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.
- 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
- APH complicates 3-5% of pregnancies
- Leading cause of perinatal and maternal mortality worldwide
Causes of uterine bleeding in pregnancy
|Placenta praevia ||Seen in 1 in 200 pregnancies and causes painless vaginal bleeding which contrasts with Placental abruption which causes vaginal bleeding and Pain. Placenta praevia can be graded into major and minor depending on whether the placenta overlies the internal os.
|Placental abruption || The most predictive historical fact is abruption in a previous pregnancy. Always ask about headache, blurred vision and abdominal pain and consider preeclampsia. Placental abruption is due to detachment of the placenta from the uterus with maternal blood loss. The blood may remain localised "concealed" or pass via the os and becomes a "revealed" haemorrhage
|Vasa Praevia|| Rare seen in 1 in 2500. Fetal blood vessels cross over the membranes in advance of the presenting part. Can lead to fetal loss from exsanguination at the time of membrane rupture. May be PV bleeding. May be detectable with doppler USS. Needs prompt CS.
|Other ||A Circumvallate placenta and Other non uterine - cervicitis, cervical polyp, cervical carcinoma
|Unknown ||In 50% of cases no cause is found however there is still an increased risk of perinatal mortality
- 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.
- 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.
- 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.
- 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.
- 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