Antepartum Haemorrhage (APH)

Prepared by Helen Cooke

August 2008

Objectives
Describe the main causes of antepartum haemorrhage Discuss the management of main causes

The Placenta

Causes of APH
Placental praevia Placenta abruption Vasa Praevia Incidental and indeterminate causes = 50-60% APH Non Placental causes - local genital tract trauma

Low Lying Placenta

Not an uncommon finding on second trimester ultrasound scan. 15-20% of pregnancies have a low lying placenta. Only 5% of these remain low lying at 32 weeks and One third of those are low lying at term (37 weeks).

Placenta Praevia
Placenta that has implanted in part or all of the lower uterine segment encroaching upon or covering the internal cervical os. Responsible for 15-20% of APHs Haemorrhage is likely in the third trimester as the lower segment grows and thins or the cervix dilates. With the increase in LSCS the clinician should consider placenta accreta, increta & percreta with placenta praevia
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Grading
Grade 1 ( 1st Degree) Part of placenta lies in the lower segment but does not reach os Grade 2 ( 2nd Degree) The lower margin of the placenta reaches the internal os but does not cover it Grade 3 ( 3rd Degree) The placenta covers the os Grade 4 ( 4th Degree) The placenta lies centrally over the os
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Maggie Myles: Textbook for Midwives

Clinical Features
Bleeding without abdo pain or uterine tenderness, usually bright red Usually between 34-38 wks (20% before 28 weeks) May be associated with contractions Bleeding usually recurs often increasing in severity with increasing gestational age Not usually precipitated by any one factor, coitus, etc. 30% women with placenta praevia will not have a APH
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Clinical management
Active vs expectant management Active management: if bleeding continues non-reassuring FHR pattern maternal compromise

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Vasa Praevia
Rare event Umbilical cord vessels are covered only by chorion and amnion (membranes) Vessels are exposed and can rupture under pressure or ARM Baby at risk of severe bleeding and death May feel like a cord pulsating on VE May be diagnosed on colour Doppler U/S
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Risk factors vasa praevia

Painless vaginal bleeding after 20 weeks gestation Low lying placnta of praevia Succenturiate lobe or velementous cord insertion IVF or multiple pregnancy

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Vasa Praevia
Exposed vessels

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Placental Abruption
Separation of a normally implanted placenta usually by haemorrhage into the decidual basalis after the 20th week of pregnancy and before birth of the baby The amount of bleeding depends on: the size of the bleeding vessel/s the amount of placental separation The more extensive the bleeding, the more likely it is to strip the membranes from the uterine wall and pass through the cervix and vagina

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Causes of abruption
Unknown cause is the most common Hypertensive disorders Previous APH Abdominal trauma: MVA, DV, fall Associations have been made with abnormal trophoblastic invasion and/or vessel formation Other predisposing factors - Rapid reduction in uterine size, ECV, Cocaine use, smoking, poor nutrition, advancing parity, multiple pregnancy, IOL
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Incidence
1 to 1.5% of pregnancies Recurs in 10-15% of cases In 5% of these women DIC occurs

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Bleeding may be
Revealed Concealed Partially revealed Painful and the womens clinical symptoms may not always match amount of blood loss

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Clinical Presentation
Vaginal bleeding of varying amount (80%) Uterine tenderness +/- (70%) Abnormal FHR pattern +/- (60%) Uterine contractions +/- (high frequency, low intensity) (35%) Uterine Hypertonus Clinical presentation features are dependant on degree of abruption and blood loss.
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Prevention of abruption
Actively treat maternal hypertension Screen for domestic violence Screening & brief intervention for smoking and substance abuse Seat belt worn under pregnant abdomen

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Complications of abruption
Maternal
Haemorrhagic shock Coagulopathy/DIC Uterine rupture Renal failure Maternal death

Fetal
Fetal Hypoxia Anaemia Growth restriction CNS damage Fetal death

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Management Considerations - APH

Maternal welfare assessment monitoring of vital signs, blood loss, urine output. Always think about a concealed haemorrhage Insert two large bore cannulars 14 or 16g Fluid replacement Cross match 4 units of packed cells Resuscitation and/or delivery In the presence of significant blood loss - oxygen
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Management Considerations cont

Fetal welfare assessment electronic FHR monitoring U/S for placental position/ vasa praevia Steroid cover if preterm Anti D if Rh -ve Make a diagnosis Clinical - Ultrasound (? Value) Maternal education and support Maternal biochem, haematology FBC/Kleihaur if Rh -ve +/- Preparation for Preterm birth transfer if required
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