Learning Objectives
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Evaluate patients with antepartum hemorrhage.
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List differential diagnoses for antepartum bleeding.
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Manage antepartum hemorrhage safely and promptly.
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Counsel patients on recurrence risks for antepartum hemorrhage.
Antepartum hemorrhage is defined as any bleeding from the genital tract after the 20th week of pregnancy and before the onset of labor. Antepartum hemorrhage complicates 2%–5% of all pregnancies . It is associated with increased rates of perinatal morbidity and mortality and contributes significantly to healthcare costs.
Causes of Antepartum Hemorrhage
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Placenta previa
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Placental abruption
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Uterine rupture
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Vasa previa
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Cervical lesions (such as polyps, ectropion, or malignancy)
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Infection
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Trauma
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Unknownk
Complications
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Maternal hypovolemic shock
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Premature birth
Types of Antepartum Hemorrhage
Placental Abruption ( Fig. 14.1 )
Placental abruption, or abruptio placentae, occurs when the placenta separates from the lining of the uterus prior to delivery. Patients typically present with bleeding in setting of abdominal pain. There are two types of placental abruption:
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Revealed placental abruption causes overt vaginal bleeding
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Concealed placental abruption occurs when there is no vaginal bleeding because the blood gets trapped inside the uterus behind the placenta
Placenta Previa
Placenta previa is abnormal implantation of the placenta over the internal cervical os. The classification of placenta previa has recently been simplified as follows:
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Placenta previa is defined when the placental overlies the internal cervical os (Fig. 14.2)
Fig. 14.2
(A) Placenta previa. This occurs when the placenta overlies the internal cervical os. It typically presents with painless vaginal bleeding. (B) Ultrasound image of placenta previa, with lower placental edge, completely covering internal cervical os.
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Low-lying placenta is defined when the placental edge is within 2 cm of but not covering the internal cervical os ( Fig. 14.3 )
Fig. 14.3
Ultarsound image of “low lying placenta” (lower placental edge within 2cm of internal cervical os).
Technical and nontechnical skills for antepartum hemorrhage.
Diagnosis and Evaluation
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History
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Expected due date/gestational age
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Timing and amount of blood loss (number of pads used, estimation of blood staining on each pad)
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Associated features (abdominal pain, contractions)
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Provoking factors (trauma, sexual intercourse)
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Fetal movements since the bleeding started
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Previous episodes of bleeding in current pregnancy
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Ultrasounds performed earlier in pregnancy, particularly noting placental site recorded on a 20-week (or later) scan
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Ultrasound
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Ultrasound is used to assess for placental and vascular abnormalities. This should be performed before vaginal examination
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An ultrasound scan is not the investigation of choice to diagnose a placental abruption; placental abruption is diagnosed clinically based on painful contractions and vaginal bleeding
Physical Exam
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Abdominal palpation for uterine tenderness and symphysis-fundal height, fetal lie and presentation
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Vaginal/cervical examination is contraindicated in patients who present with painless third-trimester vaginal bleeding until a placenta previa can be ruled out by ultrasound. A digital cervical exam in a patient with a placenta previa can cause catastrophic hemorrhage. After placenta previa is ruled out, a speculum exam can help identify the source of the bleeding
Laboratory Tests
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Blood type and antibody screen
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CBC
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Kleihauer–Betke test
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APTT, PT, fibrin degradation products
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Note blood loss (amount, consistency, and color)
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Assess fetal well-being
Management
Resuscitation
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Remember—changes in maternal vitals are a late sign!
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Record the patient’s pulse, blood pressure, temperature, respiratory rate, and oxygen saturation level
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Important steps for volume replacement:
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Obtain IV access with one or two 18-gauge or larger bore IV lines
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Infuse fluids at approximately the rate that blood is being lost. In initial resuscitation, fluid replacement with crystalloid is as effective as with colloid
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Insert an indwelling urinary catheter with urometer and record hourly urine output
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Consider need for blood transfusion
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Medications
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The need for analgesia should raise concerns of a moderate/severe placental abruption or that the woman is in labor. Offer analgesia and antiemetic medications if indicated
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Give corticosteroids if gestational age is less than 34 weeks
Simulation Checklist
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