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ANTEPARTUM HAEMORRHAGE

TEAM E11 – 08 – 06

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DEFINITION

Bleeding per vaginam after the period of viability(28 weeks) of pregnancy and before labour (delivery of the baby).

The incidence of APH in KBTH is 1.2-1.8% of total births and it accounts for about 8% of all caesarian sections in KBTH

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AETIOLOGYBleeding from placenta site

Placenta praevia Placenta abruption

Bleeding from local causes in the genital tract Cervical polyps Friable condyloma acuminata Cervicitis Cervical carcinoma Florid vaginal candidiasis Vulva varicosities

Vasa praeviaUterine ruptureUnknown causes.

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Placenta Praevia

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Placenta Praevia

Definition Placenta that is wholly or

partially located in the lower uterine segment.

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RISK FACTORS

* Increased surface area of the placenta

+Multiple pregnancy

+Succenturiate lobe

+Membranacea

+Extrachorialis

Maternal age >35

Parity

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Risk FactorsPrevious uterine surgery

-Caesarian section

-Induced abortion

-Metroplasty

-Myomectomy

-Cigarette smoking

Firmly attached placenta

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A zygote that implants low in the uterus is likely to form a placenta that lies with close proximity to the cervix

The placenta so located may

Be aborted

Migrate upward to the upper segment (placental migration)

May fail to migrate upward. With failure of the placenta to migrate, the placenta remains in the lower uterine segment and over the internal os

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The etiology of PP is unknown.

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 labour.

Bleeding then ensues as the thinned lower uterine segment is unable to contract adequately to prevent blood flow from the open vessels.

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GradingType 1: placenta is partially located in the lower segment and the lower edge of the placenta does not reach the internal os (lateral placenta praevia)Type 2: placenta is partially located in the lower segment and the lower edge of the placenta reaches the internal os but not cross it.(marginal placenta praevia)Type 3: placenta covers the internal os completely when the cervix is closed, but covers the internal os partially when the cervix is fully dilated (partial placenta praevia)Type 4: placenta completely covers the closed internal os and even at full dilatation covers it completely (central placenta praevia)

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Subgroups

- A : anteriorly situated placenta

- B : posteriorly situated placenta

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Complications Maternal

PPHPostpartum sepsis

FoetalPrematurityIUGRCongenital malformationOther risks

-Cord prolapse -malpresentation -foetal anaemia -unexpected IUFD from severe maternal

hypovolaemia

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Clinical presentationUsually presents in the 3rd Trimester

Symptoms:

painless spontaneous recurrent vaginal bleeding.

First episode is usually not heavy (warning hemorrhage).

The blood is fresh and clots readily.

Symptoms of anaemia depending on the amount of blood loss

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Examination - Soft abdomen- Abnormal lie- Malpresentation- High presenting part at term- Fetal heart usually unaffected

SPECULUM EXAM- If local lesion suspected

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Diagnosis A good history

Examination: a VE is absolutely contraindicated as it could lead to torrential bleeding

Investigations for placenta localisation 1. Ultrasound2. MRI3. CT scan4. Placenta arteriorgraphy5. Reduced placentography6. Radioisotope Tc 99

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Management of Placenta PraeviaThis depends on the severity of the bleeding and the gestational age of the pregnancy.

However in all cases of praevia you admit the patient .

Clinically assess the patient

Resuscitate depending on the severityVAGINAL EXAMINATION IS CONTRAINDICATED

Do a sterile speculum examination

Ultrasound examination when the patient is stable.

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Expectant Management

The main aim is to achieve maximum foetal maturity if possible

- Patient is admitted

- Clean white pad that does not form gel is inspected every morning

- At least 2 units of blood should be cross matched and kept on the ward.

- When patient is to visit the lavatory, she should inform the medical staff or colleague patient

- At 37 completed weeks, repeat Ultra Sound to assess foetal wellbeing in preparation for delivery

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Put mother on fetal kick countPalpate for fetal partsCheck the FH twice dailyUltrasound for placental localization at 34wksIf there is severe bleeding, that will jeopardize the health of the mother, then immediate delivery, irrespective of GA must be carried outAlso, if the patient is at 34wks and comes in with severe bleeding, delivery should be carried out

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DeliveryStage 1 & 2a – vaginal delivery if no contraindications.

Stages 2b, 3 and 4 – Caesarian section is indicated

C/S is also in the ff- Any patient with repeated bleeding- Severe bleeding- Presentation other than vertex- Other obstetric indications such as contracted

pelvis.

