Antepartum Haemorrhage

Question 1

A woman at 35 weeks gestation presents with vaginal bleeding. This began 15 hours ago after she felt some wetness . There has been no pain but the bleeding has been consistent.
On CTG the foetus shows signs of bradycardia
What is the most likely cause?

Answer 1

Vasa previa

this is the classic triad of symptoms - rupture of membranes, painless bleeding and foetal bradycardia (+/- decelerations)

Question 2

What is the definition of antepartum haemorrhage?

Answer 2

This is when there is vaginal bleeding anytime from 24 weeks gestation up until the second stage of labour.

Question 3

How many mls is classified as a minor bleed?

Answer 3

<500mls

Question 4

To classify a major haemorrhage, how much blood would be lost?

Answer 4

500-1000mls

Question 5

In a massive haemorrhage, how much blood would be lost?

Answer 5

> 1000 mls

+/- clinical signs of shock

Question 6

A term used to describe a placenta laying either partially or fully over the cervical os:

Answer 6

Placenta previa

Question 7

If a woman is shown to have a low lying placenta at 18-24 weeks what is done?

Answer 7

Another follow up scan at 32 weeks to see if placenta has moved.
If unsure, a trasnvaginal scan should be done

Question 8

How does placenta previa typically present?

Answer 8

Painless fresh red bleeding

Question 9

What cause of antepartum haemorrhage can also be a cause of abnormal foetal lie?

Answer 9

Placenta previa

Question 10

What are some of the risk factors for placenta previa?

Answer 10

Age
Previous c - section (placenta embeds in scar)
Previous placenta previa

Question 11

A patient presents 36 weeks gestation with severe abdominal pain. They are not bleeding but are clinically shocked with a BP of 86/60. What is the likely diagnosis?

Answer 11

Concealed placental abruption

No vaginal bleeding is why it’s termed concealed as the blood is being concealed behind the placenta

Question 12

What is the definitive management for placental abruption?

Answer 12

Emergency c-section

Question 13

What are some of the consequences of a placental abruption?

Answer 13

Intrauterine death
Post-partum haemorrhage
All other medical consequences of haemorrhage including DIC, shock, hypovolaemia, multiorgan failure

Question 14

What are some of the main risk factors for placental abruption?

Answer 14

Pre eclampsia
Unknown 
Hypertension
Cocaine / drug abuse
Smoking
Renal disease / diabetes / medical thrombophilia
Abnormal placenta / previous abruption
Polyhydramnios / multiple pregnancy

Question 15

What is the pathology of vasa previa?

Answer 15

This is when foetal blood vessels in the membrane are lying to close to the os.

Question 16

Vasa previa does not carry any significant maternal risk. True or false?

Answer 16

True. Unless there are further complications there is mainly only risk to the foetus.

Question 17

What is the theoretical mechanism behind placental aburption?

Answer 17

Vasospasm followed by rupture of the arteriole in the decidua, blood then escapes into the amniotic sac or under the placenta and into the myometrium. This then leads to clonic contraction of the uterus, clamping on the placental blood supply causing hypoxia

Question 18

What is the term given to the bluish uterus seen in a placental abruption?

Answer 18

Couvelaire Uterus
Caused by blood between muscle fibres so the uterus appears blue and the uterus doesn’t contract well increasing the risk of postpartum haemorrhage.

Question 19

List some of the clinical signs of placental abruption:

Answer 19

Unwell / distressed patient
(Not necessarily blood to show)
Hypovolaemia
Uterus large for dates
Hard woody uterus
Preterm labour
Foetal parts hard to find
Bradycardia or absence of foetal HR

Question 20

What will be seen on a CTG in placental abruption?

Answer 20

Irritable uterus with a "zig zag" pattern and minimal contractions 
Foetal tachycardia (or in later stages bradycardia or intrauterine death)
Loss of variability and late decelerations

Question 21

What is the normal range for variability on a CTG?

Answer 21

5-25

Question 22

What are the principles of management in placental abruption?

Answer 22

Manage mum first - maternal resus
Emergency delivery of baby (C-section)
Administer Anti-D if needed
Debrief later with families regarding future risks in pregnancy

Question 23

Is vasa previa routinely screened for?

Answer 23

No it is extremely rare

Question 24

What is the foetal mortality rate of vasa previa?

Answer 24

60%

Question 25

What are the main principles of management in vasa previa?

Answer 25

Detection early 
Steroids from 32 weeks
? inpatient management if high risk 
Elective c-section 34-36 weeks
Placenta to histology to confirm diagnosis

Question 26

In a patient with acute maternal collapse in the absence of bleeding and a soft uterus - foetal parts being palpable, what diagnosis should be considered?

Answer 26

Uterine rupture

This is mainly a clinical diagnosis - any suspicion and emergency surgery is probably the right answer as their is a high mortality rate for both mother and baby

Question 27

What are some potential risk factors for uterine rupture?

Answer 27

Previous uterine surgery which breached the uterine cavity e.g. c-section, myotomy, fibroid removals etc
Multiparity
Obstructed labour
Over stimulation through excessing infusions of syntocinon or prostaglandins

Question 28

How is a uterine rupture managed?

Answer 28

Emergency c section and foetal resus if required

Hysterectomy is sometimes needed depending on the uterine damage

Question 29

What are some of the risk factors for vasa previa?

Answer 29

IVF / assisted conception
Multiparity
Abnormal placenta (lobed)
Multiple pregnancy
History of low lying placenta in 2nd trimester in previous pregnancies

Question 30

Describe a Type 1 vasa previa

Answer 30

There is a velamentous insertion to the umbilical cord with vessels running over the surface of the os.

Question 31

Describe a Type 2 vasa previa

Answer 31

This is where there is a succenturiate or accessory lobe and there are unprotected vessels running between them and the main body of the placenta

Question 32

What investigation would be appropriate in a query vasa previa?

Answer 32

Doppler USS initially transabdominal and then transvaginal if appropriate

Question 33

Why does vasa previa have a significantly high foetal mortality rate?

Answer 33

Baby is at risk of bleeding to death

Painless usually

Question 34

Why does placental abruption sometimes lead to massive PPH?

Answer 34

The blood caught in the myometrium of the uterus prevents it from properly contracting one the baby has been delivered.
Uterine atony is the commonest cause of PPH