Antepartum Hemorrhage

Question 1

Antepartum Hemorrhage DDx

Answer 1

Placenta previa, accreta/increta/percreta, placental abruption, vasa previa / fetal cord rupture

Question 2

Previa

Answer 2

Painless vaginal bleed after 28 wks (3rd trim)
Mostly dx on u/s
Placenta often will move up (repeat u/s in 3rd trimester as lower uterine segment develops)
More common in multiple gestations, hx previa, uterine scars
Vaginal exam contraindicated!
In pregnant pt with 3rd trimester vaginal bleeding, r/o with u/s before digitalizing.

Question 3

Previa Treatment

Answer 3

Varies: generally pelvic rest, especially after sentinel bleed; hospitalize if Hct drops 3pts, etc.
Immediate C/S if unstoppable labor, fetal distress, life-threatening hemorrhage.
Stabilize, ABCs, type & cross, 2x large bore IVs, then kleihauer-Betke (KB, a blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother’s bloodstream)→ RhoGAM
If make it to 36 wks, often will amnio for fetal lung maturity → C/S between 36-37 wks

Question 4

Accreta, increta, percreta

Answer 4

Usually asymptomatic. Consider if previous s/s and low lying anterior placenta, for instance. Big problem!
Accreta = abnormal attachment into endometrium; increta = into myometrium, percreta = through to serosa

Question 5

Abruption

Answer 5

Can be concealed or revealed / external
Classic hx painful 3rd trim vaginal bleeding a/w strong abdominal pain and/or frequent, strong ctx.
30% are asx, however
Often have firm, tender uterus on exam
If abrupting during C/S, see Couvelaire uterus (if bleeding dissecting into myometrium, uterus is blue/mottled)
U/S not great for dx: only 2% have retroplacental clot, but usually use U/S to R/O previa
Tx: stabilize, type & cross, 2 large bore IVs, etc.

Question 6

Uterine rupture

Answer 6

Rare
Sudden intense abd pain, vaginal bleeding, nonreassuring fetal testing, FHT disappear, placental part regresses, IUPC → low pressure.
Immediate laparotomy & delivery of fetus, then repair!

Question 7

Fetal cord rupture

Answer 7

Velamentous cord insertion: insert between amnion / chorion away from placenta; vulnerable to rupture.
Vasa previa if cross over the internal os (can tear during delivery or ROM)
Succinuriate placenta (extra lobe with vessels going between the lobes) - also can have vasa previa /rupture from unprotected cords
Often p/w rupture → vaginal bleeding, sinusoidal FHR (anemic)
Can dx a fetal source of blood with Apt test (dilute blood, add 1% NaOH, pink = fetal, yellow/brown = maternal) or microscopy → nucleated fetal RBCs.
Tx: emergent C/S (fetus doesn’t have much blood to lose!)