Antepartum Haemorrhage Flashcards
What is this?
Antepartum haemorrhage from 24+0 weeks gestation and prior to birth of baby
What percentage of pregnancies does it complicate?
3-5% of pregnancies
Any bleeding in pregnancy is associated with…
Increased perinatal mortality
What dangerous causes are there?
Abruption
Placenta praevia
Vasa praevia - the baby may bleed to death
Other than the most dangerous causes, what other causes are there?
Uterine sources: circumvallate placenta, placental sinuses
Lower genital tract sources: cervical polyps, erosions and carcinoma, cervicitis, vaginitis, vulval varicosities
What is vasa praevia?
When fetal blood vessels cross or run near the internal opening of the uterus - they are unsupported by the umbilical cord or placental tissue
What should you always ask about in the history?
Domestic violence
How is the amount of blood lost classified?
Spotting - staining, streaking or blood spotting noted on underwear or sanitary protection
Minor haemorrhage - blood loss less than 50ml that has settled
Major haemorrhage- blood loss of 50-1000ml with no signs of clinical shock
Massive haemorrhage- blood loss greater than 1000ml and/or signs of clinical shock
If the woman is stable, what kind of questions should be asked when taking a history?
If no maternal compromise a full history should be taken
- is there pain associated with haemorrhage? Placental abruption should be considered if pain continuous, labour should be considered if intermittent
- identify risk factors for abruption and praevia
- ask about fetal movements
- previous cervical smear history
- domestic violence
What examinations should be done?
General obs - HR, BP
Abdominal palpation - assessed for tenderness or signs of acute abdomen (the tense or woody feel indicates abruption, soft and snot tender may suggest lower genital tract cause)
Speculum examination - identify dilatation or visualise a lower genital tract cause
Digital vaginal examination- not if praevia is a differential diagnosis, US done first
What investigations should be done in women presenting with APH?
Bloods - FBC, coagulation screen, cross match 4 units, UandE, LFTs (the initial Hb may not reflect the amount of blood loss initially, so use clinical judgement)
In minor haemorrhage- FBC and G&S
In all women who are rhesus neg: a Kleihauer test should be performed to quantify FMH to gauge dose of anti-D Ig required
USS - to confirm or exclude placenta praevia if placenta site not already known, the sensitivity for abruption is poor
Fetal investigation - CTG once mother stable
How should the woman be managed if bleeding severe?
Give O2 15L/ min via mask reservoir
Raise legs
If shocked give blood transfusion until BP>100mmHg
Take bloods including clotting screen
Catheterise bladder
Summon expert help, if bleeding severe deliver - CS for praevia, sometimes for abruption
Should corticosteroids be administered to women who present with APH before term?
Single course to women between 24-34 weeks at risk of preterm birth
In women who present with spotting and imminent delivery unlikely, they are unlikely to be of benefit but could still be considered
Should tocolytic therapy be used in women presenting with APH who have uterine activity?
Should not be used to delay delivery in a woman presenting with major APH who is haemodynamically unstable/fetal compromise
- senior obstetrician decision, those who are very preterm may benefit or those who need to transfer to hospital that can provide neonatal care or if need to finish steroid course
How should antenatal care be altered?
Following single/recurrent episodes from ectropion: care need not be altered
Following APH from abruption/unexplained the pregnancy should be re classified as high risk and care should be consultant led - serial USS for fetal growth
