ANTEPARTUM HAEMORRHAGE

Neoh Hui Pheng

Batch 22/A2

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reference

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• RCOG Guidelines
• Obstetrics today

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Definition

• Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 22 weeks (>500g) of pregnancy and prior to the birth of the baby.

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• complicates 3–5% of pregnancies
• leading cause of perinatal and maternal mortality worldwide.
• Up to one-fifth of very preterm babies are born in association with APH
• Most of the time unpredictable.

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RCOG

Severity

NO consistent definitions of the severity of APH.

It is recognised that the amount of blood lost is often underestimated .

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The amount of blood coming from the introitus may not represent the total blood lost (for example in a concealed placental abruption).

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It is important to assess for signs of clinical shock. The presence of fetal compromise or fetal demise is an important indicator of volume depletion.

RCOG Guidelines

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Different terminologies used:

• Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection

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• Minor haemorrhage – blood loss less than 50 ml that has settled

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• Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock

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• Massive haemorrhage – blood loss greater than 1000 ml and/or signs of clinical shock.

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• Recurrent APH - > one episode

RCOG Guidelines

Etiology

• Placenta praevia
• Abruptio placenta
• Vasa praevia
• Excessive show
• Local causes ( bleeding from cervix, vagina and vulva )

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• Inderterminate APH

Placenta Praevia (PP)

• Implantation of placenta over or near the internal os of cervix.
• Confirm diagnosis of PP can be done at 28 weeks when LUS forming.

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Leading cause of vaginal bleeding in the 2^nd and 3^rd trimester.

Classification

Risk Factors of Placenta Praevia

• Previous placenta praevia (4-8%)
• Previous caesarean sections ( risk with numbers of c-section)
• Previous termination of pregnancy
• Multiparity
• Advanced maternal age (>40 years)
• Multiple pregnancy
• Smoking
• Deficient endometrium due to presence or history of:

- uterine scar

-endometritis

-manual removal of placenta

- curettage

-submucous fibroid

• Assisted conception

RCOG

Clinical classification

• Minor :
• Type 1 (anterior/posterior)
• Type 2 anterior

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• Major:
• Type 2 posterior (dangerous type)
• Type 3
• Type 4

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Deliver vaginally

Type 1 Posterior > likelihood of fetal distress

Caesarean section

Type 2 posterior > chance of fetal distress

Type 3 & 4 anterior –cut through placenta to deliver. Hence need to be fast and efficient.

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Abruptio Placenta (AP)

• Separation of normally located placenta after 22 weeks of gestation ( > 500g) and prior to delivery of fetus.

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Risk factors:

- Previous history of AP

• Maternal hypertension
• Advanced maternal age
• Trauma ( domestic violence, accident, fall)
• Smoking/alcohol/cocaine
• Short umbilical cord
• Sudden decompression of uterus ( PROM/delivery of 1^st twins)
• Retroplacental fibroids
• Idiopathic

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Obstetrics Emergency!!

Diagnosed CLINICALLY :

• Painful vaginal bleeding -80%
• Tense and tender abdomen/back pain (70%)
• Fetal distress( 60%)
• Abnormal uterine contractions (hypertonic and high frequency)
• Preterm labour ( 25%)
• Fetal death ( 15%)

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Ultrasound is NOT USEFUL to diagnose AP. Retroplacental clots (hyperechoic) easily missed.

Obstetrics today

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Vasa Praevia (VP)

• Rupture of fetal vessels that run in membrane below fetal presenting part which is unsupported by placenta/ umbilical cord.

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• Predisposing Factors:

-Velamentous insertion of the umbilical cord

-Accesory placental lobes

-Multiple gestations

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Obstetrics today

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The term velamentous insertion is used to describe the condition in which the umbilical cord inserts on the chorioamniotic membranes rather than on the placental mass.

Diagnosis of VP

• Antenatal diagnosis –reduced perinatal mortality and morbidity.
• Painless vaginal bleeding at the time of spontaneous rupture of membrane or post amniotomy
• Fetal bradycardia
• Fetal shock or death can occur rapidly at the time of diagnosis due to blood loss constitutes a major bulk of blood volume is fetus ( 3kg fetus-300ml)
• Hence, ALWAYS check the fetal heart after rupture of membrane or amniotomy.
• Definitive diagnosis by inspecting the placenta and fetal membrane after delivery.

