Antepartum Haemorrhage Max Brinsmead MB BS PhD April 2015

When confronted with a pregnant patient who is bleeding after 20w There are five questions that need urgent answers… How much blood has been lost What is the maternal condition What is the fetal condition Is the patient in labour What is the cause of the bleeding

THINK in terms of aetiology... Bleeding from a normally situated placenta = Abruption Bleeding from a low placenta = Placenta previa Cervical bleeding: “Show” Ectropion or Cancer Other sites of bleeding i.e. rectal or urethral rare Fetal bleeding rare but serious

ACT in terms of priority... Assess maternal wellbeing Resuscitate if required Anticipate further problems Assess fetal wellbeing Is the fetus salvageable Is the fetus compromised Then attempt diagnosis

Essential observations Maternal vital signs General appearance Pulse and BP Uterus Size Tone and tenderness Contractions You can’t do this with CTG belts in place Nature and amount of PV loss Just blood or blood and liquor Fetus Fetal heart present or absent

Discretionary observations Fetal lie, presentation and engagement A deeply engaged presenting part excludes major previa Speculum examination of the cervix For minor APH where a cervical cause is expected Digital examination of the cervix For the patient in labour with an engaged presenting part Also helpful if a prior scan has shown a non previa placenta

Essential Investigations HB, Blood group and save or Xmatch Depends on the amount of blood lost And the suspected diagnosis Remember that abruption is often associated with a large concealed loss Ultrasound Best done “on the ward” if bleeding is substantial Requires skill in distinguishing blood clot from placenta Vaginal scan the best way of evaluating degrees of placenta previa Urinalysis for proteinuria May require bladder catheterisation Abruption may be associated with “acute” pre eclampsia And the blood pressure may not be raised

Discretionary investigations Clotting studies Platelets, COAG and FDPs Only of help in management of severe APHs Maternal Kleihauer Only useful for assessing Anti-D dose in Rh negative patients A bedside test for Fetal Haemoglobin Useful if fetal bleeding is suspected Typically occurs with ARM or SROM in labour Apt’s test using 1% NaOH

Immediate management Large bore IV line If estimated loss is >250 ml Or if abruption or placenta previa is diagnosed Resuscitate with IV Fluids Commence with saline Colloids if shocked Blood if estimated loss >2 L Analgesia Corticosteroids for gestation <37wks Anti-D if Rh negative Dose according to Kleihauer

Monitoring response Maternal PR and BP Watch for pre eclampsia Indwelling catheter Hourly urine output Only a few require CVP Watch for coagulopathy A bedside test of clotting Prothrombin time (aPTT) and platelets HB takes a while to adjust CTG and umbilical Dopplers for the fetus

Definitive management Conservative for placenta previa Most will settle Deliver when paediatric resources permit CS if placenta within 2 cm of internal os Aggressive management for abruption CS sooner rather than later for fetal reasons And the role of CS in averting maternal coagulopathy even with FDIU requires RCT Watch for preterm labour for all others Observe in hospital