Antepartum haemorrhage & vaginal Bleeding

Question 1

Definition of APH

Answer 1

Bleeding from or into the genital tract after the 24th week of gestation and before delivery
Earlier than this is miscarriage
Later is PPH

Question 2

APH is important because

Answer 2

It is the leading cause of obstetric admission and maternal morbidity –> may require operative intervention and there is a risk of maternal mortality

Question 3

Incidence of APH

Answer 3

2.5 to 3%

Question 4

Causes of APH

Answer 4

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

Question 5

Placenta previa

Answer 5

The partial or whole implantation of the placenta into the lower uterine segment

Question 6

Prevalence of Placenta previa

Answer 6

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

Question 7

Risk factors for Placenta Previa

Answer 7

Previous CS or uterine instrumentation
High parity or multiple gestation
Advanced maternal age or Smoking

Question 8

Pathophysiology of placenta previa

Answer 8

Normally the placenta favours the fundus as there is a better blood supply, and the uterus is thicker
Cannot implant where there is scarring

Question 9

Morbidity of placenta previa

Answer 9

Risk of haemorrhage or operative delivery complications –> can lead to placenta accetra or worse
Can lead to preterm labour

Question 10

Presentation of placenta previa

Answer 10

Painless bleeding from the 2nd trimester onwards, often following intercourse
May have preterm contractions

Question 11

Treatment of Placenta previa without bleeding

Answer 11

Expectant management and no digital examination

advise to avoid penetrative sex

Question 12

Double set up exam

Answer 12

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

Question 13

Placental abruption

Answer 13

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

Question 14

Risk factors for placental abruption

Answer 14

HTN, smoking or substance misuse
Trauma, overdistension of the uterus
Previous abruption, placental insufficiency or maternal thrombophilia

Question 15

Abruption with trauma

Answer 15

Can occur with blunt abdominal trauma or rapid deceleration injuries –> fetus should be evaluated post-trauma —> can cause prematurity, IUGR or stillbirth

Question 16

Bleeding from abruptions

Answer 16

Can be externalised (revealed) or retroplacental (concealed)
May be mixed with amniotic fluid
If no cause investigate for coagulopathy

Question 17

Couvelaire uterus

Answer 17

This occurs when retroplacental bleeding ruptures the uterus and leaks into the peritoneal cavity

Question 18

Symptoms of placental abruption

Answer 18

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

Question 19

Ultrasound of abruptions

Answer 19

A clinical diagnosis so USS just supportive
Useful for placental location and size
Signs are: retroplacental lucency and abnormal thickening of the placenta

Question 20

Abruption severity

Answer 20

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

Question 21

Treatment of placental abruption

Answer 21

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

Question 22

Coagulative abruption

Answer 22

Not usually seen with live fetus –> due consumptive coagulopathy or DIC
Give platelets and FFP –> if severe give factor VIII

Question 23

Incidence of Uterine Rupture

Answer 23

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

Question 24

Morbidity with uterine rupture

Answer 24

Maternal–> haemorrhage with anaemia, bladder rupture, risk of hysterectomy or death
Fetal –>resp distress, hypoxia, acidaemia or death

Question 25

History in Uterine Rupture

Answer 25

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

Question 26

Definition of Vasa Previa

Answer 26

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

Question 27

Management of Vasa previa

Answer 27

Immediate CS is worried

Neonatologist should be present as baby may be in shock

Question 28

Examinations of a patient with placenta previa

Answer 28

Vital signs and fetal lie and HR

Gentle speculum but never do a digital exam when you don’t know where the placenta is

Question 29

Use of ultrasound in placenta previa

Answer 29

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.

Question 30

Treatment of Placenta previa with bleeding

Answer 30

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

Question 31

Examination of placental abruption

Answer 31

signs of circulatory instability – mild tachycardia, signs of shock if over 30% loss
May be having tetanic uterine contractions

Question 32

Treatment of Uterine Rupture

Answer 32

Emergency CS and possible hysterectomy

Question 33

Risk factors for Uterine inversion

Answer 33

Fundal placentas, active management of the third stage, prolonged cord traction.

Question 34

Grades of placenta previa

Answer 34

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.