Tutorial 6: Antepartum Haemorrhage Flashcards
What is antepartum Haemorrhage?
Bleeding from the genital tract after 24 weeks gestation.
Affects 3 – 5% of pregnancies.
What are the general principles when managing bleeding?
- Admit
- ABC’s – IV access and resuscitate with fluids, give O2
- Bloods - FBC, coags (?DIC)
- Group and hold
- Assessment and diagnosis and
- Anti-D if Rhesus negative
What are common causes/ddx of antepartum haemorrhage?
Common APH:
- Undetermined 40%
- Placental abruption (bleeding, pain)
- Placenta Previa (painless, recurrent bleeding)
- Edge Bleeding (painless bleeding w. Nil findings)
Rarer APH:
- Incidental genital tractpathology
- Uterine rupture
- Vasa praevia
- Local lesion: painless, minor bleeding
- findings: cervical lesions
What is Placenta Previa?
Placenta implanted in the lower segment of the uterus.
What is the epidemiology of placenta previa?
Complicates 0.4% of pregnancies at term.
At 20/40, many more women (~28%) will have a “low-lying” placenta seen on USS which will rise away from the cervical os as the pregnancy continues, due to the growth of the lower segment.
What are the two types/classifications of placenta previa?
-
Major:
- placenta covers the internal OS
- ALWAYS requires c-section
-
Minor/Marginal:
- placenta is in the lower segment, but doesnt cover the internal os
- possibility of normal delivery
What are some risk factors for placenta previa?
- Previous uterus surgery (Caesarean)
- Multiple pregnancy
- High parity
- Increasing Age
- Fibroids (disrupts placentation)
What are some slinical features/symptoms of placenta previa?
- May be none of note (33%).
- Typically painless, intermittent bleeds over several weeks. Bleeds can be severe.
What are some commong examination findings of placenta previa?
- Breech presentation
- Transverse lie
- Head not engaged and high.
Do not perform a vaginal examination until placenta previa has been excluded, as this may exacerbate her bleeding/blood loss
What initial examination should be avoided in a woman with antepartum haemorrhage?
IMPORTANT: Avoid VE (vaginal examination) in women with APH before placenta praevia has been ruled out
- as this can exacerbate severe bleeding.
- → Placenta praevia may be asymptomatic and is often an incidental finding on ultrasound scan.
What investigations should be performed in a woman with placenta previa?
Second trimester USS: can usually see a low-lying placenta
- This scan should be repeated at 34 weeks to assess if placenta praevia present.
- NB: Transvaginal USS more sensitive.
If currently bleeding:
- CTG: to assess fetal wellbeing (Fetal distress is uncommon)
- FBC, coags etc.
What is the management of placenta previa?
Management if bleeding:
- Admit
- Bloodwork (group and hold, FBC, coags) available for transfusion if needed.
- Managing shock and observation can allow the pregnancy to be prolonged.
- May require emergency delivery, and administration of steroids.
Management if Asymptomatic:
- Can be managed at home (if circumstances good/ easy hospital access) with admit at 37 weeks.
Delivery for Placenta Previa (PP):
- Timing: All should be delivered at 39 weeks
-
Mode of delivery:
- minor PP can be considered for vaginal delivery
- otherwise or if in doubt then by Caesarean section.
What are some complications of Placenta Previa?
- Increased risk of PPH (lower segment of uterus does not contract so well)
- Placenta acreta may also occur: USS. Which may require:
- balloon compression or
- hysterectomy
What is placental abruption?
Part or all of the placenta separates from the uterus before delivery of the fetus.
-
At the site, blood accumulates between the placenta and uterus, which can result in further separation.
- The blood may t_rack between the membranes and myometrium_ to be revealed as APH
- Though it may also remain hidden in the myometrium resulting in no visible bleeding (20%).
What is the incidence of placental abruption?
Placental abruption affects 1% of pregnancies
- though many cases of APH have no identified cause which may be small abruptions, thus may be a higher figure.
What are the major risks associated with placental abruption?
MAJOR RISKS of
- Maternal:
- Coagulopathy (DIC)
- Renal failure
- Fetal demise (30%).
What risk factors are associated with Antepartum haemorrhage?
- Previous abruption (4-6%)
- Pre-eclampsia
- High parity
- Smoking
- IUGR
- Pre-existing Hypertension
- Illicit drug use (cocaine, amphetamines)- stimulants
- Autoimmune disease
- Multiple pregnancy
- Assisted reproduction
What are the clinical features/Hx of a patient with placental abruption?
