Antepartum Haemorrhage

Question 1

What is the definition of antepartum haemorrhage?

Answer 1

Bleeding after 24 weeks gestation + before the end of the second stage of labour

Question 2

What are the causes of antepartum haemorrhage?

Answer 2

Placenta praevia
Placental abruption
Local causes: ectropion, infection, cervical cancer
Vasa praevia
Uterine rupture
Indeterminate cause
Sign of preterm labour

Question 3

How is bleeding defined/quantified?

Answer 3

Spotting –> noted on underwear
Minor haemorrhage –> blood loss <500ml that has settled
Major haemorrhage –> 500-1000ml with no signs of shock
Massive haemorrhage –> >1000ml and/or signs of shock

Question 4

What is the definition of placenta praevia?

Answer 4

Placenta that is either covering the internal cervical os or is within 2cm of the cervical os

Question 5

How does placenta praevia usually present clinically?

Answer 5

Bright red painless bleeding

Question 6

What are the risk factors for placenta praevia?

Answer 6

Age
Previous placenta praevia
Previous C-section

Question 7

How is placenta praevia managed?

Answer 7

ABCDE
USS confirms diagnosis
Anti-D within 72 hours if rhesus -ve
C-section for delivery

Question 8

What is the definition of placental abruption?

Answer 8

Separation of a normally implanted placenta either partially or totally before the birth of the foetus

Question 9

What are the clinical features of placental abruption?

Answer 9

Painful vaginal bleeding
- can be painless
- can be concealed bleeding
Tender, tense (woody hard) uterus
Clinical shock - may be out of proportion to the amount of visible blood
Foetal distress on CTG

Question 10

How is placental abruption managed?

Answer 10

Resuscitate mother (mum comes before baby)
Urgent C-section + replace blood products
Anti-D if necessary

Question 11

What is vasa praevia?

Answer 11

Foetal blood vessels in the membranes overlying close to the internal cervical os

Question 12

What are the clinical features of vasa praevia?

Answer 12

Rupture of membranes is followed by small amount of dark vaginal bleeding
–> acute foetal bradycardia + decelerations (risk of foetal mortality)
Doesn’t carry maternal risk because it is foetal blood loss

Question 13

What is the management of vasa praevia?

Answer 13

If antenatal diagnosis:

• steroids at 32 weeks
• C-section before labour (34-26 weeks)

If bleeding:
- emergency C-section + neonatal resuscitation

Question 14

What are the risk factors for uterine rupture?

Answer 14

Previous uterine surgery:
- c-section
- myomectomy
- previous perforation
Overstimulation following excessive use of:
- syntocinon
- prostaglandins
Multiparity
Obstructed labour

Question 15

What are the features of uterine rupture?

Answer 15

Acute constant abdominal pain, may refer to shoulder tip
Foetal parts may be easily felt on abdominal palpation
Acute foetal distress on CTG
Sudden maternal collapse

Question 16

What is the management of uterine rupture?

Answer 16

Emergency C-section + foetal resuscitation

May result in hysterectomy depending on extent of rupture