Obstetrics & Gynaecology
A 17 year old girl presents to the Emergency Department with a 1 hour history of vaginal bleeding. She tells you she is 28 weeks pregnant. You are considering the potential causes. Which of the following clinical findings is most consistent with placenta praevia?
Answer:
| Placenta praevia | Placental abruption |
|---|---|
| Painless | Painful |
| Soft non-tender uterus | Tender 'woody' uterus on palpation |
| No signs of foetal distress | Foetal distress |
| Clinical shock in proportion to visible PV bleed | Clinical shock out of proportion to visible PV bleed |
Antepartum Haemorrhage
Obstetrics & Gynaecology
Last Updated: 12th February 2021
Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby. The most important causes of APH are placenta praevia and placental abruption, although these are not the most common.
- Minor haemorrhage – blood loss less than 50 ml that has settled
- Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock
- Massive haemorrhage – blood loss greater than 1000 ml and/or signs of clinical shock
| Placenta praevia | Placental abruption |
|---|---|
| Painless | Painful |
| Soft non-tender uterus | Tender 'woody' uterus on palpation |
| No signs of foetal distress | Foetal distress |
| Clinical shock in proportion to visible PV bleed | Clinical shock out of proportion to visible PV bleed |
Placenta praevia
Placenta praevia occurs when the placenta is inserted wholly or in part into the lower segment of the uterus. It is classified as major if the placenta is covering the internal os of the cervix, or minor if the leading edge is in the lower segment but not covering the os.Placea
Risk factors include:
- Previous placenta praevia
- Previous caesarean sections
- Previous termination of pregnancy
- Multiparity
- Advanced maternal age (>40 years)
- Multiple pregnancy
- Smoking
- Deficient endometrium due to presence or history of: uterine scar, endometritis, manual removal of placenta, curettage, submucous fibroid
- Assisted conception
It may be an incidental finding on a routine anomaly ultrasound or it may present with painless bleeding usually after the 28th week. Typically it is sudden and profuse, but does not last long and is rarely life-threatening. There may be a high presenting part or abnormal lie of the foetus. There is a high risk of preterm delivery. It is considered good practice to avoid vaginal and rectal examinations in women with placenta praevia, and to advise these women to avoid penetrative sexual intercourse.
Placental abruption
Placental abruption is the premature separation of a normally placed placenta before delivery of the foetus with blood collecting between the placenta and the uterus. It may be classified as concealed (20% of cases) where the haemorrhage is confined within the uterine cavity or revealed (80% of cases) where blood drains through the cervix.
Risk factors include:
- Previous placental abruption
- Pre-eclampsia
- Fetal growth restriction
- Non-vertex presentations
- Polyhydramnios
- Advanced maternal age
- Multiparity
- Low body mass index (BMI)
- Pregnancy following assisted reproductive techniques
- Intrauterine infection
- Premature rupture of membranes
- Abdominal trauma
- Smoking and drug misuse (cocaine and amphetamines) during pregnancy
Patients may present with vaginal bleeding, continuous abdominal pain, uterine contractions, shock or foetal distress. A tense, tender uterus with a ‘woody’ feel may be palpated on abdominal examination. Patients may be haemodynamically compromised, out of proportion to the degree of visible blood loss. Platelet count may be low, and coagulopathy is common. Ultrasound is not reliable at identifying abruption.
Assessment
- The role of clinical assessment in women presenting with APH is first to establish whether urgent intervention is required to manage maternal or fetal compromise. The process of triage includes history taking to assess coexisting symptoms such as pain, an assessment of the extent of vaginal bleeding, the cardiovascular condition of the mother, and an assessment of fetal wellbeing. The mother is the priority in these situations and should be stabilised prior to establishing the fetal condition.
- Examination
- Abdominal exam
- The woman should be assessed for tenderness or signs of an acute abdomen. The tense or ‘woody’ feel to the uterus on abdominal palpation indicates a significant abruption. Abdominal palpation may also reveal uterine contractions. A soft, non-tender uterus may suggest a lower genital tract cause or bleeding from placenta or vasa praevia.
- Speculum exam
- A speculum examination can be useful to identify cervical dilatation or visualise a lower genital tract cause for the APH.
