Antepartum haemorrhage & vaginal Bleeding Flashcards
Definition of APH
Bleeding from or into the genital tract after the 24th week of gestation and before delivery
Earlier than this is miscarriage
Later is PPH
APH is important because
It is the leading cause of obstetric admission and maternal morbidity –> may require operative intervention and there is a risk of maternal mortality
Incidence of APH
2.5 to 3%
Causes of APH
Placental Previa or Placental Abruption
Ruptured Vasa Previa
Bloody show or premature labour
Also: cervicitis, vaginal trauma, cervical polyp, uterine scar rupture, cervical Ca or ectropion
Placenta previa
The partial or whole implantation of the placenta into the lower uterine segment
Prevalence of Placenta previa
Occurs in 1/200 pregnancies which reach term
At 20 weeks is 10%, by 32 weeks 1% and 0.5% at 36 weeks
Central is covering the Os, otherwise marginal
Risk factors for Placenta Previa
Previous CS or uterine instrumentation
High parity or multiple gestation
Advanced maternal age or Smoking
Pathophysiology of placenta previa
Normally the placenta favours the fundus as there is a better blood supply, and the uterus is thicker
Cannot implant where there is scarring
Morbidity of placenta previa
Risk of haemorrhage or operative delivery complications –> can lead to placenta accetra or worse
Can lead to preterm labour
Presentation of placenta previa
Painless bleeding from the 2nd trimester onwards, often following intercourse
May have preterm contractions
Treatment of Placenta previa without bleeding
Expectant management and no digital examination
advise to avoid penetrative sex
Double set up exam
If there is marginal previa with a vertex presentation then try for vaginal delivery but prepared for emergency CS - convert to CS if: complete previa, fetal head not engaged, brisk or persistent bleeding or a mature fetus
Placental abruption
Premature seperation of the placenta from the uterine wall - either partial or complete
Occurs in 1-2% of pregnancies
Can be revealed, concealed or both
Risk factors for placental abruption
HTN, smoking or substance misuse
Trauma, overdistension of the uterus
Previous abruption, placental insufficiency or maternal thrombophilia
Abruption with trauma
Can occur with blunt abdominal trauma or rapid deceleration injuries –> fetus should be evaluated post-trauma —> can cause prematurity, IUGR or stillbirth
Bleeding from abruptions
Can be externalised (revealed) or retroplacental (concealed)
May be mixed with amniotic fluid
If no cause investigate for coagulopathy
Couvelaire uterus
This occurs when retroplacental bleeding ruptures the uterus and leaks into the peritoneal cavity
Symptoms of placental abruption
Pain is hallmark symptom - mild to severe, back pain may indicate posterior abruption
Bleeding may not reflect total blood loss, need to differentiate from bloody show
Abdomen will be hard and tender
Ultrasound of abruptions
A clinical diagnosis so USS just supportive
Useful for placental location and size
Signs are: retroplacental lucency and abnormal thickening of the placenta
Abruption severity
In Mild cases there may be only a retroplacental clot noted after delivery
Moderate cases will be painful with a tense, tender abdomen and a live fetus, and in severe cases can lead to fetal loss
Treatment of placental abruption
Assess fetal and maternal stability –> rapid delivery (vaginal if possible)
Prepare for neonatal resuscitation
Protect the kidneys –> if severe assess mother for haematological and coag status
Coagulative abruption
Not usually seen with live fetus –> due consumptive coagulopathy or DIC
Give platelets and FFP –> if severe give factor VIII
Incidence of Uterine Rupture
0.03-0.08% of all women but 0.3-1.7% if uterine scar (previous CS or uterine perforation)
Also risk if inappropriate oxytocin use or placenta percreta. Small risk in traumatic injury
Morbidity with uterine rupture
Maternal–> haemorrhage with anaemia, bladder rupture, risk of hysterectomy or death
Fetal –>resp distress, hypoxia, acidaemia or death
History in Uterine Rupture
Vaginal bleeding, sudden pain, loss of contractions and fetal HR (or suddern deterioration) –> fetal parts may be palpable through abdomen
Severe maternal tachy and hypotension
Definition of Vasa Previa
Rarest cause of haemorrhage - onset with membrane rupture - blood lost is fetal with 50% mortality. greatest risk with low lying placenta
Vessels may be palpable during vaginal examination
Management of Vasa previa
Immediate CS is worried
Neonatologist should be present as baby may be in shock
Examinations of a patient with placenta previa
Vital signs and fetal lie and HR
Gentle speculum but never do a digital exam when you don’t know where the placenta is
Use of ultrasound in placenta previa
Can be useful to confirm.
Trans-abdominal USS difficult as the presenting part of the fetus can obscure a posterior placenta previa
Transvaginal is useful to identify the internal os and the placental edge.
Treatment of Placenta previa with bleeding
Fully assess for circulatory stability
Full dose of anti-D if Rh neg - group and save and consider transfusion
May need steroids if the risk of prematurity is high
Examination of placental abruption
signs of circulatory instability – mild tachycardia, signs of shock if over 30% loss
May be having tetanic uterine contractions
Treatment of Uterine Rupture
Emergency CS and possible hysterectomy
Risk factors for Uterine inversion
Fundal placentas, active management of the third stage, prolonged cord traction.
Grades of placenta previa
I - on the lower seg. but not reaching the os
II - reaches the os but does not cover it
III - covers part of the os
IV - completely covers the os even when dilated.
