Antepartum Haemorrhage

Dr Ian W Mahady FRCOG Shanghai East International Medical Centre

Mahadys Equation

37/52

Intrauterine environment

extrauterine environment

Massive Obstetric Haemorrhage

Second most common cause Maternal Death 8.5 / million pregnancies

Also includes post-partum haemorrhage

Antepartum Haemorrhage- Definition

Bleeding in pregnancy after 28 weeks gestation

Antepartum Haemorrhage - Types

Simple

Complicated

Antepartum Haemorrhage -Simple

Local causes

Vaginal

Trauma

Cervical
Erosion Tumour Pap Smear

Blood Dyscrasia
Thrombocytopenia Anticoagulants

Antepartum Haemorrhage - Complicated

Placenta

Praevia

(Inevitable APH)

Abruptio

Placentae

(Accidental APH)

Placenta Praevia - Definition

Placenta which has implanted partially or wholly in the lower uterine segment

Placenta Praevia - Types Old Classification

Grade 1 Just enters lower segment Grade 2 Enters LUS but does not reach os Grade 3 Partially covers os but not completely Grade 4 Completely covers os

Placenta Praevia Old Classification

Placenta Praevia Types

Major

Enters LUS but does not cover os Covers internal os completely

Minor

Placenta Praevia New classification

Placenta Praevia- aetiology

Unclear Any damage to endometrium or myometrium Scar tissue impedes migration away from os Increased placental mass

Placenta Praevia Increased Mass Multiple pregnancy- large surface area Cigarette smoking- vasoconstriction Cocaine Use Vasoconstrictionhypertrophy

Placenta Praevia Endo/Myometrial Damage

Previous C/S

Spontaneous Abortion Uterine abnormalities

Placenta Praevia Other Factors Previous Placenta Praevia Maternal Age reduced uterine blood flow
needs greater surface area

Parity - 3 previous deliveries 2.6 fold

Vessels at site of previous placenta reduced flowdiscourage implantation

Placenta Praevia Associated Complications

Congenital Abnormality - 6.7% /3.2% ? Small for Dates(SGA) 19% - decreased placental perfusion Reduced nutrient transfer Malpresentation 3 fold increase Breech Transverse lie Abnormal Placentation Accreta/Percreta

Unscarred uterus 5% normal incidence

1 previous C/S 24%

4 C/S 67%

Pregnancy Induced Hypertension reduced

Placenta Praevia - Presentation Antepartum Haemorrhage

Late pregnancy Painless bleeding

Malpresentation

Breech/High Head/Unstable lie in 3rd trimester

Asymptomatic found at routine U/S scan

Placenta Praevia Diagnosis

Ultrasound
Transabdominal Transvaginal

Placenta Praevia Abdominal U/S

Placenta Praevia Transvaginal U/S

Placenta Praevia - Management

Antenatal
Inpatient vs Outpatient Major vs minor Anaemia

Regular Hb X-match/Transfuse

Placenta Praevia - Management

Delivery
Timing Mahadys equation Usually 38/52

Mode of Delivery

Minor praevia 2cm from os

Examination in theatre/ARM/Vaginal delivery

Major praevia
Caesarean Section NB Senior Obstetrician

Mahadys Equation

37/52

Intrauterine environment

extrauterine environment

Antepartum Haemorrhage - Complicated

Placenta

Praevia

(Inevitable APH)

Abruptio

Placentae

(Accidental APH)

Abruptio Placentae - Types

Revealed APH

Pain + Vaginal bleeding

Concealed
Pain/Shock No vaginal bleeding

Abruptio Placentae - Types

Placental Site - Upper Uterine Segment

Abruptio Placentae Associated risk factors

Hypertension/Pre-eclampsia - 44% of all cases Maternal Trauma - RTA /Pelvic # - 1.5-9.4%C Smoking 40% increase for each year smoked Cocaine hypertension/catecholamine release
Thrombophilia Cord complications
Raised alpha fetofeto-protein Amniocentesis Maternal Age Alcohol

Abruptio Placentae - Symptoms

Vaginal Bleeding ( Revealed) Abdominal /Back Pain (Severe) Fetal Distress Contractions (Hypertonic) Preterm Labour Fetal Death in utero

80% 70% 60% 35% 25% 15%

Abruptio Placentae - Complications

Maternal

Haemorrhagic /Hypovolaemic Coagulopathy

SHOCK

DIC/Hypofibrinogenaemia

Couvelaire Uterus / Uterine rupture Renal Failure Ischaemic Necrosis distal organs (Liver,Adrenals,Pituitary)

Abruptio Placentae - Complications

Fetal

Hypoxia Anaemia

- Fetal distress - CTG

Growth Retardation - if treated conservatively and survives CNS Abnormalities Intra Uterine Death

Abruptio Placentae - Investigations

Blood Group - X match

Rh anti D

Haemoglobin/FBC Clotting Time Urea /Creatinine

- Platelets

/ Fibrinogen /FDP /PTT

Ultrasound - exclude Praevia CTG - Non Stress Test Biophysical Profile - NB <6

Abruptio Placentae - Management

Correct SHOCK

I V access 2 large bore cannulae

Crystalloids IV emergency

BLOOD as soon as possible

Correct DIC - ? Heparin Catheterise - hourly urine output chart Assess for delivery

FH absent - induce IV oxytocin FH present- ? C/S ?Induce