Neoh Hui Pheng Batch 22/A2

ANTEPARTUM HAEMORRHAGE

reference

RCOG GuidelinesObstetrics today

DefinitionAntepartum 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.

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 APHMost of the time unpredictable.

RCOG

SeverityNO consistent definitions of the severity of APH. It is recognised that the amount of blood lost is

often underestimated .

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

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

Different terminologies used:Spotting – staining, streaking or blood spotting

noted on underwear or sanitary protection

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

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

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

Recurrent APH - > one episodeRCOG Guidelines

EtiologyPlacenta praeviaAbruptio placentaVasa praevia Excessive show Local causes ( bleeding from cervix, vagina

and vulva )

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.

Leading cause of vaginal bleeding in the 2nd and 3rd 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 conceptionRCOG

Clinical classificationMinor :

Type 1 (anterior/posterior) Type 2 anterior

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

Deliver vaginallyType 1 Posterior > likelihood of fetal distress

Caesarean sectionType 2 posterior > chance of fetal distressType 3 & 4 anterior –cut through placenta to deliver. Hence need to be fast and efficient.

Abruptio Placenta (AP)Separation of normally located placenta

after 22 weeks of gestation ( > 500g) and prior to delivery of fetus.

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 1st twins) - Retroplacental fibroids- Idiopathic

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%)

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

Obstetrics today

Vasa Praevia (VP)Rupture of fetal vessels that run in

membrane below fetal presenting part which is unsupported by placenta/ umbilical cord.

Predisposing Factors:-Velamentous insertion of the umbilical cord-Accesory placental lobes-Multiple gestations

Obstetrics today

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 VPAntenatal diagnosis –reduced perinatal

mortality and morbidity. Painless vaginal bleeding at the time of

spontaneous rupture of membrane or post amniotomy

Fetal bradycardiaFetal 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

Complications of APHMaternal complications Fetal complications

Anaemia Fetal hypoxia

Infection Small for gestational age and fetal growth restriction

Maternal shock Prematurity (iatrogenic and spontaneous)

Renal tubular necrosis Fetal death

Consumptive coagulopathy

Postpartum haemorrhage

Prolonged hospital stay

Psychological sequelae

Complications of blood transfusion

RCOG Guidelines

Clinical assessment in APHFirst and foremost Mother and fetal well

being (mother is the priority)

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

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

Assess fetal wellbeing.

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.

ExaminationSpeculum : -identify cervical dilatation or visualise a

lower genital tract cause.

Digital vaginal examination - Should NOT be done until Placenta Praevia

has been excluded by USG.

RCOG Guidelines

InvestigationsFBC Coagulation profileBlood 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

ManagementWHEN 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.

- 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.

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

ManagementFor 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.

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 PlacentaDecide 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.

Obstetrics today

ManagementFor 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.

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