Obstetrics today

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Complications of APH

RCOG Guidelines

Clinical assessment in APH

• First and foremost 🡪Mother and fetal well being (mother is the priority)

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• establish whether urgent intervention is required to manage maternal or fetal compromise.

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• Assess the extent of vaginal bleeding, cardiovascular condition of the mother

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• Assess fetal wellbeing.

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Full History

Should be taken after the mother is stable.

• associated pain with the haemorrhage?

Continuous pain : Placental abruption.

Intermittent pain : Labour.

• Risk factors for abruption and placenta praevia should be identified.
• reduced fetal movements?
• If the APH is associated with spontaneous or iatrogenic rupture of the fetal membranes : ruptured vasa praevia
• Previous cervical smear history possibility of Ca cervix. Symptomatic pregnant women usually present with APH (mostly postcoital) or vaginal discharge.

Examination

• General: PULSE & BP ( a MUST!)
• Abdomen:
• The tense, tender or ‘woody’ feel to the uterus indicates a significant abruption.
• Painless bleeding, high fetal presenting part – Placenta praevia

- soft, non-tender uterus may suggest a lower genital tract cause or bleeding from placenta or vasa praevia.

Examination

• Speculum :

-identify cervical dilatation or visualise a lower genital tract cause.

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• Digital vaginal examination
• Should NOT be done until Placenta Praevia has been excluded by USG.

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RCOG Guidelines

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Investigations

• FBC
• Coagulation profile
• Blood Grouping and CXM, GSH.
• Ultrasound- TRO PP/ IUD
• D-dimer : AP
• colour doppler TVS – VP
• In all women who are RhD-negative, a Kleihauer test should be performed to quantify FMH to gauge the dose of anti-D Ig required.

Fetal monitoring:

• CTG monitoring

RCOG Guidelines

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Management

• WHEN to admit?
• Based on individual assessment

-Discharge after reassurance and counselling

Women presenting with spotting who are no longer bleeding and where placenta praevia has been Excluded.

However, a woman with spotting + previous IUD due to placenta abruption, an admission would be appropriate.

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- All women with APH heavier than spotting and women with ongoing bleeding should remain in hospital at least until the bleeding has stopped.

Management

• If preterm delivery is anticipated, a single course of antenatal corticosteroids ( dexamethasone 12mg 12 hourly ,2 doses) to women between 24 and 34 weeks 6 days of gestation.
• Tocolytics should NOT be given unless for VERY preterm women who need time to transfer to hospital with NICU.

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• For very preterm ( 24-26 weeks) ,

-conservative management if mother is stable .

-Delivery of fetus – life threatening � At these gestations, experienced neonatologists should be involved in the counselling of the woman and her partner

RCOG

Management

For Placenta Praevia

• Conservative – MaCafee’s regime

( premature < 37 weeks;mother haemodynamically stable,no active bleeding, fetus stable)

-advise bed rest, keep pad chart, vital signs monitoring , Ultrasound, steroids, GSH, Daily CTG and biophysical profile, fetal movement count.

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• Plan for delivery ( >37 weeks)

Crossmatch 4 units of blood.

Definitive treatment

Type I,II(ant)

Type II( post), III,IV

ARM +/- oxytocin

Satisfactory progress without bleeding

Vaginal delivery

Bleeding continues

Caesarean section

Caesarean section

For Abruptio placenta,(obs emergency)

• ICU admission : Close monitoring and resuscitation!
• ABC ( high flow O2, aggressive fluid resuscitation)
• Continuous Vital signs monitoring and urine output
• Monitor vaginal bleeding – strict pad chart
• Continuous CTG for fetal heart rate
• Crossmatch 4 units of blood
• FFP – coagulopathy
• Dexamethasone – preterm

Abruptio Placenta

Decide Mode of delivery

• Vaginal delivery – when fetal death
• Caesarean section –if maternal/ fetal health compromised
• Indicated when early DIC sets in
• Consent should be taken for hysterectomy in case bleeding could not be controlled.

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Obstetrics today

Management

• For Rh negative mothers,

Anti-D Ig should be given to all after any presentation with APH, independent of whether routine antenatal prophylactic anti-D has been administered.

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In the non-sensitised RhD-negative woman for all events after 20 weeks of gestation, at least 500 iu

anti-D Ig should be given followed by a test to identify FMH, if greater than 4 ml red blood cells; additional

anti-D Ig should be given as required.

RCOG Guidelines