Objectives

2. 1 Objectives Describe the main causes of antepartum haemorrhage Discuss the management of main causes

3. 2 The Placenta The majority of vaginal bleeding during pregnancy is associated with the placenta. Think of the placenta as a tree with an extensive root system (Vessels) and branches (Cotyledons) that have the potential to be deprived of nutrients (Oxygen, water and glucose). This deprivation may cause the roots and branches to shrink and become loose causing areas of trauma or bleeding (abruption). The roots themselves may not implant over rich soil (endometrium) and instead be forced to implant on dry arid regions (cervix or scar). These arid regions may crack and separate (dilatation or rupture) causing the placenta to bleed.The majority of vaginal bleeding during pregnancy is associated with the placenta. Think of the placenta as a tree with an extensive root system (Vessels) and branches (Cotyledons) that have the potential to be deprived of nutrients (Oxygen, water and glucose). This deprivation may cause the roots and branches to shrink and become loose causing areas of trauma or bleeding (abruption). The roots themselves may not implant over rich soil (endometrium) and instead be forced to implant on dry arid regions (cervix or scar). These arid regions may crack and separate (dilatation or rupture) causing the placenta to bleed.

4. 3 Causes of APH Placental praevia Placenta abruption Vasa Praevia Incidental and indeterminate causes = 50-60% APH Non Placental causes - local genital tract trauma These are the major causes of APH, most of which have the potential to cause sudden and severe short and long term morbidity and mortality for the woman and her baby. In major cases of bleeding it is not until after the event that the cause can be identified and in many instances the true cause is never really found. Placenta edge bleeding - marginal sinus rupture. Rupture of the marginal sinus or vein at the edge of the placenta. Venous bleeding.These are the major causes of APH, most of which have the potential to cause sudden and severe short and long term morbidity and mortality for the woman and her baby. In major cases of bleeding it is not until after the event that the cause can be identified and in many instances the true cause is never really found. Placenta edge bleeding - marginal sinus rupture. Rupture of the marginal sinus or vein at the edge of the placenta. Venous bleeding.

5. 4 Low Lying Placenta Not an uncommon finding on second trimester ultrasound scan. 15-20% of pregnancies have a low lying placenta. Only 5% of these remain low lying at 32 weeks and One third of those are low lying at term (37 weeks). National Institute of Clinical Evidence (NICE) UK Guideline 62 �Because most low-lying placentas detected at the routine anomaly scan will have resolved by the time the baby is born, only a woman whose placenta extends over the internal cervical os should be offered another scan at 32 weeks. If the transabdominal scan is unclear, a transvaginal scan should be offered.�National Institute of Clinical Evidence (NICE) UK Guideline 62 �Because most low-lying placentas detected at the routine anomaly scan will have resolved by the time the baby is born, only a woman whose placenta extends over the internal cervical os should be offered another scan at 32 weeks. If the transabdominal scan is unclear, a transvaginal scan should be offered.�

6. 5 Placenta Praevia Placenta that has implanted in part or all of the lower uterine segment encroaching upon or covering the internal cervical os. Responsible for 15-20% of APH�s Haemorrhage is likely in the third trimester as the lower segment grows and thins or the cervix dilates. With the increase in LSCS the clinician should consider placenta accreta, increta & percreta with placenta praevia Placenta accreta is a severe obstetric complication involving an abnormal superficial attachment of the placenta to the myometrium (the middle layer of the uterine wall). There are three forms of placenta accreta, distinguishable by the depth of penetration accreta, percreta or increta.Placenta accreta is a severe obstetric complication involving an abnormal superficial attachment of the placenta to the myometrium (the middle layer of the uterine wall). There are three forms of placenta accreta, distinguishable by the depth of penetration accreta, percreta or increta.

7. 6 Grading Grade 1 ( 1st Degree) Part of placenta lies in the lower segment but does not reach os Grade 2 ( 2nd Degree) The lower margin of the placenta reaches the internal os but does not cover it Grade 3 ( 3rd Degree) The placenta covers the os Grade 4 ( 4th Degree) The placenta lies centrally over the os Today, ultrasound has the ability to measure the distance between the edge of the placenta and the cervix. This allows us to clearly describe the exact position of the placenta. A placenta that is > 2cm away from the cervix can attempt vaginal birth. (RCOG 2005) Placental migration occurs during the second and third trimesters, but is less likely to occur if the placenta is posterior or there has been a previous LSCSToday, ultrasound has the ability to measure the distance between the edge of the placenta and the cervix. This allows us to clearly describe the exact position of the placenta. A placenta that is > 2cm away from the cervix can attempt vaginal birth. (RCOG 2005) Placental migration occurs during the second and third trimesters, but is less likely to occur if the placenta is posterior or there has been a previous LSCS

