Antepartum Haemorrhage

By Dr. Mona Ahmed

Learning Objectives

At the end of this lecture, the students will be able to:

1. Define antepartum hemorrhage.
2. Identify the risk factors for placenta previa, abruptio placenta, and placenta accreta.
3. Describe the clinical features and diagnostic criteria for placenta previa, placental abruption, and placenta previa accreta.
4. Distinguish between placenta previa, abruptio placenta, and other possible causes.
5. Describe the appropriate management based on the cause.

Vaginal Bleeding

APH

Definition:
This is defined as vaginal bleeding after 20 weeks’ gestation.

Incidence:
It complicates 2–5% of pregnancies.

Causes

The causes can be classified into:

• Placental
• Fetal
• Maternal

Placental Causes

• - Placental Abruptio

• - Placenta Previa

Fetal Cause

• - Vasa Previa

Maternal Causes

• Vaginal Trauma
• Cervical Ectropion
• Cervical Carcinoma
• Vaginal Infection
• Cervicitis

Key Questions

The key questions are:

• Whether the bleeding is placental or not?
• Is it compromising the mother and/or fetus?
• Or whether it has a less significant cause.

History

• Triggering factors (e.g., trauma).
• Associated with pain or contractions?
• Timing & Amount of Bleeding
• Fresh or old associated with mucus?
• Site of placenta on anomaly scan
• Is the baby moving?
• Last cervical smear (date/normal/abnormal)?

Examination

• Signs of Shock (Pulse, Blood Pressure, Pallor)
• Abdominal Examination:
  • Fundal Level
  • Is the Uterus Soft or Tender and Firm?
• Fetal Heart Auscultation/CTG
• Speculum Vaginal Examination
• .PV: Should be Avoided if PP Suspected

Investigations

• Full Blood Count
• Clotting Factors
• Kleihauer Test
• Cross-Match (Save 6 Units of Blood)
• Urea & Electrolytes
• Ultrasound (Fetal Size, Presentation, Amniotic Fluid, Placental Position and Morphology)

Initial Management

• Depend on
  • ✔️ Cause
  • ✔️ Maternal & Fetal Conditions
  • ✔️ GA
  • ✔️ Degree of Bleeding
• Two Large Bore Cannula
• Resuscitation
• Liaison with Hematologist
• Prepare 4-6 Units of Blood

Acute Management Checklist

• ABC
• Hemodynamic Monitoring: Continuous ECG, Pulse Oximetry, Oxygenation: e.g., Supplemental O2
• Immediate Hemodynamic Support: Including Emergency Blood Transfusion for Hemorrhagic Shock
• Focused Gynecologic History: and Pelvic Examination
• Laboratory Studies: CBC, Coagulation Studies, Type and (ScreenCC ??)
• Fetal Heart Rate Tracing
• Transvaginal Ultrasound: to Confirm Placental Location
• Rh(D)-Negative Mothers: Kleihauer-Betke Test, Anti-D Immunoglobulin
• Urgent OB/GYN Consult to Determine Further Management

Complications of APH

• Hypovolemic Shock
• Preterm Labour
• DIC
• PPH
• Emergency C-Section
• Hysterectomy
• Complications of Blood Transfusion
• Fetal Death

Key Learning Points

• Placenta Previa is most dangerous for the mother.
• Placental Abruption is more dangerous for the fetus than the mother.
• Vasa Previa is not dangerous for the mother but is nearly always fatal for the baby.
• Management involves resuscitation and stabilization of mother and senior input regarding timing of delivery.