June 26, 2013

Antepartum Haemorrhage: An Overview

T. Titus MFM Fellow

June 26, 2013

� To understand the major and minor causes of APH

� To identify risk factors for major causes of APH

� To understand the complications and management options for patients

� Review of the management for emergency cases

� Bleeding w/c occurs after the 20wks GA but prior to the onset of labour

� Exact Incidence unknown (unrecognised; unreported)

� Incidence ~ 3-5%

� Maternal –placental

� Fetal

� Majority cases = minor

� Major = clinically significant

� Consequences – mother, fetus or both

� Placenta Previa

� Placental Abruption

� Vasa Praevia

� Marginal

� Cervicitis

� Trauma (ex. MVA)

� Vulvovaginalvaricosities

� Genital Tract Tumours

� Haematuria

� Other (ex. Intercourse)

June 26, 2013

Antepartum Haemorrhage: An Overview

� SOGC – placenta implanted in the lower segment of the uterus, presenting ahead of leading pole of the fetus

� Occurrence: 2.8/1000 singleton; 3.9/1000 twin

� Maternal Age: <20 y.o. and >35 y.o.

� Parity

� Previous Caesarean section (C/S)

� Previous uterine surgery (sx): D&C

� Smoking

� Cocaine

� Previous placenta praevia

� U/S: Transvaginal (TV) more accurate c.f. Transabdominal (TA)

� When placenta lies b/w 0 and 20mm from internal cervical os

� If U/S done b/w 18 – 24 wks, repeat in 3rd

TM

� Overlap of (> 0mm) after 35 wks GA indicates C/S as route of delivery.

� Bleeding – Usually “painless” (classic)

� PTD & PTB

� � risk of abruption

� Blood transfusion (10 fold �)

� PeripartumHysterectomy (33 fold �)

� �PPH (uterine atony)

� �Adherent placenta (accreta, increta or percreta)

� Fetal malpresentation

� Allow progress close to term as possible

� Inpt vs. Outpt (controversial) – outcomes are same

June 26, 2013

Antepartum Haemorrhage: An Overview

� Premature separation of the placenta before birth, after 20 wks GA.

� 1% pregnancies affected

� Degree of abruption varies- minor to major (fetal death, maternal morbidity)

� If placentas examined routinely –

� evidence of abruption found ~4%

� Many unrecognised

� Concealed (10%) vs. Revealed

� Classically –Painful, pale, tender “woody hard”uterus +/- contractions

� FHR absent in severe cases +/- coagulopathy

� Most often dx based on history & exam

� U/S poor for dx (50% cases no findings)

� CTG important – contractions may not be appreciated clinically (ex. MVA)

� Previous abruption: ◦ 10% recurrence risk◦ if 2 previous episodes =25% recurrence risk

� Smoking- dose response relationship; if quit before pregnancy still � risk

� Hypertension & Hypertensive disorders of pregnancy (pre-eclampsia)

� Cocaine

� Trauma ex. MVA

� PPROM

� ECV

� Multiple gestation

June 26, 2013

Antepartum Haemorrhage: An Overview

� 10% of PTB

� � rates of perinatal asphyxia, IVH, CP

� Assocn with IUGR

� Fetal death

� Coagulation ex. DIC

� Haemorrhagic shock

� PPH

� Clinical situation – degree of bleeding, GA, Fetal status

� If maternal/ fetal compromise & fetal viability = delivery

� C/S unless labour well advanced

� If fetus dead = vaginal delivery preferred

� Asymptomatic, no maternal/fetal compromise = conservative mx (20-34 wks GA)

� Defn:

� Fetal vessels coursing via membranes over internal cxcal os

� Below fetal presenting part

� Unprotected by placental tissue /umbilical cord

� Incidence:

� Varies b/w 1 in 2000 to 1 in 6000 pregnancies (1)

� May be under reported

23

Placenta praevia, placenta praeviaaccreta & vasa praevia: diagnosis &

management (Green top 27) January 2011

� Placenta with a succenturaiate lobe

� Multiple pregnancies

� IVF

June 26, 2013

Antepartum Haemorrhage: An Overview

� Often dx first made by

� Vessels felt during vaginal exam

� Presentation –unanticipated bleeding at amniotomy

� Fetal vs. maternal origin

� If bleeding due to fetus – CTG changes :

� Tachy� decels �brady

� Immediate C/S

� Admit b/w 28 to 32 wks GA

� Steroids b/c � risk PTB

� Planned C/S b/w 34-37 wks GA

� Multidisciplinary approach (haem)

� ABC’s of resuscitation

� 2 large bore IV (12 or 14G)

� IV Fluids -2L;

� GXM O neg

� CBC, U&E, T&S, PT/PTT

� Urinary catheter

� Anaesthesia