-
Pain ± bleeding. As stated, bleeding may be absent (concealed) despite massive losses into the uterus.
- Bleeding if “Revealed” is typically dark red in colour.
- Pain is typically constant and may have exacerbations.
What are common examination findings associated with placental abruption?
- Signs of shock/hypovolaemia:
- tachycardia early –> hypotension late.
- Tender & hard uterus
- Difficult to palpate fetus.
- Abnormal or absent fetal heart sounds.
- If DIC, widespread signs of bleeding elsewhere.
What investigation are required for placental abruption?
Placental Abruption is usually a clinical diagnosis
- pain and uterine tenderness should always prompt suspicion
Investigations to assess severity of placental abruption
- Fetus: CTG to monitor baby
- Mother:
- FBC, U&E’s, coags,
- insertion of IDC and measurement of urine output,
- CVP monitoring
What is the management of placental abruption?
- Admit.
-
Stabilisation of the mother is the first priority.
- IV fluids for resuscitation ± transfusion as needed.
- Opiate analgesia.
- Anti-D for Rhesus negative.
- Steroids if gestation <34 weeks
Delivery: depends on the fetal state and gestation:
- Fetal distress = urgent Caesarean section
- No fetal distress and >37 weeks = IOL (induction of labour).
- Close fetal monitoring is essential, if distress ensues –> then Caesarean needed.
- Serial USS for small abruptions with good fetal monitoring results.
- Fetal demise = IOL + Blood products
- as coagulopathy is likely
How do you determine mode of delivery during placental abruption?
Delivery: depends on the fetal state and gestation:
- Fetal distress = urgent Caesarean section
-
No fetal distress and >37 weeks = IOL (induction of labour).
- Close fetal monitoring is essential, if distress ensues –> then Caesarean needed.
- Serial USS for small abruptions with good fetal monitoring results.
- Fetal demise = IOL + Blood products, as coagulopathy is likely
How do you distinguish Placenta Previa, in terms of shock, pain, bleeding, uterus and fetus?
- Shock: consistent with external loss
- Pain: none, but may have contractions
- Bleeding:
- profuse (possibly with multiple, smaller episodes)
- bright red blood
- Uterus
- Clinically noraml
- USS: low lying placenta
- Fetus:
- breech presentation and abrnoaml (e.g. transverse) lie
- high head
How do you distinguish Placental abruption, in terms of shock, pain, bleeding, uterus and fetus?
Shock: inconsistent with external loss
Pain: severe, constant with some exacerbations
Bleeding: may be absent. dark blood
Uterus: tender, hard uterus. hard to palpate fetus.
Fetus: distress or demise
What are features of vasa previa?
Fetal blood vessels running close to the Os.
- Affects 1 in 5000 pregnancies.
- Associated with succenturiate or bilobate placentae, and in IVF pregnancies.
- Can bleed when membranes are ruptured (artificial or spontaneous) and may lead to fetal haemorrhage and death.
Presents as painless bleeding of moderate amount at ROM.
Can be detected on USS, but seldom are.
Caesarean section delivery for those detected.
What are three risk factors for vasa previa?
- Succenturiate placentae
- Bilobate placentae
- IVF pregnancies
When does bleeding in vasa previa occur?
Vasa previa bleeding occurs when the mothers membrane’s rupture (artificial or spontaneous)
- risk of fetal haemorrhage or death
What type of delivery is reccomended for vasa previa?
c-section for those cases detected
What are features of uterine rupture?
- A rare occurance in women with a scarred or abnormal uterus. Associations: previous cervical surgery, obstructed labour, high forceps delivery.
- Typically intra-abdominal blood loss.
- Usually occurs in labour; sudden loss of contractions, maternal shock, fetal distress. Vaginal bleeding is variable.
- Need laparotomy, 85% will require hysterectomy.
What are risk factors for uterine rupture?
Anything that causes scarring or an abnormal uterus
- previous c-section
- obstructed labour
- high forceps delivery
What is the classical presentation of uterine rupture?
During labour:
- sudden loss of contractions
- maternal shock
- fetal distress
- variable vaginal bleeding
What is the treatment of vaginal hysterectomy?
Laparotomy: 85% will require hysterectomy
What are some undetermined and gynaecological causes of antepartum haemorrhage?
- Many cases of APH will have no identifiable cause.
- Many of these cases are likely to be minor, non-consequential abruptions and they should be managed as such
- Gynaecological Causes e.g. cervical carcinoma. History and assessment important.
What is an important gyanecological cause of antepartum haemorhage?
Cervical carcinoma.
- History and assessment are both important.
