Antepartum Hemorrhage (>20 weeks)

  • 2-5% of all pregnancies
  • 10% maternal mortality
  • Can be hemodynamically stable due to ability to compensate (increased blood volume, third spacing)

Etiology:

  • Bloody show ( shedding of cervical mucous plug)
  • Placental previa
  • Abruptio placenta
  • Vasa previa
  • Marginal sinus bleeding
  • Cervical lesion (cervicitis, polyp, ectropion, cancer)
  • Uterine rupture
  • Other



 

Placental abruption

* Normally placenta separates 5-30 minutes after delivery.  In 1-2% of pregnancies it separates early (5-16% if history of abruption).
* Predisposing factors include:

  • HTN
  • Trauma
  • Smoking
  • Multiparity
  • Short cord
  • Rapid uterine decompression
  • Previous abruption
  • Alcohol consumption
  • Cocaine use
  • Maternal age >35yo
  • Uterine distension (polyhydramnios or multiple gestation)

* Classification:

Total (inevitable fetal death) vs. partial
External/revealed/apparent: blood dissects towards cervix
Internal/concealed: blood dissects towards fetus
Mixed

* Presentation

  • Pain (sudden onset, constant, localized to back and uterus)
  • Bleeding
  • Uterine tenderness
  • Uterine contractions
  • Fetal distress/demise
  • Bloody amniotic fluid

* Treatment

ABC’s, stabilize and monitor (mother and fetus)
Prepare for OR if necessary (fetus mature, haemorrhage dictates)
Observe – await fetal lung maturity (Dx via amniocentesis)
Rhogam

Placenta Previa

* Abnormal location of placenta over, or in close proximity to the internal cervical os
* Predisposing factors include:

  • Increasing maternal age
  • Multiiparity
  • Multiple gestations
  • Previous C-section, D&C, myotomy
  • Previous placenta previa
  • Uterine tumor or abnormal shape

* Classification:

Total: completely covers os
Partial: partially covers os
Marginal: within 2 cm of os
Low lying: in low segment but clear of os

* Presentation

  • Painless
  • Bleeding (@~30wks)

* Diagnosis by ultrasound

* Treatment

ABC’s, stabilize and monitor (mother and fetus)
Prepare for OR if necessary (fetus mature, haemorrhage dictates)
Observe – await fetal lung maturity (Dx via amniocentesis at 36-37weeks)
Rhogam

Vasa Previa

* Velamentous insertion of cord into membranes of placenta, unprotected fetal vessels pass over cervical os
* Presentation

  • Painless
  • Bleeding
  • Fetal distress

* Investigate bleeding wit Apt test (NaOH/KOH mixed with blood, if fetal no lysis supernatant turns pink)
* Treatment

  • Emergency C-section
  • Rhogam

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