8. 7

9. 8 Clinical Features Bleeding without abdo pain or uterine tenderness, usually bright red Usually between 34-38 wks (20% before 28 weeks) May be associated with contractions Bleeding usually recurs often increasing in severity with increasing gestational age Not usually precipitated by any one factor, coitus, etc. 30% women with placenta praevia will not have a APH

10. 9 Clinical management Active vs expectant management Active management: if bleeding continues non-reassuring FHR pattern maternal compromise

11. 10 Vasa Praevia Rare event Umbilical cord vessels are covered only by chorion and amnion (membranes) Vessels are exposed and can rupture under pressure or ARM Baby at risk of severe bleeding and death May feel like a cord pulsating on VE May be diagnosed on colour Doppler U/S Most Vasa Praevias go undiagnosed. May be detected via colour Doppler U/S and should be looked for in the presence of placenta praevia or other risk factors, see next slideMost Vasa Praevias go undiagnosed. May be detected via colour Doppler U/S and should be looked for in the presence of placenta praevia or other risk factors, see next slide

12. 11 Risk factors � vasa praevia Painless vaginal bleeding after 20 weeks gestation Low lying placnta of praevia Succenturiate lobe or velementous cord insertion IVF or multiple pregnancy

13. 12 Vasa Praevia

14. 13 Placental Abruption Separation of a normally implanted placenta � usually by haemorrhage into the decidual basalis after the 20th week of pregnancy and before birth of the baby The amount of bleeding depends on: the size of the bleeding vessel/s the amount of placental separation The more extensive the bleeding, the more likely it is to strip the membranes from the uterine wall and pass through the cervix and vagina Bleeding occurs between the base of the placenta and the adjacent uterine decidua. Commonly in the case of an abruption, the bleeding occurs before it shows vaginally and in all cases of abruption it is important to consider not just the blood loss but also the clinical condition of the woman. Bleeding can occur internally into the uterus and never show vaginally. This is described as a concealed abruption which may result in a �couvelaire� uterus where there is extravasation of blood into the uterine musculature and beneath the uterine peritoneum in association with premature detachment of the placenta.Bleeding occurs between the base of the placenta and the adjacent uterine decidua. Commonly in the case of an abruption, the bleeding occurs before it shows vaginally and in all cases of abruption it is important to consider not just the blood loss but also the clinical condition of the woman. Bleeding can occur internally into the uterus and never show vaginally. This is described as a concealed abruption which may result in a �couvelaire� uterus where there is extravasation of blood into the uterine musculature and beneath the uterine peritoneum in association with premature detachment of the placenta.

15. 14 Causes of abruption Unknown cause is the most common Hypertensive disorders Previous APH Abdominal trauma: MVA, DV, fall Associations have been made with abnormal trophoblastic invasion and/or vessel formation Other predisposing factors - Rapid reduction in uterine size, ECV, Cocaine use, smoking, poor nutrition, advancing parity, multiple pregnancy, IOL Commonly the cause of an abruption is unknown. Hypertension is a significant risk factor mainly due to the constriction of blood vessels at the placental level. A rapid rise in blood pressure or a very sudden fall alters the blood through the vessels and therefore the size of the vessels potentially causing them to detach from the endometrium leaving an exposed area that bleeds. The more significant the rise or fall in BP the greater the potential for blood vessels to detach and bleed. The other risk factors are associated with poor placental implantation and possibility of detachment.Commonly the cause of an abruption is unknown. Hypertension is a significant risk factor mainly due to the constriction of blood vessels at the placental level. A rapid rise in blood pressure or a very sudden fall alters the blood through the vessels and therefore the size of the vessels potentially causing them to detach from the endometrium leaving an exposed area that bleeds. The more significant the rise or fall in BP the greater the potential for blood vessels to detach and bleed. The other risk factors are associated with poor placental implantation and possibility of detachment.

16. 15 Incidence 1 to 1.5% of pregnancies Recurs in 10-15% of cases In 5% of these women DIC occurs An abruption may result in Fetal compromise Fetal demise Maternal compromise The severity of fetal distress correlates with the degree of placental separation. In near complete or complete abruption an immediate caesarean section is required to reduce morbidity & mortality. .An abruption may result in Fetal compromise Fetal demise Maternal compromise The severity of fetal distress correlates with the degree of placental separation. In near complete or complete abruption an immediate caesarean section is required to reduce morbidity & mortality. .

