Antepartum Haemorrhage(APH)

Bleeding from or in to the genital tract(vagina) , occuring from 24 weeks of pregnancy and prior to the birth of the baby.

Incidence: APH complicates 3-5% of pregnancies

Leading cause of perinatal and maternal morbidity and mortality.

1/5 of the very preterm baby are born assoc. with APH.

DEFINITION:

CAUSES:

• Placental abruption• Placental praevia• Vasa praevia

Placental

• Cervicitis• Cervical ectropian• Cervical carcinoma• Vaginal trauma• Vaginal infection

Local

When a pregnant mother at 24 weeks and above presented with vaginal bleeding, it is important….

Amount of bleeding/ number of pad / is it soak..?

What triggers it? For example: sexual intercouse, strenuous/heavy activity..

ASSOCIATED symptoms: Abdominal/pelvic pain or contractions?

How is the fetal movement?Last cervical smear (date/normal or

abnormal)?

HISTORY TAKING

Pulse, blood pressureAbdominal palpation: -Uterus is soft/tender/firm/irritable/signs of acute

abdomen. -Tense or ‘woody’ feel : Indicates a significant

abruption.Speculum examination: - to identify cervical dilatation or visualize a lower

genital tract cause for APH.Digital examination: - If placenta praevia is a possible diagnosis, digital

examination should not be performed. - Provide information of cervical dilatation if APH is

associated with pain or uterine activity.

PHYSICAL EXAMINATION

Maternal investigations (depending on the amount of bleeding)

Blood test:

- Full blood count, coagulation screen, crossmatch 6 units of blood(massive)

Ultrasound scan

- Fetal size, presentation, amniotic fluid, placental position,morphology.

Fetal investigations Cardiotocograph

INVESTIGATION

Placental causes of APH is a major concern!Patient , initially resuscitated using the structured

approach of ABC.IV lineBlood testsMajor fetal/maternal compromise: immediate delivery

irrespective week of gestation(steroid should adminitered if gestation less than 34 weeks)

Rhesus status; Kleihauer test for Rhesus negative’s mother (to determine whether or/and how much is the leaking of fetal blood into maternal circulation, if yes administer anti-D)

MANAGEMENT OF ACUTE CASES

Green-top Guidelines No.63. 1st ed. Antepartum Haemorrhage pdf. Royal College of Obstetricians and Gynaecologists. November 2011.

Ten Teachers. Antenatal obstetrics complications pg 102-104. Obstetrics. 19th Ed. CRC Press,2011.

 

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