Prepared by Helen Cooke

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Antepartum Haemorrhage (APH)
Prepared by Helen Cooke August 2008
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Objectives

• Describe the main causes of antepartum
  haemorrhage
• Discuss the management of main causes

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The Placenta
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Causes of APH

• Placental praevia
• Placenta abruption
• Vasa Praevia
• Incidental and indeterminate causes 50-60 APH
• Non Placental causes - local genital tract trauma

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Low Lying Placenta

• Not an uncommon finding on second trimester
  ultrasound scan.
• 15-20 of pregnancies have a low lying placenta.
• Only 5 of these remain low lying at 32 weeks and
  
• One third of those are low lying at term (37
  weeks).

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Placenta Praevia

• Placenta that has implanted in part or all of the
  lower uterine segment encroaching upon or
  covering the internal cervical os.
• Responsible for 15-20 of APHs
• Haemorrhage is likely in the third trimester as
  the lower segment grows and thins or the cervix
  dilates.
• With the increase in LSCS the clinician should
  consider placenta accreta, increta percreta
  with placenta praevia

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Grading

• Grade 1 ( 1st Degree)
• Part of placenta lies in the lower segment but
  does not reach os
• Grade 2 ( 2nd Degree)
• The lower margin of the placenta reaches the
  internal os but does not cover it
• Grade 3 ( 3rd Degree)
• The placenta covers the os
• Grade 4 ( 4th Degree)
• The placenta lies centrally over the os

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Maggie Myles Textbook for Midwives
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Clinical Features

• Bleeding without abdo pain or uterine tenderness,
  usually bright red
• Usually between 34-38 wks (20 before 28 weeks)
• May be associated with contractions
• Bleeding usually recurs often increasing in
  severity with increasing gestational age
• Not usually precipitated by any one factor,
  coitus, etc.
• 30 women with placenta praevia will not have a
  APH

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Clinical management

• Active vs expectant management
• Active management
• if bleeding continues
• non-reassuring FHR pattern
• maternal compromise

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Vasa Praevia

• Rare event
• Umbilical cord vessels are covered only by
  chorion and amnion (membranes)
• Vessels are exposed and can rupture under
  pressure or ARM
• Baby at risk of severe bleeding and death
• May feel like a cord pulsating on VE
• May be diagnosed on colour Doppler U/S

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Risk factors vasa praevia

• Painless vaginal bleeding after 20 weeks
  gestation
• Low lying placnta of praevia
• Succenturiate lobe or velementous cord insertion
• IVF or multiple pregnancy

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Vasa Praevia
Exposed vessels
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Placental Abruption

• Separation of a normally implanted placenta
  usually by haemorrhage into the decidual basalis
  after the 20th week of pregnancy and before birth
  of the baby
• The amount of bleeding depends on
• the size of the bleeding vessel/s
• the amount of placental separation
• The more extensive the bleeding, the more likely
  it is to strip the membranes from the uterine
  wall and pass through the cervix and vagina

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Causes of abruption

• Unknown cause is the most common
• Hypertensive disorders
• Previous APH
• Abdominal trauma MVA, DV, fall
• Associations have been made with abnormal
  trophoblastic invasion and/or vessel formation
• Other predisposing factors - Rapid reduction in
  uterine size, ECV, Cocaine use, smoking, poor
  nutrition, advancing parity, multiple pregnancy,
  IOL

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Incidence

• 1 to 1.5 of pregnancies
• Recurs in 10-15 of cases
• In 5 of these women DIC occurs

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Bleeding may be

• Revealed
• Concealed
• Partially revealed
• Painful and the womens clinical symptoms may
  not always match amount of blood loss

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Clinical Presentation

• Vaginal bleeding of varying amount (80)
• Uterine tenderness /- (70)
• Abnormal FHR pattern /- (60)
• Uterine contractions /- (high frequency, low
  intensity) (35)
• Uterine Hypertonus
• Clinical presentation features are dependant on
  degree of abruption and blood loss.

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Prevention of abruption

• Actively treat maternal hypertension
• Screen for domestic violence
• Screening brief intervention for smoking and
  substance abuse
• Seat belt worn under pregnant abdomen

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Complications of abruption

• Maternal
• Haemorrhagic shock
• Coagulopathy/DIC
• Uterine rupture
• Renal failure
• Maternal death

• Fetal
• Fetal Hypoxia
• Anaemia
• Growth restriction
• CNS damage
• Fetal death

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Management Considerations - APH

• Maternal welfare assessment monitoring of vital
  signs, blood loss, urine output. Always think
  about a concealed haemorrhage
• Insert two large bore cannulars 14 or 16g
• Fluid replacement
• Cross match 4 units of packed cells
• Resuscitation and/or delivery
• In the presence of significant blood loss -
  oxygen

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Management Considerations cont

• Fetal welfare assessment
• electronic FHR monitoring
• U/S for placental position/ vasa praevia
• Steroid cover if preterm
• Anti D if Rh -ve
• Make a diagnosis Clinical - Ultrasound (?
  Value)
• Maternal education and support
• Maternal biochem, haematology FBC/Kleihaur if
  Rh -ve
• /- Preparation for Preterm birth transfer if
  required