17. 16 Bleeding may be Revealed Concealed Partially revealed Painful and the women�s clinical symptoms may not always match amount of blood loss Again, always consider the blood loss that you can�t see and the clinical condition of the woman needs to be watched closely. Keep in the back of your mind the woman with the significant postpartum haemorrhage that appears stable who then suddenly drops her BP and faints. The woman can lose 1/3 circulating blood volume before being symptomaticAgain, always consider the blood loss that you can�t see and the clinical condition of the woman needs to be watched closely. Keep in the back of your mind the woman with the significant postpartum haemorrhage that appears stable who then suddenly drops her BP and faints. The woman can lose 1/3 circulating blood volume before being symptomatic

18. 17 Clinical Presentation Vaginal bleeding of varying amount (80%) Uterine tenderness +/- (70%) Abnormal FHR pattern +/- (60%) Uterine contractions +/- (high frequency, low intensity) (35%) Uterine Hypertonus Clinical presentation features are dependant on degree of abruption and blood loss. Although he majority of abruptions present with some level of vaginal blood loss, there are still about 20% where no vaginal bleeding is seen. When women present with uterine tenderness and uterine irritability � high frequency/low intensity type contractions - consider the presence of an abruptionAlthough he majority of abruptions present with some level of vaginal blood loss, there are still about 20% where no vaginal bleeding is seen. When women present with uterine tenderness and uterine irritability � high frequency/low intensity type contractions - consider the presence of an abruption

19. 18 Prevention of abruption Actively treat maternal hypertension Screen for domestic violence Screening & brief intervention for smoking and substance abuse Seat belt worn under pregnant abdomen Early identification of potential / actual domestic violence situations assists with keeping women safe. Wherever possible offer women assistance to stop smoking or drug programs as required.Early identification of potential / actual domestic violence situations assists with keeping women safe. Wherever possible offer women assistance to stop smoking or drug programs as required.

20. 19 Complications of abruption Maternal Haemorrhagic shock Coagulopathy/DIC Uterine rupture Renal failure Maternal death Fetal Fetal Hypoxia Anaemia Growth restriction CNS damage Fetal death Once there has been some level of placental separation the woman is at risk of bleeding, so therefore all the complications of bleeding are possible and can happen very rapidly as there pressure can not be placed on the bleeding point. Because of the separation there is a reduction in the transfer of oxygen to the fetus and at risk of the fetus developing all the complications associated with hypoxia of varying degrees. Particularly growth restriction as the fetus compensates for the reduction of oxygen and glucose.Once there has been some level of placental separation the woman is at risk of bleeding, so therefore all the complications of bleeding are possible and can happen very rapidly as there pressure can not be placed on the bleeding point. Because of the separation there is a reduction in the transfer of oxygen to the fetus and at risk of the fetus developing all the complications associated with hypoxia of varying degrees. Particularly growth restriction as the fetus compensates for the reduction of oxygen and glucose.

21. 20 Management Considerations - APH Maternal welfare assessment � monitoring of vital signs, blood loss, urine output. Always think about a concealed haemorrhage Insert two large bore cannulars � 14 or 16g Fluid replacement Cross match 4 units of packed cells Resuscitation and/or delivery In the presence of significant blood loss - oxygen

22. 21 Management Considerations con�t Fetal welfare assessment electronic FHR monitoring U/S for placental position/ vasa praevia Steroid cover if preterm Anti D if Rh -ve Make a diagnosis � Clinical - Ultrasound (? Value) Maternal education and support Maternal biochem, haematology � FBC/Kleihaur if Rh -ve +/- Preparation for Preterm birth � transfer if required Diagnosis of Abruption is in most cases a clinical diagnosis and U/S provides very little information regarding the position or amount of bleeding and it may be difficult to see any blood loss at all. If delivery is required consultation with an anaesthetist may be necessary if the woman is showing any signs of compromise following the bleed If transfer for fetal reasons is required consider the risks of ongoing bleeding during transfer. Tocolysis is not helpful as preterm birth is not the issue. Contractions may be present due to uterine irritation by blood rather than the initiation of labour.Diagnosis of Abruption is in most cases a clinical diagnosis and U/S provides very little information regarding the position or amount of bleeding and it may be difficult to see any blood loss at all. If delivery is required consultation with an anaesthetist may be necessary if the woman is showing any signs of compromise following the bleed If transfer for fetal reasons is required consider the risks of ongoing bleeding during transfer. Tocolysis is not helpful as preterm birth is not the issue. Contractions may be present due to uterine irritation by blood rather than the initiation of labour.