Tutorial 6: Antepartum Haemorrhage

Question 1

What is antepartum Haemorrhage?

Answer 1

Bleeding from the genital tract after 24 weeks gestation.

Affects 3 – 5% of pregnancies.

Question 2

What are the general principles when managing bleeding?

Answer 2

1. Admit
2. ABC’s – IV access and resuscitate with fluids, give O2
3. Bloods - FBC, coags (?DIC)
4. Group and hold
5. Assessment and diagnosis and
6. Anti-D if Rhesus negative

Question 3

What are common causes/ddx of antepartum haemorrhage?

Answer 3

Common APH:

1. Undetermined 40%
2. Placental abruption (bleeding, pain)
3. Placenta Previa (painless, recurrent bleeding)
4. Edge Bleeding (painless bleeding w. Nil findings)

Rarer APH:

1. Incidental genital tractpathology
2. Uterine rupture
3. Vasa praevia
4. Local lesion: painless, minor bleeding
   
   • findings: cervical lesions

Question 4

What is Placenta Previa?

Answer 4

Placenta implanted in the lower segment of the uterus.

Question 5

What is the epidemiology of placenta previa?

Answer 5

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.

Question 6

What are the two types/classifications of placenta previa?

Answer 6

1. Major:
   
   1. placenta covers the internal OS
   2. ALWAYS requires c-section
2. Minor/Marginal:
   
   1. placenta is in the lower segment, but doesnt cover the internal os
   2. possibility of normal delivery

Question 7

What are some risk factors for placenta previa?

Answer 7

• Previous uterus surgery (Caesarean)
• Multiple pregnancy
• High parity
• Increasing Age
• Fibroids (disrupts placentation)

Question 8

What are some slinical features/symptoms of placenta previa?

Answer 8

• May be none of note (33%).
• Typically painless, intermittent bleeds over several weeks. Bleeds can be severe.

Question 9

What are some commong examination findings of placenta previa?

Answer 9

• 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

Question 10

What initial examination should be avoided in a woman with antepartum haemorrhage?

Answer 10

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.

Question 11

What investigations should be performed in a woman with placenta previa?

Answer 11

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:

1. CTG: to assess fetal wellbeing (Fetal distress is uncommon)
2. FBC, coags etc.

Question 12

What is the management of placenta previa?

Answer 12

Management if bleeding:

1. Admit
2. Bloodwork (group and hold, FBC, coags) available for transfusion if needed.
   
   1. Managing shock and observation can allow the pregnancy to be prolonged.
   2. May require emergency delivery, and administration of steroids.

Management if Asymptomatic:

1. 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.

Question 13

What are some complications of Placenta Previa?

Answer 13

1. Increased risk of PPH (lower segment of uterus does not contract so well)
2. Placenta acreta may also occur: USS. Which may require:
   
   • balloon compression or
   • hysterectomy

Question 14

What is placental abruption?

Answer 14

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%).

Question 15

What is the incidence of placental abruption?

Answer 15

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.

Question 16

What are the major risks associated with placental abruption?

Answer 16

MAJOR RISKS of

• Maternal:
  
  • Coagulopathy (DIC)
  • Renal failure
• Fetal demise (30%).

Question 17

What risk factors are associated with Antepartum haemorrhage?

Answer 17

• 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

Question 18

What are the clinical features/Hx of a patient with placental abruption?

Answer 18

• 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.

Question 19

What are common examination findings associated with placental abruption?

Answer 19

• 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.

Question 20

What investigation are required for placental abruption?

Answer 20

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

Question 21

What is the management of placental abruption?

Answer 21

1. Admit.
2. Stabilisation of the mother is the first priority.
   
   1. IV fluids for resuscitation ± transfusion as needed.
   2. Opiate analgesia.
   3. Anti-D for Rhesus negative.
3. Steroids if gestation <34 weeks

Delivery: depends on the fetal state and gestation:

1. Fetal distress = urgent Caesarean section
2. No fetal distress and >37 weeks = IOL (induction of labour).
   
   1. Close fetal monitoring is essential, if distress ensues –> then Caesarean needed.
   2. Serial USS for small abruptions with good fetal monitoring results.
3. Fetal demise = IOL + Blood products
   
   1. as coagulopathy is likely

Question 22

How do you determine mode of delivery during placental abruption?

Answer 22

Delivery: depends on the fetal state and gestation:

1. Fetal distress = urgent Caesarean section
2. No fetal distress and >37 weeks = IOL (induction of labour).
   
   1. Close fetal monitoring is essential, if distress ensues –> then Caesarean needed.
   2. Serial USS for small abruptions with good fetal monitoring results.
3. Fetal demise = IOL + Blood products, as coagulopathy is likely

Question 23

How do you distinguish Placenta Previa, in terms of shock, pain, bleeding, uterus and fetus?

Answer 23

• 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

Question 24

How do you distinguish Placental abruption, in terms of shock, pain, bleeding, uterus and fetus?

Answer 24

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

Question 25

What are features of vasa previa?

Answer 25

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.

Question 26

What are three risk factors for vasa previa?

Answer 26

1. Succenturiate placentae 2. Bilobate placentae 3. IVF pregnancies

Question 27

When does bleeding in vasa previa occur?

Answer 27

Vasa previa bleeding occurs when the mothers membrane's rupture (artificial or spontaneous) * risk of fetal haemorrhage or death

Question 28

What type of delivery is reccomended for vasa previa?

Answer 28

c-section for those cases detected

Question 29

What are features of uterine rupture?

Answer 29

* 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.

Question 30

What are risk factors for uterine rupture?

Answer 30

Anything that causes scarring or an abnormal uterus * previous c-section * obstructed labour * high forceps delivery

Question 31

What is the classical presentation of uterine rupture?

Answer 31

During labour: * sudden loss of contractions * maternal shock * fetal distress * variable vaginal bleeding

Question 32

What is the treatment of vaginal hysterectomy?

Answer 32

Laparotomy: 85% will require hysterectomy

Question 33

What are some undetermined and gynaecological causes of antepartum haemorrhage?

Answer 33

* 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.

Question 34

What is an important gyanecological cause of antepartum haemorhage?

Answer 34

Cervical carcinoma. - History and assessment are both important.