Antepartum haemorrhage

Related Subjects: |Antepartum haemorrhage |Postpartum haemorrhage |Acute Haemorrhage

The most important causes of APH are placenta praevia and placental abruption, although these are not the most common. See link to RCOG guidance below.

About

• APH is defined as any vaginal bleeding after 24 weeks of gestation up until the birth of the infant.
• It is an important cause of maternal and perinatal morbidity and mortality.
• There can be severe and rapid blood loss as uterine supply is very high 600-800 mL/min at term

Incidence

• APH complicates 3-5% of pregnancies
• Leading cause of perinatal and maternal mortality worldwide

Causes of uterine bleeding in pregnancy

Clinical

• Placental abruption should be considered when the pain is continuous.
• Labour should be considered if the pain is intermittent.
• Ask about her awareness of fetal movements and attempts
• Attempt to auscultate the fetal heart.
• If the APH is associated with spontaneous or iatrogenic rupture of the fetal membranes, bleeding from a ruptured vasa praevia should be considered.
• A pelvic examination should be avoided initially as it can worsen bleeding from a placenta praevia. Scan first to exclude a placenta praevia.
• Abdominal exam: look for tenderness or signs of an acute abdomen.
• Tense or woody feel to the uterus indicates a significant abruption.
• Abdominal palpation may also reveal uterine contractions.
• A soft, non-tender uterus may suggest a lower genital tract cause or bleeding from the placenta or vasa praevia.
• If no obvious cause then a speculum may be passed to just excluded other causes of bleeding from the lower genital tract e.g. etc.

Assessing severity

• Spotting staining, streaking or blood spotting noted on underwear or sanitary protection
• Minor haemorrhage blood loss less than 50 ml that has settled
• Major haemorrhage blood loss of 500-1000 ml, with no signs of clinical shock
• Massive haemorrhage blood loss greater than 1000 ml and/or signs of clinical shock.

Investigations

• Full blood count and coagulation screen and 4 units of blood cross-matched.
• Urea, electrolytes and liver function tests should be assayed
• Check Blood pressure and urinalysis for proteinuria.
• Cardiotocography should be performed to assess the fetus
• In all women who are RhD-negative, a Kleihauer test should be performed to quantify FMH to gauge the dose of anti-D Ig required.

Management

• ABC's - Urgent resuscitation as needed. Oxygen 15 L/min.
• Get IV access and start Crystalloids. Get help.
• Give ABO rhesus matched blood or O negative
• Abruption may be associated with having been physically assaulted or other trauma such as a road traffic accident
• With a placenta praevia lying within 2 cm of the internal os delivery by caesarean section is advised
• With abruption the patient may be severely shocked despite minimal bleeding as the bleeding may be "concealed" within the uterus.
• Clinicians should offer a single course of antenatal corticosteroids to women between 24+0 and 34+6 weeks of gestation at risk of preterm birth.
• Coagulopathy: consultant Haematologist Consider Up to 4 units of FFP and 10 units of cryoprecipitate whilst awaiting the results of the coagulation studies.

Delivery

• If the fetus is compromised, a caesarean section is the appropriate method of delivery with concurrent resuscitation of the mother.
• Women with APH and associated maternal and/or fetal compromise are required to be delivered immediately.
• Involve senior paediatrician/neonatologist.

Complications for Mother

• Anaemia, Infection, Maternal shock, Renal tubular necrosis
• Following Abruption Postpartum haemorrhage is seen in 25%.
• Sheehan's syndrome, Consumptive coagulopathy, DIC
• AKI, Post partum haemorrhage, Complications of transfusion

Complications for Fetus

• Fetal hypoxia, Fetal death, Prematurity
• Small for gestation age and growth restriction

References

• Antepartum Haemorrhage at RCOG