Antepartum Haemorrhage

(APH)

MCQs

1. Placenta Accreta

A. The optimum management is Caesarean hysterectony

B. Is commonly associated with placenta praevia

C. Is associated with placenta praevia in over 50% of cases

D. Methotrexate can be given in selected cases

2. Antepartum haemorrhage (APH)

A. Is defined as bleeding from the genital tract after 24 weeks’ gestation.

B. If associated with labour – like pains, a vaginal examination is advisable.

C. In cases of placental abruption, there is coincident placenta praevia in 1% of patients

3. Placental abruption

A. Is defined as the premature separation of an abnormally sited placenta

B. 70-80% result in vaginal bleedingC. The bleeding is typically bright red and

clottingD. In 50% of cases the bleeding occurs

after 36 weeks’ gestation E. Blood loss is invariable of maternal

originF. Tends to recur in subsequent

pregnancies

4. Placenta Praevia

A. Nulliparity is a risk factorB. Complicates approximately 1 in 400

pregnancies.C. Is associated with intra-uterine growth

restriction D. Fetal growth restriction is more

commonly encountered in association with placenta praevia than with normally sited placentas

E. Transvaginal ultrasound is the diagnostic technique of choice.

5. The following statements are true about placenta praevia

A. Transabdominal ultrasound (TAS) has a false-positive rate of 20% for the diagnosis of placenta praevia

B. An overdistended maternal bladder makes the diagnosis easier by TAS

C. TH diagnostic accuracy of transvaginal ultrasound (TVS) is greater than abdominal ultrasound

D. The diagnostic accuracy of 93-97%E. Only 5% of patients diagnosed as having a

low-lying placenta in the second trimester continue to have placenta praevia at delivery.

6. Placenta PraeviaA. Complicates approximately 1:400

pregnanciesB. IS associated with a maternal mortality

rate of 0.3% in the UKC. Transvaginal ultrasound is the

diagnostic technique of choice.D. If the placenta edge is less than 3cm

from the internal cervical os, a caesarean section should be performed.

E. There is significant association between placenta praevia and placenta accreta

A. The risk of recurrence is 8.3-16.7%.B. The commonest reason is blunt trauma

to the abdomen. C. Causes are usually obvious clinicallyD. Many patients with placental abruption

are hypertensive at presentation.E. Nearly 50% of patients are in

established labour.F. Approximately 10% of patients are in

established labour.

7. Placental Abruption

Answers

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Epidemiology

• Late pregnancy or third trimester bleeding

• Complicates 4% of pregnancies

APH - Causes Major causes

• Placenta Previa (20%)• Placental Abruption (30%)• Ruptured Vasa Previa - Fetal blood vessels

across presenting membranes• Uterine Scar Disruption

Other• Cervicitis or other genital tract infection• Bloody show (may indicate Preterm Labor)• Cervical polyp• Cervical Cancer• Cervical Ectropion• Vaginal trauma

HistoryBleeding characteristics

• Amount (pads/day), Colour of blood (dark or bright red)

Associated factors• Pelvic, abdominal pain or back pain • Contractions

Inciting factors• Recent examination• Abdominal or pelvic Trauma • Intercourse

Fetal movementPrevious ultrasounds

Examination Vital signs

• Blood Pressure and pulse• Often normal despite significant bleeding

Abdominal Exam• Pain on palpation• Palpable contractions• Hypertonic uterus

Pelvic examination (if no Placenta Previa)

• Bimanual exam if placental location known

Laboratory Investigations

Haemoglobin Type and cross 2 to 6 units RCC Type and cross platelets Coagulation studies

• Prothrombin Time (PT) • Partial Thromboplastin Time (PTT)

Investigations

• Ultrasound• Transabdominal• Transvaginal Ultrasound

• Placental location• Placental Abruption

Management Depends upon

• Stage of Pregnancy and fetal viability

• Amount of Bleeding

Conservative• Hospitalization• Bed rest• Avoid vaginal examination• Correct anaemia• Blood cross match• Serial scans for fetal growth• Discharge if all well for follow up

Management: Emergency Indications

• Brisk Vaginal Bleeding • Unstable vital signs • Fetal Distress

Immediate interventions • Oxygen • Trendelenburg position (raise foot end)• Obtain immediate Intravenous Access

• Two large bore IV (16-18 gauge) • Initiate Isotonic crystalloid bolus

• Normal saline • Ringer Lactate

• Type, cross and transfuse RCC, FFPs, platelets as needed

• Record Vital signs, intake output • Call for immediate Obstetric and neonatal support for

delivery

Complications of Abruption

• Coagulation failure• Renal failure• IUD

Placenta Previa

Definition

Placenta previa is a condition in which the placenta is attached in lower uterine segment close to or covering the cervix

PathophysiologyPlacenta usually implants at fundus

Fundal blood supply is better than lower uterus

Risk factors Previous C Section, myomectomy Associated with placenta accreta High parity Multiple Gestation – large placenta Previous uterine instrumentation – D&C, E&CPast history of placenta previa

Pathophysiology

Associated Conditions• Abnormal presentation (placenta raises

presenting part)• Oblique Lie• Transverse Lie

• Placental Abruption• Intrauterine Growth Retardation (IUGR)• Placenta accreta (especially prior C

section)• Postpartum Haemorrhage

TypesType I: low implantation

• Lower margin dips into lower uterine segment• Does not reach internal os

Type II: marginal placentaReaches but does not cover internal os,

Type III: partial previa• Covers internal os when closed• Does not cover os when fully dilated

Type IV: complete previa (central previa)• Covers internal os even when fully

dilated

Types

Clinical presentation • Sudden Painless, profuse uterine

bleeding 27-32 weeks• May be mild (warning haemorrhage) • May be provoked with intercourse,

contractions • Abdomen soft and non-tender – less

placental separation• Fetal malpresentation• IUGR• Fetal heart present

Diagnosis

• Obstetric Ultrasound• EUA if ultrasound not

available, active bleeding, borderline case

• MRI

Counselling

• Risk of severe life-threatening hemorrhage • Risk of fetal death • Risk of maternal death

• Blood transfusion may be necessary

• Hysterectomy may be needed to control bleeding

Management

•Hospitalisation •Avoid digital cervical exam mild/No bleedning•Gentle speculum exam is permitted •Delay delivery until lung maturity

•Caesarean section at tertiary care centre• Indications

•Severe haemorrhage despite fetal immaturity•Major degrees of placenta previa

Management

Spontaneous Vaginal Delivery: Indications • Spontaneous vaginal delivery in type I & II

(anterior) or type I (posterior)• Head engaged: Can tamponade marginal previa• No brisk bleeding on exam• Close fetal and maternal monitoring• EUA in OT with full preparation of emergency

Caesarean section Bleeding management

• Syntocinon• Prostaglandin• Hot packs• Internal iliac ligation• Obstetric hysterectomy

COMPLICATIONS

• Maternal• Anaemia• Hemorrhage and shock• cesarean hysterectomy• death

• Fetal• Prematurity• intrauterine growth retardation• perinatal death

Thank you