ANTEPARTUM

HAEMORRHAGE

Eileen Whitehead 2010

East Lancashire Hospitals NHS Trust

ANTEPARTUM

HAEMORRHAGE

Definition

Bleeding from the vagina any time after 24 weeks

gestation until the birth of the baby

Blood loss greater than 300mls or any amount

causing hypovolaemic shock

Incidence 3-5% of all pregnancies

ANTEPARTUM

HAEMORRHAGE

One of the leading causes of:

antenatal hospitalization

maternal morbidity

operative intervention

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HAEMORRHAGE

Causes:

1. Placenta praevia

2. Placental abruption

3. Uterine scar disruption

4. Vasa praevia

Life

Threatening

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HAEMORRHAGE

Can also be caused by:

Unexplained accidental haemorrhage

Incidental haemorrhage – vulval veins, polyps,

cervical cancer, cervicitis and vaginal trauma

ANTEPARTUM

HAEMORRHAGEPlacenta Praevia - the implantation of the placenta

over or near the internal os of the cervix.

ANTEPARTUM

HAEMORRHAGE

Risk factors:

Previous caesarean section

High parity

Advanced maternal age

Smoking

Multiple gestation

ANTEPARTUM

HAEMORRHAGE

Placental Abruption - is the premature separation

of the placenta from the uterine wall.

This can be either:

Partial

Complete

Concealed

Visible

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HAEMORRHAGE

ANTEPARTUM

HAEMORRHAGE

Risk factors include:

Hypertensive disease of pregnancy

Smoking

Substance abuse

Trauma

Overdistension of the uterus

History of previous abruption

ANTEPARTUM

HAEMORRHAGE

Uterine Scar Disruption can be:

An occult separation, thinning or dehiscence that is

discovered at repeat caesarean section.

Complete uterine rupture which is symptomatic

requires emergency laparotomy

ANTEPARTUM

HAEMORRHAGE

Monitor tracing demonstrating fetal heart rate

decelerations, and continuation of uterine contractions in

a patient with uterine rupture

ANTEPARTUM

HAEMORRHAGE

Risk factors include:

Previous uterine scar

Inappropriate oxytocin usage

Trauma

Congenital uterine anomaly

Uterine over distension

Difficult manual removal of the placenta

ANTEPARTUM

HAEMORRHAGE

Vasa Praevia - The presence of fetal vessels from

the placenta crossing the internal os of the

cervix

May be due to either:

Velamentous insertion of the cord

Succenturiate lobe

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HAEMORRHAGE

Type 1 vasa praevia with velamentous insertion of the cord

Type 2 vasa praevia with vessels running between the main placenta and succenturiate lobe

Type 1 Type 2

Succenturiate

lobe

Velamentous

Insertion

Placenta

Placenta

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HAEMORRHAGE

Risk factors include:

Multiple pregnancies

Second-trimester low-lying placentas

Succenturiate lobed placentas

Pregnancies resulting from in vitro fertilization

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HAEMORRHAGE

TREATMENT

ANTEPARTUM

HAEMORRHAGE

Accurate and timely identification of the cause of

the bleeding

A team approach which optimizes patients

safety

Well timed intervention specific to the diagnosis

ANTEPARTUM

HAEMORRHAGE

History

Any initiating factors

Amount of bleeding

Abdominal pain

Contractions

SRM

Previous vaginal bleeding

Fetal movements

Placental site (scan)

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HAEMORRHAGE

Maternal Assessment

General Condition: TPR, BP, Pallor

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HAEMORRHAGE

Abdominal Examination:

Pain or contractions

Tender, tense or irritable uterus (abruption)

Soft uterus, high head (placenta praevia)

Bleeding coinciding with SRM (vasa praevia)

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HAEMORRHAGE

Speculum Examination

Assess amount of bleeding

Is liquor present

Cervical dilatation

Other obvious cause of bleeding

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HAEMORRHAGE

Note - speculum examination

should only be carried out:

By a doctor - whatever the duration

of pregnancy

If there is no suspicion of placenta

praevia

In theatre if the bleeding is heavy

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HAEMORRHAGE

Fetal Assessment

Fetal position

Fetal heart rate

CTG > 28 weeks

Kleihauer

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HAEMORRHAGE

In the case of severe bleeding call for:

Experienced midwife

Obstetric registrar

Anaesthetic registrar

Neonatologist registrar

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HAEMORRHAGE

IV access with 14 G cannula

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HAEMORRHAGE

Obtain blood for

Group and Cross match 4 units

Full blood count

U&E

LFT

Coagulation screen and FDP

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HAEMORRHAGE

Transfuse

1 litre of crystalloid

(Normal Saline or

Hartmans)

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HAEMORRHAGE

Continuous Blood Pressure

Pulse Oximeter

Foley catheter

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HAEMORRHAGE

Options for further treatment, e.g. steroids,

theatre, depends on findings and

observations

ANTEPARTUM

HAEMORRHAGE