Antepartum haemorrhage (APH) is defined as bleeding from the birth canal or genital tract
after the 24th week (some authors define this as the 20th week, others
up to the 28th week) of pregnancy. APH complicates 3–5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide.
CAUSES
No definite cause is diagnosed in about 40% of all women who present with Antepartum Haemorrhage. Some causes are :
1. Placenta praevia
2. Placental abruption - most common pathological cause
3. Local causes e.g. vulval or cervical infection, trauma or tumours
4. Vasa praevia (bleeding from fetal vessels in the fetal membranes)
5. Uterine rupture
6. UTI
CLINICAL FEATURES
1. Bleeding, which may be accompanied by pain (suggestive of abruption) or be painless (suggesting praevia)
2. Uterine contractions may be provoked
3. Malpresentation or failure of the fetal head to engage
4. There may be associated signs of fetal distress
5. If severe bleeding : the mother may show signs of hypovolaemic shock
MANAGEMENT
1. The mainstays of management are resuscitation and accurate diagnosis of the underlying cause.
2. Severe bleeding or fetal distress: urgent delivery of the baby, irrespective of gestational age.
3. 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.
4. No vaginal examination should be attempted, at least until a placenta praevia is excluded by ultrasound. It may initiate torrential bleeding from a placenta praevia.
5. Resuscitation can be inadequate because of underestimation of blood loss and misleading maternal response. A young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs.
6. Take blood for FBC and clotting studies. Crossmatch, as heavy loss may require transfusion.
7. Gentle palpation of the abdomen to determine the gestational age of the fetus, presentation and position.
8. Fetal monitoring.
9. Arrange urgent ultrasound.
10. With every episode of bleeding, a rhesus-negative woman should have a Kleihauer test and be given prophylactic Anti-D immunoglobulin.
11. Further managenent :
- Further management will depend on fetal distress, the cause of the antepartum haemorrhage (APH), the extent of bleeding and gestation.
- In slight haemorrhage with blood loss less than 500 ml and no disturbance of maternal or fetal condition, ultrasound shows the placenta not lying in the lower uterine segment, no retroplacental clots, the patient may be discharged or have the baby induced, if it is after 37 weeks and other conditions are suitable.
- Placenta praevia : separate
COMPLICATIONS
1. Maternal Complications :-
- Anaemia
- Infection
- Maternal shock
- Renal tubular necrosis
- Consumptive coagulopathy
- Postpartum haemorrhage
- Psychological sequelae
- Placenta accreta
2. Fetal complications :-
- Fetal hypoxia
- Small for gestational age and fetal growth restriction
- Prematurity (iatrogenic and spontaneous)
- Fetal death
MNEMONIC
1. Antepartum hemorrhage (APH): major differential
APH
Abruptio placentae
Placenta previa
Hemorrhage from the GU tract
CAUSES
No definite cause is diagnosed in about 40% of all women who present with Antepartum Haemorrhage. Some causes are :
1. Placenta praevia
2. Placental abruption - most common pathological cause
3. Local causes e.g. vulval or cervical infection, trauma or tumours
4. Vasa praevia (bleeding from fetal vessels in the fetal membranes)
5. Uterine rupture
6. UTI
CLINICAL FEATURES
1. Bleeding, which may be accompanied by pain (suggestive of abruption) or be painless (suggesting praevia)
2. Uterine contractions may be provoked
3. Malpresentation or failure of the fetal head to engage
4. There may be associated signs of fetal distress
5. If severe bleeding : the mother may show signs of hypovolaemic shock
MANAGEMENT
1. The mainstays of management are resuscitation and accurate diagnosis of the underlying cause.
2. Severe bleeding or fetal distress: urgent delivery of the baby, irrespective of gestational age.
3. 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.
4. No vaginal examination should be attempted, at least until a placenta praevia is excluded by ultrasound. It may initiate torrential bleeding from a placenta praevia.
5. Resuscitation can be inadequate because of underestimation of blood loss and misleading maternal response. A young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs.
6. Take blood for FBC and clotting studies. Crossmatch, as heavy loss may require transfusion.
7. Gentle palpation of the abdomen to determine the gestational age of the fetus, presentation and position.
8. Fetal monitoring.
9. Arrange urgent ultrasound.
10. With every episode of bleeding, a rhesus-negative woman should have a Kleihauer test and be given prophylactic Anti-D immunoglobulin.
11. Further managenent :
- Further management will depend on fetal distress, the cause of the antepartum haemorrhage (APH), the extent of bleeding and gestation.
- In slight haemorrhage with blood loss less than 500 ml and no disturbance of maternal or fetal condition, ultrasound shows the placenta not lying in the lower uterine segment, no retroplacental clots, the patient may be discharged or have the baby induced, if it is after 37 weeks and other conditions are suitable.
- Placenta praevia : separate
COMPLICATIONS
1. Maternal Complications :-
- Anaemia
- Infection
- Maternal shock
- Renal tubular necrosis
- Consumptive coagulopathy
- Postpartum haemorrhage
- Psychological sequelae
- Placenta accreta
2. Fetal complications :-
- Fetal hypoxia
- Small for gestational age and fetal growth restriction
- Prematurity (iatrogenic and spontaneous)
- Fetal death
MNEMONIC
1. Antepartum hemorrhage (APH): major differential
APH
Abruptio placentae
Placenta previa
Hemorrhage from the GU tract
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