Antepartum Haemorrhage (APH)
Antepartum haeomorrhage describes any PV bleed after 24 weeks gestation . There can be many causes, but eh most common are placenta praevia and placental abruption
All bleeds during pregnancy are associated with increased risk of fetal death. APH also presents a mortality risk to the mother.
Other causes of bleeding in pregnancy
- Cervical erosions / ectropion – ectropion is a normal variation of the cervical os, whereby columnar epithelium from the lining of the uterus extend down to the vaginal surface of the os. It is often seen in young women and in pregnancy. It may appear slightly inflamed, and can cause discharge and bleeding (often on contact – i.e. post-coital, but sometimes spontaneous)
- Cervical Carcinoma – just because the woman is pregnant does not mean she cant have cervical cancer too! Can be difficult to distinguish ectropion and cervical cancer from history alone (usually contact / post-coital bleeding), but cancer is more likely to be hard and irregular, whereas ectropian will look like a surface lesion.
- Cervical polyps
- Vulval varicosities
This is a condition whereby the placenta is implanted unusually low within the cervix (within the bottom 1/3), resulting in increasing risk of APH and problems during labour.
It occurs in about 1/200 pregnancies, and doesn’t usually present until >20 weeks. In instances where praevia is noted <20 weeks, it often resolves as the placenta grows.
- previous c-section
- uterine abnormalities (e.g. fibroids or previous curettage)
- older maternal age
- multiple pregnancy
There are four classifications:
- Placenta Praevia type I – the placenta is in the lower 1/3 of the uterus, and close to the cervical os
- Placenta praevia type II – the placenta reaches the edge of the cervical os
- Placenta praevia type III – the placenta partially covers the os
- Placenta praevia type IV – the placenta totally covers the os
- Painless PV bleeding, with bright red blood. Usually starts of light and becomes heavier. Sometimes there may be accompanying contractions.
- If the bleeding is especially heavy, the mother may be shocked. The degree of shock will typically correlate to the degree of blood loss
- Uterus is often soft and non-tender
- The foetus is often in an abnormal lie
- Foetal heart sounds are however usually normal
In this condition, part of the placenta separates from the lining of the uterus. Risk factors include:
- Previous pelvis surgery
It occurs after 20 weeks gestation, and in about 1% of pregnancies. Foetal mortality ranges from 20-40%.
- Usually a single instance of large blood loss
- The amount of blood loss may not be correlated to the degree of maternal shock
- Constant pain and contractions
- a hard, painful, tender, sometimes enlarged uterus
- foetal lies is usually normal
- foetal heart may be distressed / abnormal
- Placental abuption increases the risk of PPH (Post-Partum Haemorrhage)
Management of APH
- ALWAYS admit these patients!
- Give 15L O2
- Get IV access, and set up drip
- Order blood (if shocked) or crossmatch if not
- Get systolic BP >100
- Get clotting screen (for thrombophilia)
- Catheterise – keep urine output >30ml/hour
- Get expert help!
- Ultrasound (transvaginal or abdominal) and speculum exam to get diagnosis
- WARNING – digital vaginal exam can increase the bleeding in placenta praevia, - and be fatal, and thus is contra-indicated until this has been excliuded.
- If very severe at presentation, immediate delivery may be necessary
- If not immediately life threatening to mother of foetus, patients will usually require inpatient care until delivery
- Delivery is usually by elective caesarean section at 37-38 weeks
- Amniocentesis is usually performed at 36 weeks to asses foetal lung maturity in readiness for delivery
- Steroids may be considered if presentation occurs <34 weeks to accelerate fetal lung maturation in case pre-term delivery is required,
- Delivery is indicated if: massive loss of blood / maternal shock or life in danger, fetal distress noted on CTG
- Vaginal delivery is possible, but is often difficult, and results in the loss of the fetus.