ANTEPARTUM HAEMORRHAGE

(APH)FAHAD ZAKWAN

INTRODUCTION

Antepartum haemorrhage (APH), also called prepartum hemorrhage,

is bleeding from the genital tract during pregnancy from 28 weeks

gestational age to term

CLASSIFICATION

(A) Placental site bleeding : (62%)

•Placenta praevia (22%): Bleeding from separation of a placenta wholly or partially implanted in the lower uterine segment.

•Abruptio placentae (30%): Premature separation of a normally implanted placenta.

•Marginal separation (10%): Bleeding from the edge of a normally implanted placenta.

(B) Non-placental site bleeding : (28%)

•Vasa praevia : Bleeding from ruptured foetal vessels.

•Rupture uterus: 3-Bloody show.

•Cervical ectopy , polyp or cancer.

•Vaginal varicosity.

It should be considered as an obstetric emergency (regardless of whether there

is pain or not) and medical attention should be sought immediately, because if it is left untreated it can lead to death

of the mother and/or featus.

NOTE

Avoid doing vaginal examination in patients with antepartum haemorrhage until placenta praevia has been excluded

either clinically or by USS

EPIDEMIOLOGY

•It Affects 3-5% of all pregnancies.

•It is 3 times more common in multiparous than primiparous

women

DIFFERENTIAL DIAGNOSIS OF APH

•Bloody show - most common benign cause of APH

•Uterine rupture

•Bleeding from the lower genital tract •Cervical bleeding - cervicitis, cervical neoplasm,

cervical polyp•Bleeding from the vagina itself - trauma, neoplasm

PLACENTA PRAEVIA

•Abnormally implanted placenta in the lower segment of the uterus

•Although almost all the blood loss from placental site is maternal, some fetal loss is possible particularly if the substance of the placenta is traumatized.

•Bleeding from the vasa praevia is the only cause of pure fetal haemorrhage.

•Bleeding is thought to occur in association with the development of the lower uterine segment in the third trimester.

•Placental attachment is disrupted as this area gradually thins in preparation for the onset of labor.

•When this occurs, bleeding occurs at the implantation site as the uterus is unable to contract adequately and stop the flow of blood from the open vessels.

RISK FACTORS

•Previous placenta praevia

•Multiple pregnancies

•Multiparity

•Previous c/s scar

•Advanced age

•History of threatened abortion in index pregnancy

•Deficient endometrium due to pre-existent •Uterine scar (previous CS) •Endometritis •Manual removal of placenta •Curettage (especially for miscarriage or termination of pregnancy) •Submucous fibroid

Typically:

•First episode of bleeding occurs: •After 36th week: in 60% of cases •32-36th week: in 30% of cases•Before 32nd week: in 10% of cases

CLINICAL PRESENTATIONPainless vaginal bleeding, usually bright red, but variable amount.

Soft non tender uterus.

Fetal malpresentation

unusually high and mobile presenting part

Fetal kicks are usually present.

Normal foetal heart tones – foetal distress if blood loss is severe

ABDOMINAL EXAMINATION

Uterus is soft and non-tender

The presenting part is usually high

Fetal malpresentation may be found.

Fetal heart heard

No contraction.

Vaginal examination should be avoided, if done should, be in theatre under GA with

preparation for emergency c/s in case profuse bleeding occurs. Explore the fornices

first then the head. Passing the finger through the cx should be avoided.

GRADING PLACENTA PRAEVIA

Placenta praevia is classified according to the placement of

the placenta:

GRADE 1 – low lying

•Placenta encroaches lower segment but does not reach the cervical os.

GRADE 2 - marginal

•Placenta reaches

cervical os but does not

cover it

GRADE 3 - partial

•Placenta covers part of the cervical os.•The placenta

covers the internal os when it is closed or partially dilated but not when it is fully dilated

GRADE 4 - total

•Placenta completely covers the os, even when the cervix is dilated.

• The placenta covers the internal os completely whether the cervix is partially or fully dilated.

LOCALIZATION OF THE PLACENTA

Ultrasound

i. Transabdominal

ii. Transvaginal.

iii. Transperineal done if instrumentation of the vagina is likely to cause problems.

The transvaginal US is the most accurate route to locate the

placenta but the probe should not touch the cx or the placental

placental site.

Management

•Depends on

-Gestation age

-Severity of bleeding

-Viability of fetus.

IMMEDIATE MEASURES

Call for help!!! Involve the senior staff on call

put in 2 large bore (14 gauge) IV cannulas.

Keep patient flat and worm.

Send blood for group, cross matching diagnostic tests and ask for at least 2 units of blood

Infuse rapidly 2 litres of normal saline (crystalloids) to re-expand the vascular bed.

Give oxygen by mask 10 – 15L/min

Insert Foley catheter to empty the bladder and monitor urine output.

Monitor the following:pulse

BP

RR

urine output (continuous cathetarization)

type and amount of fluid the patient received

The management includes

•Restore blood volume by giving IV fluids – normal saline or ringers lactate

•Assess blood loss:• If bleeding is heavy or continuous, arrange or do

caesarean section delivery irrespective of foetal maturity within 6 – 8 hrs.

• If bleeding is light and stopped and the foetus alive and premature consider expectant management until 37/38 wks.