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Vaginal DeliveryThe Double Set-up Approach

Preparation

-Two units of cross-matched blood in theatre

-Patient starved over night

-Two trolleys set, on for EUA and the other for CS

Procedure

-Two obstetricians, one to do EUA the other scrubbed for a CS if need be.

-If EUA provokes heavy bleeding a CS is performed.

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Abruptio placentae

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Abruptio Plancentae

Premature separation of a normally situated placenta before the delivery of the foetus

Incidence-1.1% in KBTH and 95% results in perinatal deaths

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Aetiology

Primarily unknown

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Predisposing FactorsMaternal hypertensionChronic hypertensionPIHTrauma to the abdomenPolyhydramniosPROMAnticoagulant therapyAdvanced parityLow socio-economic statusSmokingObstetric procedures e.g.. External cephalic version, amniocentesis, amniotomy in polyhydramniosIncreasing Maternal age

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Mechanism

Follows spontaneous rupture of blood vessels at placenta bed with haematoma formation.

Couvelaire uterus- blood dissect into the myometrium

Deranged metabolic exchange- foetal hypoxia and probable death

Release of tissue thromboplastin-DIC-consumptive coagulopathy- bleeding disorder

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Clinical presentationRevealed

Concealed

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SYMPTOMS

+ Bleeding pv

+ Abdominal pain

+ Onset of premature labour

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Signs- Distressed patient- Hypovolaemic shock- ABDOMEN

- Tender

- Woody hard

- Fetal parts difficult to palpate

- Fetal Heart tone Slow/Absent

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Diagnosis

Made by clinical judgement

USG may help (retro-placental haematoma)

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Grading

1. Not recognised before delivery

2. Classical signs, Foetus alive

3. A. Foetus dead

No Coagulopathy

B. Foetus dead

Coagulopathy present

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DifferentialsThis must considered in terms of causes of vaginal

bleeding and causes of abdominal pain.1. Abdominal pains

Acute appendicitisPyelonephritisTwisted ovarian cystRed degenerating uterine fibroidRetroperitoneal haemorrhageRectus sheath haematomaChorioamnionitisLumbar or sacral strainRuptured uterus

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2 Vaginal bleeding

Placenta praevia

Vasa praevia

Local genital lesions

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ComplicationsMaternal

Life threatening maternal haemorrhage and shockDICIncreased risk of PPHAcute tubular necrosis of kidneysUraemiaMaternal death

FoetalHypoxia (asphyxia)AnaemiaIUGR associated with expectant managementFoetal death

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General ManagementAdmit the patientSet up an IV line with a wide bore cannulaTake blood for:

FBC and sicklingGXM (about 2-4 units of blood;2-4 units FFP)Coagulation profile (including platelet count) Clot observation testBUE and CrLFTRh status

Apt test on vaginal bleed (if possible)IVF (crystalloids and colloids) while waiting for bloodPass catheter to measure urine output

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Specific Measures

Expectant management

Immediate delivery

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Expectant management This may be done for mild cases in which the foetus is

immature. Such cases may develop mild localised tenderness over the uterus. USG identifies a small retro placental clot.Admit patient Pain reliefContinuous electronic FHR monitoring (if available)Repeat USG for first few hours to monitor the rate of progression of retro placental clot.Mature foetal lung with corticosteroidsMonitor foetus subsequently by

daily foetal kick count2x weekly CTG2x weekly USG

If abruption progresses deliver as soon as possibleIf abruption does not progress continue expectant management till 37 completed weeks and deliver.

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Immediate DeliveryIUFD

Resuscitate mother Induce labour (if no contraindications present)Aim at vaginal deliveryCS may be necessary when there is uncontrollable maternal bleeding

Live foetusImmediate delivery by CS( foetal distress)Vaginal delivery may be acceptable when patient presents in labour and rapid delivery is anticipated

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Prognosis

Foetal outcome is very poor

-hypoxia

-prematurity

Maternal death is very high but depends on availability of blood ;hard working house officers and residents; time of presentation.

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VASA PRAEVIAThis is bleeding from foetal vessels. It often results from velamentamous insertion of the umbilical cord.The cord inserts at a distance from the placenta and it is not protected by Wharton’s jelly.The umbilical cord vessels traverse between the chorion and amnion without protection and might cross the os.Bleeding from foetal vessels is usually associated with abnormal foetal heart pattern and delivery should be rapid by emergency CS.Incidence is approx 1 per 5000 singleton deliveryFoetal mortality is very high ;about 75 – 100% of cases of rupture these vessels. The apt test is used in diagnosis of vasa praevia by mixing suspected bloody vaginal fluid with water and centrifuging. The supernatant is mixed with 1.0% NaOH. A pink colour after another centrifuge indicates the presence of foetal blood

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