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Antepartum Haemorrhage. Max Brinsmead PhD FRANZCOG March 2010. 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
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Antepartum Haemorrhage Max Brinsmead PhD FRANZCOG March 2010
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 compromised • Is the fetus salvageable • 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
