APH & PPH

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ANTEPARTUM HAEMORRHAGE

Definition

  1. Bleeding from the birth canal after the 20th week (some use 24th week) of pregnancy.

Epidemiology

  1. Affects 2–5% of all pregnancies.
  2. 3 times more common in multiparous than primiparous women

Causes

  1. Idiopathic: 40%
  2. Placental abruption (abruptio placentae): 20–30%
  3. Placenta praevia: 30%
  4. Vasa praevia: Rare
  5. Uterine rupture: Rare
  6. Others: Trauma, polyps, infection, vulval varices

Placental abruption (30% of all cases of APH)

  1. Normal placenta separates from uterus prematurely and blood collects in between
  2. Incidence: <1%
  3. Risk factors/causes:
    1. High blood pressure (140/90 or greater)
    2. Trauma (usually a car accident or maternal battering)
    3. Increasing maternal age and parity
    4. Smoking, EtOH, cocaine use
    5. Premature or prolonged rupture of membranes
    6. Short umbilical cord or retroplacental fibroid
    7. Abruption in previous pregnancies (10% recurrence risk)
    8. Amniocentesis
  4. Features:
    1. PVB (80%), abdominal pain (70%), shock or fetal distress (60%), uterine contraction (35%), prem labour (25%), foetal death (15%).
  5. Inv:
    1. FBC, coags, DIC screen, XM, USS (not good at seeing haemorrhage, but may exclude placenta praevia), CTG.
  6. Mx:
    1. Resuscitate (O2, fluids, IVF/blood), urgent O&G referral, monitor for coagulopathy, consider steroids or urgent delivery. Anti-D if Rh-ve.

Placenta praevia

  1. Insertion of part/all of placenta, in the lower segment of the uterus.

Grades

  1. Grade I: placenta encroaches lower segment but does not reach the cervical os.
  2. Grade II (marginal): reaches cervical os but does not cover it.
  3. Grade III (partial): covers part of the cervical os.
  4. Grade IV (total): completely covers the os, even when the cervix is dilated.

Risk factors/causes

  1. prior praevia/LSCS/TOP, multiparous, multiple gestations, advanced maternal age, smoking

Features

  1. Bright red, painless & recurrent PVB ± shock. Usually >32/40._ Don’t perform VE
  2. Inv: USS 95% sens, FBC, XM, Kleihauer-Betke test (quantifies fetal RBC:maternal RBC)
  3. Mx: Monitor mother & foetus, IV fluids, consider steroids ± delivery (LSCS if Grade II/IV). Anti-D if Rh-ve.
  4. Cx: Placenta accreta (abnormally firm attachment of placenta to uterine wall).

Vasa praevia (bleeding from fetal vessels in the fetal membranes)

  1. Incidence <0.3%
  2. Umbilical cord vessels may attach laterally to membranes instead of placenta.
  3. Features:
    1. PVB –before or often after labour begins. Foetal distress . Mother stable.
  4. Inv:
    1. abnormal CTG, USS (bi-lobed placenta or poor placental blood flow). Apt test (qualitative test for presence of HbF) on vaginal blood.
  5. Mx:
    1. Immediate LSCS.

Uterine rupture

  1. Rare but very dangerous for both mother and baby.
  2. Risk factors:
    1. Prior uterine surgery incl LSCS (40%), grand multip, trauma, excessive oxytocin, shoulder dystocia, certain types of forceps deliveries
  3. The rupture may occur before or during labour or at the time of delivery.
  4. Mx:
    1. Urgent surgical delivery.

Other Causes

  1. Idiopathic in ~40%.
  2. Local causes, e.g. vulval or cervical infection, trauma or tumours.
  3. Inherited bleeding problems are very rare, occurring in 1 in 10,000 women.

Complications

  1. Premature labour
  2. Disseminated intravascular coagulopathy
  3. Renal tubular necrosis
  4. Postpartum haemorrhage

Prognosis

  • APH has been found to be an independent risk factor for perinatal mortality.
  • The fetus may die from hypoxia during heavy bleeding.
  • Perinatal mortality low if expertly managed & no VE before admission to hospital.

POSTPARTUM HAEMORRHAGE

  1. Primary PPH: Bleeding from birth canal in 1st 24h >500ml post-vaginal delivery or 1L post-CS.
  2. Secondary PPH: Bleeding in excess of normal lochial loss after 24h.
  3. Epidemiology: Most common cause of maternal death.

Causes

  1. Primary:
    1. Atonic uterus, trauma, retained placenta, coagulopathy.
  2. Secondary:
    1. RPOC, infection
  3. RF:
    1. Multiple pregnancy, polyhydramnios, macrosomia, abnormal uterus, long/precipitate delivery, coagulopathy (pre-eclampsia, HELLP, abruption, sepsis, drugs, IUFD), forceps, CS, previous PPH.

Management

Primary

  1. IVC x 2, Fluid/blood, give ergometrine syntocinon, rub uterus, compress uterus if soft/boggy, manually remove placenta, suture any local canal lacerations, external abdo aortic compression, transexamic acid, misoprostol, ?Factor VII, uterine packing or balloon tamponade, selective arterial embolisation, or Sx (suture, arterial ligation, hysterectomy)

Secondary

  1. ABC, fluids, analgesia, ergometrine 0.5mg IV/IM, ampicillin, gentamicin & metronidazole, D&C