Antepartum Haemorrhage (APH)

MCQs

1. Placenta Accreta The optimum management is Caesarean hysterectony Is commonly associated with placenta praevia Is associated with placenta praevia in over 50% of cases Methotrexate can be given in selected cases

2. Antepartum haemorrhage (APH) Is defined as bleeding from the genital tract after 24 weeks’ gestation. If associated with labour – like pains, a vaginal examination is advisable. In cases of placental abruption, there is coincident placenta praevia in 1% of patients

3. Placental abruption Is defined as the premature separation of an abnormally sited placenta 70-80% result in vaginal bleeding The bleeding is typically bright red and clotting In 50% of cases the bleeding occurs after 36 weeks’ gestation Blood loss is invariable of maternal origin Tends to recur in subsequent pregnancies

4. Placenta Praevia Nulliparity is a risk factor Complicates approximately 1 in 400 pregnancies. Is associated with intra-uterine growth restriction Fetal growth restriction is more commonly encountered in association with placenta praevia than with normally sited placentas Transvaginal ultrasound is the diagnostic technique of choice.

5. The following statements are true about placenta praevia Transabdominal ultrasound (TAS) has a false-positive rate of 20% for the diagnosis of placenta praevia An overdistended maternal bladder makes the diagnosis easier by TAS TH diagnostic accuracy of transvaginal ultrasound (TVS) is greater than abdominal ultrasound The diagnostic accuracy of 93-97% Only 5% of patients diagnosed as having a low-lying placenta in the second trimester continue to have placenta praevia at delivery.

6. Placenta Praevia Complicates approximately 1:400 pregnancies IS associated with a maternal mortality rate of 0.3% in the UK Transvaginal ultrasound is the diagnostic technique of choice. If the placenta edge is less than 3cm from the internal cervical os, a caesarean section should be performed. There is significant association between placenta praevia and placenta accreta

7. Placental Abruption The risk of recurrence is 8.3-16.7%. The commonest reason is blunt trauma to the abdomen. Causes are usually obvious clinically Many patients with placental abruption are hypertensive at presentation. Nearly 50% of patients are in established labour. Approximately 10% of patients are in established labour.

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Epidemiology Late pregnancy or third trimester bleeding Complicates 4% of pregnancies

APH - Causes Major causes Other Placenta Previa (20%) Placental Abruption (30%) Ruptured Vasa Previa - Fetal blood vessels across presenting membranes Uterine Scar Disruption Other Cervicitis or other genital tract infection Bloody show (may indicate Preterm Labor) Cervical polyp Cervical Cancer Cervical Ectropion Vaginal trauma

History Bleeding characteristics Associated factors Inciting factors Amount (pads/day), Colour of blood (dark or bright red) Associated factors Pelvic, abdominal pain or back pain Contractions Inciting factors Recent examination Abdominal or pelvic Trauma Intercourse Fetal movement Previous ultrasounds

Examination Vital signs Abdominal Exam Blood Pressure and pulse Often normal despite significant bleeding Abdominal Exam Pain on palpation Palpable contractions Hypertonic uterus Pelvic examination (if no Placenta Previa) Bimanual exam if placental location known

Laboratory Investigations Haemoglobin Type and cross 2 to 6 units RCC Type and cross platelets Coagulation studies Prothrombin Time (PT) Partial Thromboplastin Time (PTT)

Investigations Ultrasound Transabdominal Transvaginal Ultrasound Placental location Placental Abruption

Management Depends upon Conservative Stage of Pregnancy and fetal viability Amount of Bleeding Conservative Hospitalization Bed rest Avoid vaginal examination Correct anaemia Blood cross match Serial scans for fetal growth Discharge if all well for follow up

Management: Emergency Indications Brisk Vaginal Bleeding Unstable vital signs Fetal Distress Immediate interventions Oxygen Trendelenburg position (raise foot end) Obtain immediate Intravenous Access Two large bore IV (16-18 gauge) Initiate Isotonic crystalloid bolus Normal saline Ringer Lactate Type, cross and transfuse RCC, FFPs, platelets as needed Record Vital signs, intake output Call for immediate Obstetric and neonatal support for delivery

Complications of Abruption Coagulation failure Renal failure IUD

Placenta Previa

Definition Placenta previa is a condition in which the placenta is attached in lower uterine segment close to or covering the cervix

Pathophysiology Placenta usually implants at fundus Risk factors Fundal blood supply is better than lower uterus Risk factors Previous C Section, myomectomy Associated with placenta accreta High parity Multiple Gestation – large placenta Previous uterine instrumentation – D&C, E&C Past history of placenta previa

Pathophysiology Associated Conditions Abnormal presentation (placenta raises presenting part) Oblique Lie Transverse Lie Placental Abruption Intrauterine Growth Retardation (IUGR) Placenta accreta (especially prior C section) Postpartum Haemorrhage

Types Type I: low implantation Type II: marginal placenta Lower margin dips into lower uterine segment Does not reach internal os Type II: marginal placenta Reaches but does not cover internal os, Type III: partial previa Covers internal os when closed Does not cover os when fully dilated Type IV: complete previa (central previa) Covers internal os even when fully dilated

Types

Clinical presentation Sudden Painless, profuse uterine bleeding 27-32 weeks May be mild (warning haemorrhage) May be provoked with intercourse, contractions Abdomen soft and non-tender – less placental separation Fetal malpresentation IUGR Fetal heart present

Diagnosis Obstetric Ultrasound EUA if ultrasound not available, active bleeding, borderline case MRI

Counselling Risk of severe life-threatening hemorrhage Risk of fetal death Risk of maternal death Blood transfusion may be necessary Hysterectomy may be needed to control bleeding

Management Hospitalisation Caesarean section at tertiary care centre Avoid digital cervical exam mild/No bleedning Gentle speculum exam is permitted Delay delivery until lung maturity Caesarean section at tertiary care centre Indications Severe haemorrhage despite fetal immaturity Major degrees of placenta previa

Management Spontaneous Vaginal Delivery: Indications Spontaneous vaginal delivery in type I & II (anterior) or type I (posterior) Head engaged: Can tamponade marginal previa No brisk bleeding on exam Close fetal and maternal monitoring EUA in OT with full preparation of emergency Caesarean section Bleeding management Syntocinon Prostaglandin Hot packs Internal iliac ligation Obstetric hysterectomy

COMPLICATIONS Maternal Fetal Anaemia Hemorrhage and shock cesarean hysterectomy death Fetal Prematurity intrauterine growth retardation perinatal death

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