- Digital vaginal exam
- If placenta praevia is a possible diagnosis (for example, a previous scan shows a low placenta, there is a high presenting part on abdominal examination or the bleed has been painless), digital vaginal examination should not be performed until an ultrasound has excluded placenta praevia. Digital vaginal examination can provide information on cervical dilatation if APH is associated with pain or uterine activity.
- Abdominal exam
Investigations
- Blood tests
- In cases of major or massive haemorrhage, blood should be analysed for full blood count and coagulation screen and 4 units of blood cross-matched. Urea, electrolytes and liver function tests should be assayed. The initial haemoglobin may not reflect the amount of blood lost and therefore clinical judgement should be used when initiating and calculating the blood transfusion required. The platelet count, if low, may indicate a consumptive process seen in relation to significant abruption; this may be associated with a coagulopathy.
- In minor haemorrhage, a full blood count and group and save should be performed. A coagulation screen is not indicated unless the platelet count is abnormal.
- The Kleihauer test should be performed in rhesus D (RhD)-negative women to quantify fetomaternal haemorrhage (FMH) in order to gauge the dose of anti-D immunoglobulin (anti-D Ig) required.
- Ultrasound
- Women presenting with APH should have an ultrasound scan performed to confirm or exclude placenta praevia if the placental site is not already known. Ultrasound scanning is well established in determining placental location and in the diagnosis of placenta praevia.
- Placental abruption is a clinical diagnosis and there are no sensitive or reliable diagnostic tests available. However, when the ultrasound suggests an abruption, the likelihood that there is an abruption is high.
- Fetal investigation
- An assessment of the fetal heart rate should be performed, usually with a cardiotocograph (CTG) in women presenting with APH once the mother is stable or resuscitation has commenced, to aid decision making on the mode of delivery.
- Ultrasound should be carried out to establish fetal heart pulsation if fetal viability cannot be detected using external auscultation.
Management
- Women presenting with spotting who are no longer bleeding and where placenta praevia has been excluded can go home after a reassuring initial clinical assessment.
- All women with APH heavier than spotting and women with ongoing bleeding should remain in hospital at least until the bleeding has stopped.
- Women with APH and associated maternal and/or fetal compromise are required to be delivered immediately. If the fetus is compromised, a caesarean section is the appropriate method of delivery with concurrent resuscitation of the mother. Delivery of the fetus and placenta will control bleeding by allowing the uterus to contract and stop bleeding from the site of placental separation, and will also remove placental tissue, a source of production of coagulation activators which predisposes to the development of DIC.
- Anti-D Ig should be given to all non-sensitised RhD-negative women after any presentation with APH, independent of whether routine antenatal prophylactic anti-D has been administered.
- Initial management of massive APH
- ABCD assessment
- A high concentration of oxygen (10–15 litres/minute) via a facemask should be administered.
- Establish two 14-gauge intravenous lines; a 20 ml blood sample should be taken and sent for diagnostic tests, including full blood count and assessment of FMH if RhD-negative, coagulation screen, urea and electrolytes and cross match (4 units)
- Position in left lateral tilt
- Keep the woman warm using appropriate available measures
- Transfuse blood as soon as possible; if cross-matched blood unavailable and the clinical situation is urgent, give uncrossmatched group-specific blood or give O RhD-negative blood; consider the use of red-cell salvage if available
- Until blood is available, infuse up to 3.5 litres of warmed crystalloid Hartmann’s solution (2 litres) and/or colloid (1–2 litres) as rapidly as required
- With continuing massive haemorrhage and whilst awaiting coagulation studies, up to 4 units of FFP and 10 units of cryoprecipitate (two packs) may be given empirically
- Assess the fetus and decide on delivery
- The main therapeutic goal of the management of massive blood loss is to maintain:
- Haemoglobin > 8 g/dl
- Platelet count > 75 x 109/l
- Prothrombin time < 1.5 x mean control
- Activated partial prothromboplastin time < 1.5 x mean control
- Fibrinogen > 1.0 g/l.
Complications
- Maternal
- Anaemia
- Infection
- Maternal shock
- Renal tubular necrosis
- Consumptive coagulopathy
- Postpartum haemorrhage
- Prolonged hospital stay
- Psychological sequelae
- Complications of blood transfusion
- Fetal
- Fetal hypoxia
- Small for gestational age and fetal growth restriction
- Prematurity (iatrogenic and spontaneous)
- Fetal death
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
