Antepartum Haemorrhage (APH)
Antepartum haemorrhage (APH) is defined as vaginal bleeding after the 20th week of pregnancy. APH is associated with increased foetal and maternal morbidity and mortality. The fetal and maternal status will depend on amount, duration, and cause of bleeding. The causes of APH are:
Extraplacental bleeding: From sites other than the placental surface, including cervical lesions, e.g., trauma, cancer of the cervix, cervical polyps; vaginal lesions, e.g,. Tears\lacerations (rare), and infections; and vulvoperineal tears(rare).
Placental causes:
Placental abruptio (abruptio placentae): This is defined as occurring when a normally implanted placenta separates from the uterine wall (decidua basalis) after the 20th week and prior to the 3rd stage of labour. Bleeding may be absent, mild, moderate, or severe (this does not reflect extent of separation or severity). Bleeding may be concealed when little or no bleeding is seen PV or revealed when bleeding PV is evident.
Placenta praevia: This occurs when any part of the placenta implants in the lower part/segment of the uterus. Further clinical classification is feasible depending on the relationship to internal cervical as:
-Minor degree:
-Type 1: Placenta in the lower uterine segment but not encroaching the internal os.
-Type 2: Placenta partially encroaches the internal os but not during labour.
-Major degree:
-Type 3: Placenta partially encroaches the internal os and remains the same even during labour.
-Type 4: Placenta totally covers the internal os and this relationship does not change during labour.
Vasa praevia: This is a rare cause of antepartum haemorrhage in which the umbilical cord is inserted into placental membranes with blood vessels traversing and presenting over the internal cervical os.
Investigations
Haemoglobin
Urinalysis: Haematuria, proteinuria
Bedside clotting time
Platelet count
Others: Ultrasound, which offers a high degree of diagnostic accuracy in antepartum haemorrhage
Management-General
Always admit to hospital a patient with a history of antepartum hemorrhage even if bleeding is not apparent and the patient appears quite well.
Take a careful history and note:
Amount and character of bleeding
Any associated pain
History of bleeding earlier in pregnancy
History of trauma
Do a thorough physical exam, including abdominal examination for
Tenderness/guarding
Contractions
Foetal heart presence
Carry out speculum examination:
Bleeding from uterus
Other sites of bleeding
Cervical dilatation
In patients with antepartum haemorrhage:
Quickly evaluate the maternal and foetal status
Take blood for grouping and cross-matching.
Start IV 5% dextrose or normal slime using a wide bore branula.
Monitor vital signs; blood pressure, respiratory rate, pulse rate, temperature and insert an indwelling urethral catheter.
If bleeding is severe or patient is in shock then:
Ensure open airway and breathing.
Establish and maintain adequate circulation: may transfuse whole blood or packed cells.
Monitor fluid input and output: insert indwelling Foley’s catheter.
Management-Specific management depends generally on:
Gestational maturity
Conditions of fetus
Continuous bleeding or not
Onset of spontaneous labour
Management-Specific
Essentials of diagnosis:
Abruptio placentae
Continuous abdominal and/or back pain
Irritable, tender and often hypertonic uterus
Visible or concealed haemorrhage
Board-like rigidity
Evidence of fetal distress
Rapture of the uterus may be confused with abruptio placentae. The following features suggest rapture of the uterus:
Efforts at resuscitation of the mother unrewarding (e.g., blood pressure remains low while the puls remains rapid and thready).
Uterine contractions absent.
Difficulties in determining shape and outline of the uterus (due to peritoneal irritation and the empty uterus): This is a very important sign.
For mothers who have been in labour, recession of the foetal presenting part and disappearance of foetal heart sounds suggest rapture of the uterus.
Once rapture of the uterus has been ruled out, then treatment for abruptio placentae should be instituted.
Principles of treatment:
Rapid correction of hypovolaemia/shock or anaemia, as above
Correction of coagulation defect:
Whole blood
Fresh frozen plasma
Early uterine emptying
Vaginal delivery whenever possible
Prevention of postpartum haemorrhage
Thorough physical examination, including abdominal examination for:
Tenderness/guarding
Contractions
Foetal heart presence
Speculum examination: Bleeding from uterus, other sites of bleeding, cervical dilatation.
If above measures do no establish diagnosis, then do examinations under anaesthesia (EUA) in theatre;rule out placenta praevia then do:
Artificial rupture of membranes, start oxytocin infusion (if no contraindications) 5 units in 500ml of 55 dextrose (10 drops per minute for 30 minutes and increase by 10 drops every half hourly to a maximum of 60 drops per minute or 3 contractions per 10 minutes, whichever is earlier).
This is done when vaginal delivery is evaluated as imminent and feasible.
Indications for abdominal delivery: Cesarean section, hysterotomy
Intrauterine fetal death with severe uterine bleeding
Severe degree of placental abruption with a viable fetus.
Haemorrhage severe enough that it jeopardizes life of mother\Any incidental complication of labour
Postpartum: Continue oxytocin for about 2 hours.
Placenta Praevia
The management of placenta praevia depends on gestation, extent of bleeding and clinical findings. Conservative management is done when: bleeding is minimal and significant risk of prematurity exists. The decision follows evaluation based on complete examination of maternal and foetal status.
Speculum examination is mandatory. The following must be done:
Hospitalization is mandatory in a place with cesarean section facilities.
Restriction of physical activities.
Weekly haemoglobin.
Avoid unnecessary physical examinations.
Ultrasound monitor if possible.
Patient may be discharged if placenta is normally situated and be re-admitted at 38 weeks (as below); then:
If no bleeding recurs by 37 weeks prepare the patient for theatre under DOUBLE SET-UP for EUA and for cesarean section.
If a minor degree of placenta praevia is found, then do artificial rupture of membranes (ARM), start oxytocin, and DELIVER.
If a major degree of placenta praevia is found, prepare the patient for theatre immediately for cesarean section.
Do cesarean section if: Bleeding is severe and a threat to life, in doubt about degree of placenta praevia, and any contraindication for normal delivery.
Level of care for antepartum haemorrhage is 4-6