Antepartum hemorrhage Flashcards
What is Antepartum hemorrhage
Vaginal bleeding after 24 weeks of gestation
Antepartum Hemorrhage can be categorized into 3 broad causes
- Vaginal causes
- Uterine causes
- Cervical causes
What are the Vaginal causes of Antepartum hemorrhage?
1) Trauma - tears & lacerations
2) Infection
What are the Uterine causes of Antepartum hemorrhage?
1) Placental abruption
2) Placenta previa
3) Vasa previa
4) Uterine rupture
What is Placental Abruption?
The premature separation of a normally implanted placenta from the uterine wall.
What is Placenta previa
Abnormal placental implantation either in the lower uterine segment, near the cervix, partially over cervix or completely over the internal cervical os
What are the 4 types of Placenta Previa?
1) Low lying placenta previa
2) Marginal placenta previa
3) Partial placenta previa
4) Complete placenta previa
What is Low Lying Placenta Previa
Placenta attches in the lower uterine segment, more than 2cm from the internal os
What is Marginal Placenta Previa?
Placenta attaches within 2cms from the internal cervical os
What is Partial Placenta Previa?
Placenta attaches partly over the cervical os
What is Complete Placenta Previa?
Placenta attaches completely over the internal cervical os.
What is Vasa Previa?
painless vaginal bleeding from the fetus due to tearing of exposed fetal vessels lying near or across the internal cervical.
What are the 3 types of Placental Abruption?
1) Complete abruption
2) Partial abruption
3) Marginal abruption
What is Complete Abruption?
Placenta completely separates from the uterine wall.
What is Partial Abruption?
A part of the placenta separates from the uterine wall.
What is Marginal Abruption?
the edge of the placenta separates from the uterine wall.
What is a Concealed Abruption?
where the blood from placental separation gets trapped behind the placenta. There`s little to no vaginal bleeding
What is a Revealed Abruption?
active vaginal bleeding from the site of placental separation
Placental Abruption can be classified by the: ?
1) presence or absence of vaginal bleeding
2) degree of separation
3) severity of abruption
Based on the presence or absence of vaginal bleeding, what are the types of placental abruption?
1) Concealed Abruption
2) Revealed Abruption
Based on the degree of separation, what are the types of placental abruption?
1) Complete abruption
2) Partial abruption
3) Marginal abruption
What are the different sites of bleeding in a Concealed Abruption?
1) Subchorionic bleeding
2) Retroplacental bleeding
3) Preplacental bleeding
4) Intraplacental bleeding
What is Subchorionic bleeding?
bleeding between myometrium and chorionic membrane
What is Retroplacental bleeding?
bleeding between myometrium and placenta
What is Preplacental bleeding?
bleeding between placenta and amniotic fluid
What is Intraplacental bleeding?
bleeding inside the placenta
Based on the severity, placental abruption can be classified into?
Grade 0 abruption
Grade 1 abruption
Grade 2 abruption
Grade 3 abruption
Describe the severity of Placental abruption
What is the pathophysiology behind a Placental Abruption?
Tearing of a maternal decidual artery or vein results in bleeding into the decidua basalis of the placenta, which forms a hematoma. As the hematoma enlarges it pushes the placenta further away from the uterine wall, worsening the abruption.
If the hematoma reaches the placental edge, blood will tract down and escape through the cervix and vagina. This is called a revealed hemorrhage.
If the hematoma remains hidden between the placenta and uterine wall, then its called a concealed hemorrhage
What risk factors predispose you to a Placental Abruption?
1) Previous abruption
2) Twin pregnancy
3) Preeclampsia, Gestational hypertension
4) Sudden decompression of uterus (e.g., rupture of membranes in polyhydramnios or after delivery of multiple fetuses)
5) Abdominal trauma
6) Previous caesarean section
7) External cephalic version
8) Maternal smoking and recreational drug use (especially cocaine)
9) Maternal thrombophilia
What are the Presenting Complaints (PC) of a Placental abruption?
Painful P/V bleeding
- dark red blood
Sudden, Persistent dull lower abdominal pain or back pain, associated with:
- Nausea
- Vomiting
- Reduced or absent fetal movements
What are the signs of a Placental Abruption?
1) Signs of maternal shock (maybe grade 3 abruption)
2) Tender uterus
3) On CTG:
» Decelerations of fetal heart rate
» Intermittent contractions (> 5 per 10 minutes - “ sawtooth pattern”) with an elevated baseline tone
» Hypertonic uterus or Tetanic contractions
4) In the case of membrane rupture: blood-stained amniotic fluid
For a Placental Abruption, what questions should I ask in my HPC?
