Anterpartum Haemorrhage

Question 1

What is antepartum haemorrhage

Answer 1

Bleeding from the genital tract between 20 weeks of gestation until the onset of labour. 24/40 as the cut off

Question 2

What are some of the symptoms and parameters of antepartum haemorrhage?

Answer 2

• spotting: straining, streaking or blood spotting noted on underwear or sanitary protection
• Minor haemorrhage - blood loss less than 50 ml that has settled
• Major haemorrhage - blood loss of 50-1000 ml with no signs of clinical shock
• Massive haemorrhage : Blood loss greater than 1000 ml and/or signs of clinical shock
• Remember bleeding may be concealed look for signs of shock

Question 3

Name 6 causes of Antepartum haemorrhage??

Answer 3

• Placental abruption
• Placenta praevia
• Marginal placental bleeding
• local causes: cervical/ vaginal/ uterine pathology
• uterine rupture (rare)
• Vas praevia (rare)
• Intimate partner violence

Question 4

Maternal Antepartum haemorrhage complications

Answer 4

• anaemia
• infection
• maternal shock
• Renal tubular necrosis
• Consumptive coagulopathy
• Post partum haemorrhage
• Prolonged hospital stay
• Psychological Sequelae
• Complications of blood transfusions

Question 5

Fetal antepartum haemorrhage complications

Answer 5

Fetal hypoxia
Small for gestational age, fetal growth restrictions
prematurity
Fetal death

Question 6

what does placental abruption mean?

Answer 6

Premature separation of a normally planted placenta from the uterine wall prior to the delivery of the fetus

Question 7

What are the risk factors for a placental abruption?

Answer 7

Trauma
Smoking
PPROM
Previous abruption
Smoking
Cocaine use
Hypertensive disorders of pregnancy

Question 8

Clinical Presentation of placental abruption?

Answer 8

Vaginal bleeding
Uterine tenderness
Uterine contractions/ pain ( esp back pain)
Non reassuring fetal status
Maternal haemodynamic compromise if substantial blood lost

Question 9

What is placenta praevia?

Answer 9

Placenta praevia occurs when the placenta is partially or completely in the lower uterine segment?

Question 10

What is the difference between major and minor placenta praevia?

Answer 10

Major: Placenta covers the internal os
Minor: Placenta does not cover the internal os

Question 11

What are the three types of placental adhesive disorders which generally coexist with placenta praevia?

Answer 11

Placenta accrete: morbidly adherent to the myometrium
Placenta increta: Invaded into, but not through , the myometrium
PLacenta percreta: invaded through the myometrium into the surrounding structures

Question 12

Name the risk factors for placenta praevia

Answer 12

Prior placenta praevia
Prior C section
Prior ToP
Multiparity
Multiple pregnancy
Advanced maternal age
ART

Question 13

Should a vaginal examination be performed if placenta praevia is suspected?

Answer 13

No massive iatrogenic haemorrhage may occur, a speculum examination is okay. Placental location should be routinely monitored in mid trimester Fetal morphology svan

Question 14

What is the commonest local cause of antepartum haemorrhage?

Answer 14

Cervical Ectropian: Eversion of the endocervix exposes columnar epithelium to the vaginal milieu

Question 15

What is a rare but serious causes of APH

Answer 15

Cervical malignancy

• pap smear must be checked
• HPV history
• Colposcopy

Question 16

What are the scenarios where Uterine Rupture is likely to occur?

Answer 16

• Generally occurs in labour, in women with prior uterine surgery (C section, myomectomy)
• May occur prelabour

Question 17

Sudden abdominal painat is the clinical presentation of uterine rupture?

Answer 17

• sudden abdominal pain
• Distension
• Hypovolaemic bleeding
• Management is with aggressive maternal resuscitation nd immediate laparotomy
• Fetal demise likely if delivery not effected within minutes
• Focus must be on maternal well being

Question 18

What is vasa praevia?

Answer 18

Fetal vessels coursing through the membranes, below the fetal presenting part over the internal cervical os, unprotected by placental tissue or the umbilical cord.

It poses a minimal risk to the mother but a major risk to the fetus, especially due to low blood volume

If vessels rupture e.g. spontaneous or artificial rupture of membranes, then 60% mortality is reported

Question 19

What is unexplained APH?

Answer 19

Often attributed to marginal placental bleeding or marginal separation that is not true abruption

Question 20

Pregnancies with these complications at increased risk of adverse outcomes

Answer 20

Increased rates of pre-term birth, SGA babies, admission to NICU, still birth

Fetal anomalies also more common in this context

As a result women with APH are often induced at term 37+ weeks of gestation