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Antepartum Haemorrhage, Basic principles of resuscitation should be…
Antepartum Haemorrhage
Epidemiology
Definition: Bleeding from or into the genital tract, occuring from 24 weeks of pregnancy and prior to delivery of the baby
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Obstetric haemorrhage:
Cause of up to 50% of estimated 500,000 maternal deaths per year. 6th highest direct cause (2006-2008 UK Confidential Enquiry)
No consistent definitions for severity as amount often underestimated. Presence of fetal compromise is an indicator of volume depletion.
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UK maternal mortality rate <1/100,000
Causes
Placenta Praevia
Risk factors
- Previous placenta praevia
- Previous C/S: Risk increases with increasing C/S
- Previous TOP
- Multiparity
- Advanced maternal age
- Multiple pregnancy
- Smoking
- Deficient endometrium: Uterine scar, manual removal, curettage, submucous fibroid, endometritis
- Assisted reproductive techniques
Placental Abruption
Risk factors
- Previous abruption (risk is 19-25% if 2 previous abruptions)
- Pre-eclampsia
- Fetal growth restriction
- Non-vertex presentations
- Polyhydramnios
- Advanced maternal age
- Multiparity
- Low BMI
- Assisted reproductive techniques
- Smoking and drug use (cocaine and amphetamines)
- Intrauterine infection
- Abdominal trauma (accidental, domestic violence)
- Premature rupture of membranes
- First trimester bleeding +/- intrauterine haematoma
- Maternal thrombophilias
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Can be concealed: Consider if classic signs of hypovolaemia present (tachycardia, hypotension) in the absence of revealed bleeding
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Unexplained/marginal
Increased risk of preterm delivery, small babies, stillbirth, and fetal anomalies
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Management
Access and resuscitation
- 2 large bore cannulae
- Bloods: FBC, G&S, cross-match 4 units, U&Es, LFTs, coagulation screen
- Start IV fluid resuscitation
Clinical assessment
- Abdominal palpation
- Speculum examination
- Ultrasound assessment
APH with maternal/fetal compromise
- Expedite delivery: Instrumental/Caesarean section
- Prepare for PPH: Active 3rd stage, synto infusion following delivery
APH without maternal/fetal compromise (term pregnancy)
- Placenta low-lying: Admit. IV access. Bloods and cross match. Twice daily CTG. Consider formal US. Senior review. Can go home if bleeding settles for 24 hours.
- Placenta NOT low-lying: Admit. Consider induction of labour.
APH without maternal/fetal compromise (preterm pregnancy)
- Admit
- IV access + bloods
- Steroids if appropriate
- Discuss with neonatal team: Consider transfer to appropriate NICU if <34 weeks
- Ultrasound if none recent
- CANNOT do fetal fibronectin
Spotting including post-coital: Home if stopped, placenta not low, cervical ectropion or cervicitis on speculum
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Mild bleeding: Home if observations stable, ultrasound normal, bleeding settled for 24 hours
Complications
Maternal
- Anaemia
- Infection
- Shock/collapse
- Renal tubular necrosis
- Consumptive coagulopathy
- Postpartum haemorrhage
- Prolonged hospital stay
- Psychological sequelae
- Complications of blood transfusion
Fetal
- Hypoxia
- Anaemia
- SGA/IUGR
- Prematurity
- Death
Assessment
Full history
Association with pain/contractions: Consider abruption if pain is continuous and labour if pain is intermittent. Abruption with a posterior placenta may present with back pain.
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Volume/type, onset, triggers, duration of bleeding
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Examination
Fetal: CTG/fetal heart auscultation, gestation, presentation/lie
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Abdominal palpation: Abruption is associated with a tense woody abdomen. Soft, non-tender uterus suggests placenta praevia or lower genital tract cause.
Speculum examination: Useful in identifying cervical dilatation or lower genital tract cause for APH
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Investigations
Bloods: FBC, G&S, cross-match 4 units, U&Es, LFTs, coagulation screen
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Ultrasound: Can be used to diagnose placenta praevia but does not exclude abruption. Review previous US and placental location.
General Principles
Following APH, the pregnancy should be classified as high risk and increased fetal surveillance (serial growth scans) performed due to risk of oligohydramnios, PROM, SGA/FGR, preterm labour, and C/S delivery.
Anti-D Ig should be given to all non-sensitised Rhesus negative women after any presentation with APH. If recurrent after 20 weeks, give at 6 weekly intervals. Administer 500 IU followed by Kleihauer to identify FMH >4mls red blood cells, in which case additional anti-D should be given.
Women on anti-coagulant therapy should be advised to stop medication in the event of vaginal bleeding and to attend hospital immediately. Postpartum, recommence due to the risk of VTE.
Avoid vaginal and rectal examinations in women with placental praevia, and advise avoiding penetrative sexual intercourse
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Basic principles of resuscitation should be adhered to in all women presenting with collapse or major haemorrhage (ABCDE) - Major obstetric haemorrhage pathway 2222
Volume of vaginal loss may not represent true volume of total blood loss - Degree of maternal/fetal compromise is an indicator of volume depletion