Antepartum Haemorrhage

Defined as bleeding from genital tract after 22nd week of gestation.




Management of major obstetric haemorrhage

 
Two major causes :

Abruptio Placentae

PV bleeding as a result of pre-mature separation of a normally cited placenta. 2/3 of the cases, the bleeding is revealed and 1/3 of the cases, bleeding is concealed.

Risk factors

Crack cocaine use
Anticoagulants
Trauma (assault, MVA, or external cephalic version)
Hypertension
Polyhydramnios
IUGR
Low socioeconomic status
Smoking

Clinical features

Classical clinical presentation is :

Abdominal pain, PV bleeding and uterine contraction

The PV bleeding is usually dark, without any clots. However, absence of PV bleeding doesn't rule out abruptio placentae. This condition tends to occur near term.
Other symptoms includes : faintness, restlessness, nausea

On examination : Tense, tender abdomen with uterine size > than period of gestation and fetal parts are relatively more difficult to be felt.

Sometimes, there might be signs of hypovolemic shock.
Complications includes : Renal compromise and DIC

Diagnosis

Diagnosis is usually clinical. Sometimes, after 3rd stage of labour, upon placental inspection. USG scan is occasionally useful, in which finding of retroplacental clot rules out placenta praevia.

Differential diagnosis :

Placenta praevia
Vasa praevia
Uterine rupture
Miscarriage
Pre-term labour

Effects on mother

1) Hypovolemic shock

Blood loss is often underestimated, since the haemorrhage can be obsured (behind placenta/uterine cavity). Sometimes, mothers with PIH/pre-eclampsia, effects of hypotension is masked by elevated BP. CVP measurement is vital, both for assessment of degree of blood loss and accurate fluid replacement.

2) DIC

Serial measurements of PT, APTT, INR, Platelet counts and FDP during resuscitation is indicated.

3) Acute renal failure

Acute renal failure develops secondary to hypovolemia, DIC and hypotension. Patient initially might be oliguric, which later complicates as acute tubular necrosis. After fluid resuscitation and treatment of DIC, urea and creatinine may still be increasing in it's level.

Fluid, acid-base and electrolyte balance need to be monitored closely.

Dialysis may be required.  

However, prognosis for ARF developed secondary to Placental abruption, with adequate treatment is excellent.

4) Feto-maternal haemorrhage

This is due to exposure of maternal circulation to the fetal blood group antigens, especially the Rhesus D antigen.

For mothers who are rhesus negative,

To assess the extent of feto-maternal haemorrhage -> Klaihauer's test
And to administer anti-D immunoglobulins adequately

*Note that placental abruption can cause significant maternal mortality if severe and rate of recurrence is about 10%

Effects on fetus

Increased perinatal mortality rate
IUGR : Either due to chronic, recurrent abruption or due to inadequate trophoblastic invasion of spiral arteries and decidua.

Management

Severe abruption

Management for major haemorrhage (discussed above)
If fetus is alive, urgent LSCS and resuscitation to be done.
If fetus is dead, after maternal stabilisation, vaginal delivery of the demised fetus is commenced, with or without oxytocics.

Mild abruption

If there's no evidence of fetal distress, and gestational age permits prolonging the pregnancy to gain more fetal maturity, management is conservative.
Fetal surveillence need to be done closely :

Serial fetal biometry through USG
Amniotic fluid volume
Umbilical artery doppler
Biophysical profile

Placenta praevia

Defined as placental encroachment or covering of the cervical os at lower uterine segment, which can cause provoked or spontaneous bleeding.

Grades of placenta praevia

Type I : Lateral
Type II : Marginal
Type III : Placenta covering the os asymmetrically over LUS
Type IV : Placenta covering the os symmetrically over LUS 

Differences in between placenta previa and abruption
Risk factors 

Multiple gestation
Assisted conception
Congenital uterine anomaly
Previous LSCS

Investigations

Hb estimation and Rh status
Transabdominal/Transvaginal ultrasound

Note that transabdominal ultrasound may fail due to high maternal BMI, fetal shadowing, localised thickening of myometrium, posterior praevia.

Hence, TVS is indicated in such cases.

Treament 

For mild cases, where there's no further bleeding, patient needs to be admitted for bed rest.

Hematinics supplementation and blood bank support (Hb maintain above 11-12 gm% and blood grouping/cross matching to be done)

Pregnancy is maintained till term and LSCS will be performed (unlikely to be able to delivery vaginally)

Digital vaginal examination - CONTRAINDICATED!

Repeated USG examination for placental location (in minor cases, the placenta may have migrated upwards), and fetal biometry.

If there's significant risk for pre-term delivery -> 12mg dexamethasone, 2 doses, 12 hours apart is given to mother for inducing fetal lung maturation.

For severe cases, manage as for major haemorrhage.
Indications for delivery includes :

a) Severe blood loss (>1.5L)
b) Continuity of blood loss of less severity
c) Term (37-38 weeks)

Category: Obstetrics Notes