•Keep the woman in hospital for bed rest until delivery

•Correct anaemia •Give iron/ folic acid, vit. B12•Blood transfusion•Packed cells•Whole blood

NOTE•Decide management after weighing benefits and risks

to the woman and fetus.

•PRIORITY IS SAVING THE MOTHER!!

•ALL GRADES OF PLACENTA PRAEVIA ARE DELIVERED BY C/S EXCEPT GRADE IA WHERE THE PLACENTA JUST DIPS IN THE LOWER SEGMENT AND ITS ANTERIORLY

LOCATED

Bloods Tests• Complete blood picture and D-Dimer

• Group and cross match 4 units

• Consider need for Anti-D if Rh negative.

Ultrasound • Confirm diagnosis.

Corticosteroids• Consider corticosteroid prophylaxis if < 34 weeks

ABRUPTIO PLACENTA

•Refers to bleeding due to the premature separation of a normally sited placenta from its

attachment to the uterus.

May be described as •Concealed ( if no external bleeding is seen)•Revealed (if there is obvious external bleeding)

RISK FACTORS• Hypertension

• Maternal thrombophilias

• Increasing maternal age, parity

• Cigarette smoking

• Abdominal trauma e.g. motor vehicle accident

• Substance abuse (crack, cocaine, amphetamines)

• Sudden decrease in uterine volume (e.g. SROM in the presence of polyhydramnios, or after delivery of a first twin)

• External cephalic version (ECV) or instrumental delivery.

CLASSIFICATION

•Classification of placental abruption is based on: • extent of separation (ie, partial vs complete) and • location of separation (ie, marginal vs central).

Clinical characteristics include the following:

Class 0 is asymptomatic.

Diagnosis is made retrospectively by finding an

organized blood clot or a depressed area on a delivered

placenta.

Class 1 is mild

• represents approximately 48% of all cases.

•Characteristics include the following: • No vaginal bleeding to mild vaginal bleeding • Slightly tender uterus • Normal maternal BP and heart rate • No coagulopathy • No fetal distress

Class 2 is moderate

• represents approximately 27% of all cases.

• Characteristics include the following: • No vaginal bleeding to moderate vaginal bleeding • Moderate-to-severe uterine tenderness with possible

tetanic contractions • Maternal tachycardia with orthostatic changes in BP and

heart rate • Fetal distress • Hypofibrinogenaemia (i.e. 50-250 mg/dL)

Class 3 is severe•represents approximately 24% of all cases. Characteristics include the following: •No vaginal bleeding to heavy vaginal bleeding •Very painful tetanic uterus •Maternal shock •Hypofibrinogenemia (ie, <150 mg/dL) •Coagulopathy • Fetal death

Clinical features• Vaginal bleeding is usually associated with abdominal pain,

uterine contractions, tenderness and / or irritability

• May be faint and / or collapse

• Signs of haemorrhagic shock

• Consider concealed abruption if abdominal or back pain is present

• Fetal moments are usually absent unless it is an early abruption or partial

•Contractions/uterine tenderness•Uterine contractions are a common finding with placental abruption.•Contractions progress as the abruption expands, and uterine hypertonus may be noted.•Contractions are painful and palpable.

Principles of early management

• Intravenous (IV) access (2 large bore iv lines must be put in place)

• Indwelling catheter

• Start intensive care list (fluid balance, blood pressure, pulse rate etc)

• The cornerstone of appropriate management is adequate resuscitation with intravenous fluids (plasma volume expanders, blood)

• Consider need for early delivery dependent on maternal and fetal condition

• Achieving adequate perfusion is essential to allow the reticulo-endothelial system (Kupfer cells, spleen) to clear fibrinogen / fibrin degradation products (FDPs). Acceptable perfusion is signalled by urine output of > 30 mL per hour

• Cross match blood

• Urgent complete blood picture, D-dimer, thrombin time, fibrinogen levels, creatinine

• Bed side clotting time (NORMAL – 7mins)

• Consider giving FFP if there is prolonged bed side clotting time or abnormal bleeding indices.

Later on

•Monitor in-put and output

•Monitor maternal vital signs.

•Continuous CTG to assess for signs of fetal compromise if the fetus was alive at the time of diagnosis.

•Anti D prophylaxis for Rh negative women

Active management:

• Consultation with anaesthetist as indicated

• Consider central venous pressure monitoring

• Ensure adequate blood, blood products (6-8 packed cells to start with in case of total abruption), and fresh frozen plasma (FFP) guided by fibrinogen levels and mostly also 1 FFP unit required for each 4-6 units of blood transfused. Specific replacement of coagulation factors is very rarely required - only in consultation with laboratory / haematologist

• If fetal death is confirmed

• Aim for vaginal delivery with ARM and Syntocinon® if condition allow.

Delivery

• Consider vaginal delivery with continuous electronic fetal monitoring if fetus is alive and rapid recourse to caesarean section depending on fetal/maternal condition.

• Caesarean section if acute fetal compromise occurs (if it was alive at diagnosis) or if other obstetric indications dictate so.

Following delivery:

• Recognize increased risk of PPH

After delivery do placental examination for:

• Completeness

• Any area of abruption

• Associated pathological features e.g. abnormal degree of calcification

• Send for histopathology