Antepartum haemorrhage is defined as bleeding from the birth canal after the 24th week.

 

 

 

It affects 3-5% of all pregnancies.

It is 3 times more common in multiparous than primiparous women.

 

Placenta praevia. Insertion of the placenta, partially or fully, in the lower segment of the uterus.

Placental abruption (20% of all cases of antepartum haemorrhage) A normally situated placenta separates from the uterus prematurely and blood collects between the placenta and the uterus.

Local causes, e.g. vulval or cervical infection, trauma or tumours.

Vasa praevia (bleeding from foetal vessels in the foetal membranes) ⁰³⁰¹

Occurs in about 1 of every 1,000 pregnancies.

The baby's blood vessels from the umbilical cord may attach to the membranes instead of the placenta.

• Uterine rupture:

  Rare but very dangerous for both mother and baby.

  About 40% of women who have uterine rupture had prior surgery of their uterus, including caesarean section.

• Cause Unknown: No definite cause is diagnosed in about 40% of all women who present with antepartum haemorrhage.

 

 

May need resuscitation measures if shocked.

Admit to hospital, even if bleeding is only a very small amount. There may be a large amount of concealed bleeding with only a small amount of revealed vaginal bleeding.

No vaginal examination should be attempted at least until a placenta praevia is excluded by ultrasound as this could  initiate torrential bleeding from a placenta praevia.

Resuscitation can be inadequate because of under-estimation of blood loss and misleading maternal response. A young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs

Take blood for full blood count and clotting studies. Cross match as heavy loss may require transfusion.

Gentle palpation of the abdomen to determine gestational age of fetus, presentation and position.

Fetal monitoring.

Arrange urgent ultrasound.

With every episode of bleeding, a Rhesus negative woman should have a Kleihauer test and be given prophylactic anti-D immunoglobulin.

Further management will depend on fetal distress, the cause of the APH, extent of bleeding and gestation:

For pre-term delivery and immediate delivery is not necessary, maternal steroids may be indicated in order to promote fetal lung development and reduce the risk of respiratory distress syndrome

Severe bleeding or fetal distress may require urgent delivery of baby irrespective of gestational age.

Less severe bleeding, fetus less than 36 weeks and not distressed: expectant treatment with mother in hospital. If no further severe bleeding, continue pregnancy until 38 weeks when delivery mode can be chosen depending on degree of placenta praevia.

In slight haemorrhage with blood loss less than 500 ml and no disturbance of maternal or fetal condition. Ultrasound shows placenta not lying in lower uterine segment, no retroplacental clots. Patient may be discharged or have baby induced if after 37 weeks and other conditions suitable.

Moderate or severe placetal abruption:

Restore blood loss, prevent coagulopathy, monitor urinary output. In moderate cases, give 1500 ml of blood, and in severe cases, give 2500 ml (first 500 ml transfused rapidly). Ideally measure central venous pressure (CVP) and adjust transfusion accordingly.

Measure venous blood for coagulation 2 hourly, treat accordingly.

Measure urine output 2 hourly. Oliguria may occur, but if sufficient blood has been given, then diuresis will follow birth.

If fetus is alive, perform either caesarean section or artificial rupture of the amniotic membranes (restore blood volume first). Monitor fetus and switch to caesarean if fetal distress develops.

 

Premature labour.

Disseminated intravascular coagulopathy.

Renal tubular necrosis.

Postpartum haemorrhage.

Prognosis Fetus may die from hypoxia during heavy bleeding. Perinatal mortality less than 50 per 1000, maternal mortality is low if managed by experienced obstetrician and no vaginal examination performed before admission to hospital.