1) Recent trauma? (such as a fall or recent motor vehicle accident )
2) (see PC…)
For a Placental Abruption, what questions should I ask in my Past Medical Hx?
H/o Placental abruption
H/o Polyhydramnios
H/o Gestational Hypertension
H/o Preeclampsia
For a Placental Abruption, what questions should I ask in my Surgical Hx?
H/o Lower abdominal caesarean section (LSCS)
For a Placental Abruption, what questions should I ask in my Social Hx?
H/o smoking
H/o recreational drug use (esp. cocaine)
H/o domestic violence
For a Placental Abruption, what questions should I ask in my Family Hx?
H/o Placental abruption in first degree relatives
How do you diagnose a Placental Abruption?
1) Through clinical suspicion, so pregnant pts with a H/o:
- Vaginal bleeding
- Abdominal pain
- Back pain
- Trauma {with or without symptoms}
- Unexplained preterm labor
2) Confirmed by visual inspection of the placenta after delivery
On inspection of the placenta after suspecting an abruption, what are some of things you will look for?
» Recent abruption: look for dark blood clots with depression in placenta
» Old abruption: look for fibrin deposits at site of abruption
» Total abruption: placenta may look normal
What are some differential diagnosis you should consider, after suspecting a placental abruption?
» For P/V bleeding, other causes include:
♦ Placenta previa
♦ Vasa previa
» For Abdominal / Pelvic pain, other causes include:
♦ Onset of normal labor
♦ Preterm labor
♦ Fibroid degeneration
♦ UTI
♦ Ovarian pathology
♦ Appendicitis
♦ Ovarian pathology
What investigations should be done in suspicion for placental abruption?
♦ Baseline CBC
♦ For Rh negative mothers→ Kleihauer - Betke Test (to measure how much fetal blood has mixed with maternal blood & dose of anti - D immunoglobulin needed)
♦ Group & Crossmatch (GXM)
♦ Arterial Blood Gas (ABG) {to evaluate shock}
♦ Lactate {to evaluate shock}
♦ Urea & Electrolytes (U&E)
♦ Ultrasound (U/S) { to rule out Placenta Previa & Intrauterine fetal death if viability cant be determined on auscultation}
♦ F/U CBCs until patient is stable
♦ Continuous CTG trace for fetal monitoring (if active bleeding during labor)
What causes Placenta Previa?
Endometrial scaring or damage due to:
♦ Uterine fibroids causing abnormality in the uterine cavity
♦ prior Cesarean section
♦ Myomectomy
♦ Endometrial curettage
♦ Endometrial ablation
♦ short intervals between pregnancies
♦ prior / recurrent abortions
What are the risk factors for Placenta previa
♦ Twin pregnancies (due to large placental size)
♦ prior Placenta Previa
♦ Maternal smoking
♦ Maternal age over 40 years
What are the Presenting complaints of Placenta previa?
Sudden, Painless P/V bleeding
- bright red blood
(often after sexual intercourse)
For a Placenta Previa, what questions should I ask in my HPC?
how often does the bleeding occur?
Ans: P/V bleeding in placenta previa is often episodic or intermittent (rarely continuous)
(see PC….)
In Placenta Previa, is blood lost from the fetus or mother?
Mother
What are the signs of Placenta Previa?
Soft, nontender uterus
On CTG:
Normal Fetal Heart Rate as blood loss is from the mother (unless the mother is profoundly shocked, in which case the fetus would be in distress)
What are some differential diagnosis you should consider, after suspecting placenta previa?
1) Placental Abruption
2) Vasa Previa
3) Preterm Labor
4) Preterm Premature Rupture of Membranes (PPROM)
5) Premature Rupture of Membranes at term (term PROM)
6) Bloody show
7) Infection such as Cervicitis
8) Cervical or vaginal varicosities
9) Genital / Pelvic trauma
10) Coagulopathy
What investigations should be done in suspicion for placental previa?
♦ Baseline CBC (to check Hb level & R/o Coagulopathy)
♦ Blood Transfusion if Hb < 7
♦ For Rh negative mothers→ Kleihauer - Betke Test (to measure how much fetal blood has mixed with maternal blood & dose of anti - D immunoglobulin needed)
♦ Group & Crossmatch (GXM)
♦ Arterial Blood Gas (ABG) {to evaluate shock}
Transabdominal U/S {for diagnosis}
What Pelvic l exam should I do to narrow down my differential diagnosis in placenta previa?
Speculum exam prior to U/S
What Pelvic exam should I avoid when suspecting Placenta Previa?
Digital Vaginal exam
How do you diagnose Placenta Previa?
Transabdominal U/S. If it can’t be ruled out, F/u with Transvaginal U/S. → If it can’t be ruled out, F/u with Translabial U/S
