Antepartum Haemorrhage (APH)

Last updated 20.09.12

 

Index

 

Definition

-  Bleeding from genital tract after 20/40 gestation of pregnancy prior to onset of labour

 

Features

-  Incidence of 2-5% pregnancies

-  Associated w perinatal mortality & morbidity

-  Primarily through preterm delivery

-  Some ass w IUGR

 

Causes

-  Cervical, vaginal or lower genital tract 45%

-  Most common causes

-  Ectropion, cervical dysplasia, cervicitis

-  Vaginitis, varicies

-  Polyps, Ca (Cervical..)

-  Placenta praevia 30%

-  Placental abruption 25%

-  Uterine rupture (rare)

-  Vasa praevia (rare)

-  Remainder idiopathic: ?marginal separation of placenta

 

DDx

-  Haematochezia

-  Haematuria

 

Associated S/S

-  Abdo pain + bleeding in pregnancy = abruption until proven otherwise

-  Vaginal bleeding

-  Presenting complaint in 20% abruptions

-  Count & weigh pads, clots

-  Observed loss may significantly underestimate actual loss (esp in abruption)

-  Precipitant cause: trauma (MVA, violence), cocaine, post-coital, fall

-  Foetal blood loss from vasa praevia

-  Maternal blood loss from all other causes

-  Abdo pain

-  + back pain: consider placental abruption

-  Contractions

-  Abdo exam

-  Peritonitis: abruption, uterine rupture

-  Consider other causes esp in context of trauma

-  Abdo palpation

-  Foetal lie & presentation: mode of delivery if needs expediation

-  Fundal height: possible increase in abruption

-  Rigid uterus: Placental abruption w Couvelaire uterus

-  Uterine tenderness

-   Presenting complaint in 70% abruptions

-  Uterine contractions

-   Presenting complaint in 35% abruptions

-  Rupture of membranes

-  Vasa preavia rare in context of intact membranes

-  May provoke vasa praevia bleed

-  Foetal movements since bleeding: foetal welfare

 

Ix

-  Vitals

-  HR, BP: hypotension, shock

-  Beware compensation w rapid decompensation in otherwise healthy women

-  Speculum

-  Determine source, volume & current state of bleeding (active or resolved)

-  Dx local causes, need to take time & inspect vulva, vagina & cervix

-  +/- VE

-  Cautious & considered use unless placental location known

-  Can cause immediate & severe haemorrhage in presence of vasa praevia &/or placenta praevia

-  +/- PR to exclude haematochezia

-  CTG

-  Foetal wellbeing

-  Reduced variability, tachycardia, recurrent late decels, sinusoidal trace

-  TV US

-  Determine placental site, placenta praevia, vasa praevia, velamentous cord insertion

-  Not used to Dx abruption, 2% Dx on US by placental separation

-  Uterine rupture, scar dehescience

-  FBE

-  Hb: anaemia

-  Plt: thrombocytopaenia

-  Group & Hold

-  Rhesus status for Anti-D

-  Blood transfusion

-  +/- Coags

-  To exclude, monitor for DIC

-  Kleihauer

-  Dx foetomaternal haemorrhage

-  Poor correlation w presence of abruption

-  Determine dose required of Anti-D

-  +/- Apt test

-  Not commonly performed

-  Used to DDx foetal from maternal blood

-  +/- ABG

-  In severe cases: acidosis

-  Record blood loss: pad chart

-  Poor correlation w actual blood loss (underestimated)

-  Urine dipstick +/- MCS

-  DDx haematuria (presence does not exclude APH)

 

Mx

-  Majority of women will not require immediate resuscitation

-  No high level evidence to support routine admission

-  If local causes not identified, pt unstable, Hx unclear admit for 48hrs observation

-  Allows time for US

-  Be wary of rapid decompensation

-  +/- BLS & ALS

-  +/- Help

-  Consultant Obstetrician

-  Anaesthetist, Haematologist

-  MET call

-  Cannulation: x2 large bore

-  IV fluids +/- Blood transfusion

-  Analgesia

-  Anti-D

-  All rhesus negative mothers

-  +/- IDC: fluid balance

-  +/- O2

-  +/- Expediated delivery

-  Mode dependant on cause: LUSCS vs vaginal

-  Consider steroids if <34/40, MgSO4 if <30/40

-  Mx of cause as indicated

 

 

 

References

 

LRH Clinical/Departmental Guideline: Antepartum Haemorrhage (APH) Protocol, 24/08/11

UpToDate: Overview of the etiology and evaluation of vaginal bleeding in pregnant women, Norwitz et al, 11/01/11

3 Centres Collaboration: Antepartum Haemorrhage (APH), Including Placenta Praevia, Abruption and Vasa Praevia, 21/12/11, 3centres.com.au/guidelines/antepartum-haemorrhage-aph-including-placenta-praevia-and-abruption/