Antepartum haemorrhage
Def: vaginal bleeding after 20 weeks of gestation and before delivery of the baby.
Causes @ DDx
1) Placenta Previa
a. Def: implantation of the placenta in the lower segment of the uterus.
b. Incidence: 1/200
c. RFx:
i. PHx of CS (risk varies from 1-4% on subsequent pregnancy, risk is > 10% if more
than 4 pregnancies)
ii. IVF
iii. multiparity
iv. age > 35
v. smoking
vi. drugs
d. Types:
i. Type I (marginal)
1. Encroaches on lower segment but doesn’t reach the internal os (2.5cm
from the os).
ii. Type II (minor)
1. Reaches the internal os but doesn’t cover it.
iii. Type III (major)
1. Partially covers the internal os.
iv. Type IV (major)
1. Completely covers the internal os.
e. Clinical presentation:
i. Painless vaginal bleeding that stops spontaneously but may recur.
ii. Associated with uterine contraction or irritability.
f. Pathophys
i. Thinning of the lower part of the uterus
ii. Disrupt placental attachment
g. Ix:
i. U/S – if unstable use transabdominal, if stable can use transabdominal ,
transvaginal or transperineal.
ii. FBE, coags, cross-match 6 units of blood.
iii. MUST NOT PERFORMED VE UNTIL PP HAS BEEN EXCLUDED BY U/S
h. Mx:
i. Depend on the severity:
1. If M & F unstable
a. Emergency resuscitation and CS
2. M stable, < 37 weeks
a. Conservative medicine, blood transfusion
3. If premature delivery required (< 34 weeks)
a. Corticosteroid (?)
4. If bleeding stops
a. Observation In hospital at least 48 hrs (60% chance to recur)
2) Placental Abruption
a. Def: uterine bleeding following premature separation of the placenta from the uterus,
total or partial.
b. Incidence: 0.5 – 2.0%, 20% perinatal mortality
c. RFx:
i. Advanced maternal age
ii. Multiparity
iii. Multipregnancy
iv. Smoking
v. Drugs (anti coags)
vi. Maternal HT
vii. PPROM
viii. Chorioamnionitis
ix. Abdominal trauma
x. Maternal thrombophilia
xi. PHx of PA
xii. IUGR, polyhydramnios
xiii. Low SES
d. Clinical presentation
i. Sx:
1. Abdominal pain (tender tense uterus)
2. Vaginal bleeding (dark, non-clotting)
3. Uterine contraction
4. Usually close to term
5. Nausea, faintness and restlessness
Minor
Mild VB
With or w/o contraction
normal Fetal HR
Major
Sever VB
Bleeding from venupuncture sites
Bruising (DIC)
ii. Sg:
1.
2.
3.
iii. Types:
1.
Tachycardia, hypotension, signs of peripheral vasoconstriction
‘woody hard’ uterus on palpation, maybe larger than gestation suggests
Difficult to palpate fetus
Revealed haemorrhage
a. VB, pain not significant
2. Concealed haemorrhage
a. Slight bleeding, tense uterus, ?pain (due to retroplacental clot)
3. Mixed haemorrhage
a. Some VB, some passage of clots, build up of clots behind
placenta
4. Large haemorrhage
a. Bruised uterus (blood forced into muscle layers)
b. IUF demise
iv. Dx:
1. Exam placenta after delivery (?send to laboratory for biopsy)
2. U/S – if negative, it doesn’t exclude PA.
v. Mx:
Minor
Emergency CS (stop DIC)
Investigate coags on M (APTT, PT, fibrinogen, DDimer) but if results are abnormal consult with
haematologist for transfusion
Major
Conservative or CS
Baby is monitored in NICU
3) Vasa Previa
a. Def: umbilical vessels run in the membrane close to the internal os instead of the
placenta
b. Clinical presentataion:
i. Small VB at the time of rupture
c. Mx:
i. CS (because it can cause fetal blood loss)
4) Bleeding from LGT
a. Cuases:
i. Post coital
ii. Cervical condition (ectropion and polyps, carcinoma)
iii. Infection (candida, trichomonas)