Antepartum Haemorrhage

Max Brinsmead MB BS PhD April 2015

When confronted with a pregnant patient who is bleeding after 20w

There are five questions that need urgent answers…

How much blood has been lost What is the maternal condition What is the fetal condition Is the patient in labour What is the cause of the bleeding

THINK in terms of aetiology...

Bleeding from a normally situated placenta = Abruption

Bleeding from a low placenta = Placenta previa

Cervical bleeding:• “Show”• Ectropion or Cancer

Other sites of bleeding i.e. rectal or urethral

• rare Fetal bleeding

• rare but serious

ACT in terms of priority...

Assess maternal wellbeing Resuscitate if required Anticipate further problems

Assess fetal wellbeing Is the fetus salvageable Is the fetus compromised

Then attempt diagnosis

Essential observations

Maternal vital signs• General appearance• Pulse and BP

Uterus• Size• Tone and tenderness• Contractions• You can’t do this with CTG belts in place

Nature and amount of PV loss Just blood or blood and liquor

Fetus• Fetal heart present or absent

Discretionary observations

Fetal lie, presentation and engagement

• A deeply engaged presenting part excludes major previa

Speculum examination of the cervix• For minor APH where a cervical cause is

expected Digital examination of the cervix

• For the patient in labour with an engaged presenting part

• Also helpful if a prior scan has shown a non previa placenta

Essential Investigations

HB, Blood group and save or Xmatch• Depends on the amount of blood lost• And the suspected diagnosis• Remember that abruption is often associated with

a large concealed loss Ultrasound

• Best done “on the ward” if bleeding is substantial• Requires skill in distinguishing blood clot from

placenta• Vaginal scan the best way of evaluating degrees

of placenta previa Urinalysis for proteinuria

• May require bladder catheterisation• Abruption may be associated with “acute” pre

eclampsia• And the blood pressure may not be raised

Discretionary investigations

Clotting studies• Platelets, COAG and FDPs• Only of help in management of severe APHs

Maternal Kleihauer• Only useful for assessing Anti-D dose in Rh

negative patients

A bedside test for Fetal Haemoglobin• Useful if fetal bleeding is suspected• Typically occurs with ARM or SROM in labour• Apt’s test using 1% NaOH

Immediate management

Large bore IV line• If estimated loss is >250 ml• Or if abruption or placenta previa is diagnosed

Resuscitate with IV Fluids• Commence with saline• Colloids if shocked• Blood if estimated loss >2 L

Analgesia Corticosteroids for gestation <37wks Anti-D if Rh negative

• Dose according to Kleihauer

Monitoring response

Maternal PR and BP• Watch for pre eclampsia

Indwelling catheter• Hourly urine output• Only a few require CVP

Watch for coagulopathy• A bedside test of clotting• Prothrombin time (aPTT) and platelets• HB takes a while to adjust

CTG and umbilical Dopplers for the fetus

Definitive management

Conservative for placenta previa• Most will settle• Deliver when paediatric resources permit• CS if placenta within 2 cm of internal os

Aggressive management for abruption

• CS sooner rather than later for fetal reasons• And the role of CS in averting maternal

coagulopathy even with FDIU requires RCT

Watch for preterm labour for all others• Observe in hospital