Antepartum Hemorrhage

Family Medicine Specialist CMEUniversity of Health Sciences

Objectives

For antepartum hemorrhage:• Describe and define the two major causes of

bleeding in pregnancy • Discuss the history and clinical examination

for a patient presenting with bleeding in pregnancy

• Describe the management and care of a pregnant patient with bleeding

Clinical Case

20 year-old G3P1A1 female presents to the district hospital with vaginal bleeding. She is pregnant but is unsure of her dates as she got pregnant while breastfeeding. You can palpate a fetus in a breech position and the fetal heart rate is heard.

What is the differential diagnosis?What questions are you going to ask her?What is your management plan for her?

Antepartum Hemorrhage

Definition

Antepartum Hemorrhage

Definition:

Vaginal bleeding from 22 weeks to term or delivery.

Incidence and Etiology

• Incidence: – Occurs in 2% - 5% of all pregnancies

• Etiology:– Placental abruption (40%)– Placenta previa (20%)– Unclassified (35%)– Lower genital tract (5%)

Definition

Placental Abruption• Premature separation of

the placenta from the uterine wall

Placenta Previa• Implantation of the

placenta in the lower segment of the uterus either close to or over the internal cervical os

• Total/complete previa – entirely covers the os

• Partial previa – partially covers the os

• Marginal previa – placenta lying close to the os

Placenta Previa Classification

Complete Previa Partial Previa Marginal Previa

Risk FactorsPlacental Abruption• Idiopathic• Maternal hypertension• Prior abruption• Abdominal trauma –

MVA/Assault/Falls• Substance Abuse - Maternal

smoking/Alcohol/Cocaine• Multiparity• Advanced maternal age• Uterine malformation• Rapid uterine decompression -

PROM

Placenta Previa

• Prior cesarean section or uterine surgery

• Multiple gestation• Advanced maternal age• Multiparity• Smoking• Prior placenta previa

HistoryPlacental Abruption

• Abdominal pain • Backache• Prior hypertension• Trauma• Fall• Assault

Placenta Previa

• Prior uterine surgery or cesarean section

• Painless bleeding

ExaminationPlacental Abruption• Vital signs – Shock out of

proportion to blood loss• Uterus – tender, increased

tone, irritable, contractions • Normal fetal presentation• Abnormal or absent fetal

heart rate

Placenta Previa• Vital signs – Shock

corresponds to blood loss• Uterus – soft, not tender,

no irritability or contractions

• Abnormal fetal presentation or high presenting part

• Normal fetal heart rate

Diagnosis

Placental Abruption• Ultrasound – Abdominal

may be diagnostic but a negative ultrasound does not rule out abruption

Placenta Previa• Ultrasound – Definitive

diagnosis • Better with transvaginal

ultrasound but can be made with abdominal ultrasound

• 75% of women will have a bleed in the early third trimester

• Must be at a hospital that can perform cesarean section

Clinical Management

• Call for HELP• ABC’s -Airway/Breathing/Circulation• Talk to the patient – explanation & plan• Monitor vital signs• Elevate legs/roll to side to avoid aspiration• Obtain History and do Examination

– NO CERVICAL EXAM UNTIL PREVIA RULED OUT• Pelvic ultrasound to locate placenta• Ausculate for fetal heart rate

Clinical Management - 2• Laboratory

– CBC– Type and Screen/Crossmatch for blood– PT/PTT

• Provide oxygen to mother• 2 Large bore IV’s 16/18 with Normal Saline or

Ringer’s Lactate (1 L in 20 minutes)• Reassess maternal & fetal status• Transfer to facility where a cesarean section can

per performed when patient stable

Clinical Management – 3Unstable Patient

• Primary objective:– Fluid replacement– Delivery

• Simultaneously:– Oxygen to mother & O2 saturation– Active fluid resuscitation in 1 H - 2 larger bore IV’s

rapidly infuse 2 L Normal saline/Ringer’s Lactate – Assessment of maternal vital signs/urine output– Continuously monitor fetal well-being

Clinical Management – 4Unstable Patient

• Arrange for delivery– Transfer if required– Possible Cesarean section

• Placenta previa (partial or complete)• Abruption with unstable maternal or fetal status

Clinical Management – 5Stable Patient

• Maternal & fetal surveillance for 12 – 24 hours• If abruption secondary to abdominal trauma –

monitor for minimum of 4 hours after trauma• Attention to maternal hemodynamic status –

at risk for subsequent bleed• If preterm, expectant management• Transfer to higher risk facility if indicated

Bedside Clot test - Coagulopathy

• 2 mLs of venous blood in plain glass tube• Hold tube in closed fist to keep it warm• After 4 minutes, tip the tube slowly to see if

clot is forming. Tip every minute until the blood clots and tube can be turned upside down

• Failure of a clot after 7 minutes or a soft clot suggests coagulopathy

Clinical Case

20 year-old G3P1A1 female presents to the district hospital with vaginal bleeding. She is pregnant but is unsure of her dates as she got pregnant while breastfeeding. You can palpate a fetus in a breech position and the fetal heart rate is heard.

What is the differential diagnosis?What questions are you going to ask her?What is your management plan for her?

Conclusion

• Antepartum hemorrhage most often due to:– Placental abruption– Placenta previa

• Primary difference is presence or absence of abdominal pain

• Rapid diagnosis and appropriate treatment required to prevent maternal and neonatal mortality

• May need to transfer patient for appropriate care for mom and baby