ANTEPARTUM HAEMORRHAGE

1. ANTEPARTUM HAEMORRHAGE APH

2. Antepartum Haemorrhage • vaginal blood loss >15 mL after 20 weeks’ gestation • 5% of all pregnancies • Accounts for 20 -25% of perinatal mortality APH

3. Causes • Placenta praevia 20% • Placental abruption 30% • Others/ unknown 45% • Vasa praevia • Marginal sinus bleeding • Rupture uterus • Local causes 5% APH

4. Local causes of APH • Only 5% of APH • Causes include: • Cervicitis • Cervical erosion, polyp • Cervical cancer • Vaginal/ vulval varicocities • Vaginal infections • Foreign bodies • Genital lacerations • Bloody show • Degenerating fibroids • non-genital tract bleeding APH

5. Severity of bleeding • Mild (<15% circulatory volume) • No change in vital signs • No postural hypotension • Normal urine output • Moderate (15 - 30%) • Postural changes in BP or pulse • Symptoms (thirst, dypsnoea etc.) • Severe (>30%) • Shock • Fetal distress • Oliguria APH

6. Admit History Examination Observation NO PV Exam IV access/ resuscitate Clotting screen Cross match Kleihauer test CTG Placental localization Speculum examination when placenta praevia excluded, bleeding settled Anti-D if Rh-negative Initial management of APH APH

7. Placental abruption • Separation of placenta before delivery • Starts with bleeding into decidua basalis • Impairs placental function • About 1.5% of pregnancies • Perinatal mortality 10% APH

8. Complications • DIC • Fetal death • Hypovolaemic shock • Fetomaternal hemorrage APH

9. Predisposing factors of abruption • Hypertension • External trauma - MVA, ECV • Acute decompression of polyhydramnios • PROM • Substance abuse -tobacco, cocaine, amphetamines • Past history of abruption • Antiphospholipid syndrome • Multiple pregnancy APH

10. Classification of abruption • Mild • Blood loss < 200 mL • No uterine tenderness or rigidity • Normal CTG • Moderate • Blood loss > 200 mL OR • Uterus tense and tender OR • Abnormal CTG • Severe • Fetal death - DIC in 30% APH

11. Clinical features • Vaginal bleeding in 80% (Revealed) • Abruption is ‘Concealed in 20% • Initial bleeding • Pain, uterine tenderness, rigidity • Sudden increase in fundal height • Fetal distress or death • DIC APH

12. Diagnosis • Clinical diagnosis, confirmed retrospectively by examination of placenta • Clinical features important in concealed abruption • Ultrasound unreliable • Only shows 25% of abruptions APH

13. Management • Admit • History, examination • Assess blood loss • Nearly always more than revealed • IV access, X match, DIC screen • Assess fetal well-being • Placental localization APH

14. Clinical flow chart Severe abruption (10% of cases) Resuscitate Induction of labour Vaginal delivery No No Caesarean section ?DIC Is the fetus alive? Abnormal CTG Yes Correct IOL CTG Uterus tense Abnormal Normal CTG Yes CTG Normal Conservative management Uterus soft Vag del > 38/52 < 38/52 APH

15. Placenta praevia • Placenta implanted on lower uterine segment • 1% of all pregnancies • Perinatal mortality rate ~ 3% • Major problem is preterm delivery • At 18 weeks, ~5% of placentas are ‘low lying’ APH

16. Classification 4 grades or degrees of placenta praevia: 1. Low-lying: edge not near internal os, but could be palpated by finger through cervix. 2. Marginal: edge of placenta reaches but does not cover os. 3. Partial: placenta partially covers internal os. 4. Total: placenta completely covers internal os. APH

17. Aetiology/ associations • Uterine surgery or instrumentation • Previous CS, D&C, myomectomy • 1 previous CS + anterior placenta praevia = 25% risk placenta accreta • P H placenta praevia • Increasing parity and age • Multiple pregnancy APH

18. Clinical presentation • Painless Recurrent Vaginal bleeding • 1/3 < 30 weeks • 1/3 30-35 weeks • 1/3 > 36 weeks • Usually first episode mild • Earlier is worse • Often gets worse • Abnormal presentation or lie APH

19. Diagnosis • Placental localization is by ultrasound examination • Transvaginal ultrasound better • Not always right • PPV 93%, NPV 96% • At 18 weeks, 5-10% of placentas low lying. • Repeat scan at 32 - 34 weeks APH

20. Management • Admit to hospital • NO VAGINAL EXAMINATION • IV access • Placental localization • Conservative treatment until fetal maturity if possible APH

21. Management Severe bleeding Caesarean section Resuscitate >34/52 Moderate bleeding Gestation <34/52 Unstable Resuscitate Steroids Stable <36/52 Mild bleeding Gestation Conservative care >36/52 APH

22. Delivery • Delivery is by Caesarean section • Usually LSCS, go around placenta • Beware morbidly adherent placenta • Occasionally Caesarean hysterectomy necessary APH

23. Outpatient management • Inpatient observation for 72 hours without bleeding • Stable haematocrit > 35% • Reactive CTG • Can call ambulance 24 hours/day • Rest at home, no intercourse • Patient understands complications • Weekly follow-up until delivery APH

24. Asymptomatic patients • Placenta praevia now diagnosed prior to bleeding • If no bleeding, no need to admit before 34 weeks • Admit if bleeds • Delivery still by CS at 37-38 weeks • Uncertainty about admission between 34 and 37 weeks - admit grades 3 and 4 APH

25. Vasa Praevia • Vellamentous insertion of cord, bipartite or succenturriate placenta • Fetal vessels in membranes over cervix • May rupture at or before ROM • Suspect in small APH with abnormal CTG • Confirm with Apt test APH

26. How to do an Apt test • Place 5 mL water in each of 2 test tubes • To 1 test tube add 5 drops of vaginal blood • To other add 5 drops of maternal (adult) blood • Add 6 drops 10% NaOH to each tube • Observe for 2 minutes • Maternal (adult) blood turns yellow-green-brown; fetal blood stays pink. • If fetal blood, deliver STAT. APH

27. APH of uncertain origin • 2.5% of all deliveries • PNM 2% (3x background rate) • Initial management as for all APH • Monitor fetal well-being • Marginal sinus bleeding • Retrospective diagnosis • Increased incidences of PROM, preterm labour APH