Antepartum Haemorrhage

Question 1

30yo G3P2 presents at 24 weeks with PV bleeding.

2020 stem: Pt 22 weeks with painless PV bleeding (1 pad). Foetal movements still felt. Hx/Ex/Ix/short term Mx/long term Mx. Now the patient is 32 weeks pregnant and has PV bleeding : ½ cup bright red blood + mid abdominal pain. Hx/Ex/Mx

Answer 1

Impression:
This lady presents with an antepartum haemorrhage given >20wks gestation. stratified according to size of bleed:
- spotting:
- minor: <50mL
- major: 50-1000mL
- massive: >1L and signs of shock.

Concerned about vasa praevia, or other placental abnormalities including placenta praevia, placental abruption, early onset of labour, or other causes of PV bleeding unrelated to pregnancy

Priorities

• ensure haemodynamic stability, exclude complications of significant APH
• provide appropriate treatment and management

Question 2

Antepartum haemorrhage - Assessment

Answer 2

Assessment
Check for ongoing and active bleeding, assess for evidence of hypovolaemic shock
A -
B -
C - 2xIVC access, ECG, BP monitoring, consider IV fluid resus/blood transfusion if massive (>1L bleed) and evidence of haemodynamic compromise. Send bloods: FBC, group + xmatch, kleihauer (to titrate how much anti-D if Rh -ve), coags, LFT, UEC, VBG (POC)
D -
E - abdominal ultrasound, CTG monitoring.

Question 3

Antepartum haemorrhage - History

Answer 3

History

• sx: bleeding onset, duration, volume (number of pads), colour, clots
• associated sx: abdo pain, fetal movements, vaginal discharge, consequences of blood loss (loc, hypotension - signs of shock)
• RISK: past CS, previous placental abnormalities, SNAP, multiparty
• antenatal history: scans, LMP/gestational age, infective status (GBS, STI, etc), rh status
• PMHx, PSHx
• Medications

Question 4

Antepartum haemorrhage - Examination

Answer 4

Examination

• general appearance + vital signs
• document any ongoing/stopped blood loss
• Abdominal palpation (lie, position, pain/rigidity, contractions)
• pelvic examination: speculum (identify source of bleeding), avoid bimanual until placenta/vasa praaevia ruled out on abdo US

Question 5

Antepartum haemorrhage - Investigations

Answer 5

Investigations

• bloods as per AtoE resus
• imaging: abdominal ultrasound

Question 6

Antepartum haemorrhage - Management

Answer 6

Management

• initial management as per AtoE resuscitation, with any stabilising/temporising measures
• escalation to senior colleagues (O&G registrar)

General

• VTE prophylaxis
• regular obs and monitoring
• administer anti-D, consider steroids if pre-term and likely delivery

Definitive - depends on underlying pathology
Placenta praevia:
- monitor fetal growth, potentially for delivery if viable,
- stay in hospital 24-48 hrs post bleed for monitoring

Placental abruption:
- Unstable -> goes for emergency C-section, steroid administration if baby pre-term

Vasa praevia:
- immediate category 1 c-section