
Vasa praevia is a condition where the fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os. The fetal membranes surround the amniotic cavity and developing fetus.

Uterine rupture

Bleeding of gynaecological origin

Question 29

How is bleeding of undetermined origin diagnosed?

Answer 29

When APH is small and painless, but the placenta is not praevia

May be impossible to find a cause

Question 30

When does vasa praevia occur?

Answer 30

When a foetal blood vessel runs in the membranes in front of the presenting part - these vessels usually result from the umbilical cord being attached to the membranes rather than the placenta (velamentous insertion) or where the placenta is in parts. Occurs in 1% of pregnancies

Question 31

Which vessels are more likely to rupture in ruptured vasa praevia?

Answer 31

vessels closer to the cervix

Occurs in 1 in 5000 pregnancies - usually when the membranes rupture. massive foetal bleeding follows

Question 32

What is the presentation of ruptured vasa praevia?

Answer 32

painless, moderate vaginal bleeding at rupture of the membranes, which is accompanied by severe foetal distress

C-section is often not fast enough to save the foetus

Question 33

When does uterine rupture occur?

Answer 33

very rare

rupture can occur before labour in women with other uterine scars or a congenitally abnormal foetus

Question 34

What is the managment of bleeding in pregnant women who’s smears are overdue?

Answer 34

undergo speculum examination and colposcopy

cervical polyps, ectropion and vaginal lacerations may be evident