Antepartum Haemorrhage

Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour

Aetiology

• Most common causes are placental abruption and placenta praevia

• Other causes:
• Local causes - ectropion, polyp, infection, carcinoma
• Uterine problem - rupture
• Vasa praevia
• Indeterminate

Pathophysiology

Quantifying APH

Placental abruption

• Separation of a normally implanted placenta from the wall of the uterus - partially or totally before the birth of the fetus

• Clinical diagnosis

Aetiology

• Unknown - 70% occur in low risk pregnancies

• Pre-eclapsia/hypertension

• Trauma (blunt, forceful)

• Smoking, cocaine, amphetamine

• Medical thrombophilias, renal disease, diabetes

• Polyhydramnios

• Multiple pregnancy

• Preterm

• Abnormal placenta

• Previous abruption

Pathophysiology

• Vasospasm followed by arteriole rupture into the decidua; blood escapes into the amniotic sac or further under the placenta and into myometrium

• Causes tonic contraction and interrupts placental circulation which causes hypoxia

• Results in Couvelaire uterus - haematoma bruised uterus

Clinical presentation

• Severe continuous abdominal pain (labour pain is continuous with contraction)
• Backache with posterior placenta

• Bleeding (may be concealed)

• Preterm labour

• May present with maternal collapse

• Unwell distressed patient

• Abdominal examination:
• Uterus LFD or normal
• Uterine tenderness
• Woody hard uterus
• Fetal parts difficult to identify
• May be in preterm labour (with heavy show)

• Fetal condition:
• Bradycardia/absent heart rate
• CTG shows irritable uterus

Management

• ABCDE approach

• Resuscitate mother
• 2 large bore IV access
• Bloods - FBC, clotting, LFT and U+Es, type and cross match 4-6 units RBC, Kleiheuer (if Rh neg)
• IV fluids
• Catheterise - urometer

• Assess and deliver the baby
• Fetal heart - CTG, USS if no fetal heart
• Urgent delivery by c/section, induction of labour by amniotomy, expectant management only if minor (allow steriod cover)

• Manage complications

• Debrief parents

Complications

• Hypovolaemic shock

• Anaemia

• PPH (25% )

• Renal failure from renal tubular necrosis

• Coagulopathy (FFP, cryoprecipitate)

• Infection

• Complications of blood transfusion

• Thromboembolism

• Prolonged hospital stay

• Psychological sequelae

• Mortality - rare

• Fetal death (IUD)

• Hypoxia

• Prematurity - iatrogenic and spontaneous

• Small for gestational age and fetal growth restriction

Placenta praevia/low lying placenta

• Placenta praevia: should be used when the placenta lies directly over the internal os

• After 16/40 the term low lying placenta should be used when the placental edge is less than 20mm from the internal os on transabdominal or transvaginal scanning

Aetiology

• Caesarean delivery is associated with an increased risk of placenta praevia in subsequent pregnancies; this risk rises as the number of prior caesarean sections increases

• Previous termination of pregnancy

• Advanced maternal age (> 40 years)

• Multiparity

• Assisted conception

• Multiple pregnancy

• Smoking

• Deficient endometrium due to e.g. uterine scar, endometritis, D+C, submucous fibroid

Clinical presentation

• Painless bleeding >24 weeks

• Usually unprovoked but coitus can trigger bleeding

• Bleeding can be minor e.g. spotting or severe

• Fetal movements usually present

• Patient's condition directly proportional to the amount of observed bleeding

• Abdominal exam:
• Uterus soft and non-tender
• Presenting part high
• Malpresentations - breech, transverse, oblique

• Fetal heart - CTG usually normal

• DO NOT perform vaginal exam until you exclude placenta praevia

Investigations

• Midtrismester fetal anomaly US scan should include placental localisation (transvaginal scan is superior)

• MRI if placenta accreta suspected

Management

• Resuscitation mother - ABCDE
• Large bore IV access
• Bloods - FBC, clotting, LFT and U+Es, type and cross match 4-6 units RBC, Kleiheuer (if Rh neg)
• IV fluids or transfuse
• Anti D (if Rh neg)

• Assess baby's condition +/-
• Steriods 24-35+6 weeks
• MgSO4 if <32 weeks delivery likely for neuroprotection

• Conservative management if stable and observe in hospital for at least 24 hours

• Delivery
• Consider delivery at 34-36 weeks if history of PVB or other risk factors for preterm delivery; for uncomplicated placenta praevia consider delivery between 36 and 37 weeks
• C section if placenta covers os or <2cm from os
• Vaginal delivery if placenta >2cm from os and no malpresentation

Placenta accreta

• A morbidly adherent placenta (abnormally adherent to the uterine wall)

• Associated with retained placenta requiring surgical management and have high risk of massive postpartum haemorrhage

Aetiology

• Major risk factors include placenta praevia and prior caesarean delivery
• Increased risk with multiple c/sections

Clinical presentation

• Ideally, placenta accreta is diagnosed antenatally by ultrasound

• Often causes no signs or symptoms during pregnancy, although vaginal bleeding during the third trimester might occur

• It may be diagnosed at birth, when it becomes difficult to deliver the placenta - it is cause of significant postpartum haemorrhage

Investigations

• MRI

Management

• Prophylactic internal iliac artery balloon

• Caesarean hysterectomy

• Conservative management (+ methotrexate?)

Uterine rupture

• Full thickness opening of uterus, including serosa
• If serosa is intact - uterine dehiscence

Aetiology

• Previous caesarean section/uterine surgery

• Multiparity and use of prostaglandins/syntocinon

• Obstructed labour

Clinical presentation

• Severe abdominal pain

• Shoulder tip pain

• Maternal collapse

• PV bleeding

• Intra-partum - loss of contractions

• Acute abdomen

• PP rises

• Peritonism

• Fetal distress/ IUD

Management

• Urgent resuscitation and surgical management
• Large bore IV access
• Bloods - FBC, clotting, LFT and U+Es, type and cross match 4-6 units RBC, Kleiheuer (if Rh neg)
• IV fluids or transfuse
• Anti D (if Rh neg)

Vasa praevia

• Unprotected fetal vessels traverse the membranes below the presenting part over the internal cervical os

Aetiology

• Placental anomalies such as a bilobed placenta or succentuiate lobes (the fetal vessels run through the membranes, joining the separate lobes together)

• History of low-lying placenta in the second trimester

• Multiple pregnancy

• IVF

Pathophysiology

• Type I: vessel connected to a velamentous umbilical cord

• Type II: vessel connects the placenta with a succenturiate or accessory lobe

Clinical presentation

• Will rupture during labour or at amniotomy - sudden dark red bleeding

• Fetal bradycardia/death

Investigations

• Ultrasound TA and TV with Doppler

Management

• Antenatal diagnosis
• Steroids from 32 weeks
• Consider inpatient management if risks of preterm birth (32-34 weeks)
• Deliver by elective c/section before labour (34-36 weeks)

• In the presence of bleeding vasa praevia (APH), delivery should be achieved by emergency caesarean section

• Placenta for histology

Other causes

• Cervical - ectropion, polyp, carcinoma

• Vaginal causes

• Unexplained (1/3)