ANTEPARTUM HEMORRHAGE

Definition:

 It is bleeding per vagina after 28th week of pregnancy also known as third
trimester bleeding

Etiology:

 Differentiation must be made between obstetric causes of bleeding

(usually more hazardous) and nonobstetric causes (usually less
hazardous)

Obstetric causes

a) Placenta previa
b) Abruptio placenta
c) Vasa previa
d) Bloody show
e) Uterine rapture
f) Disseminated Intravascular Coagulopathy

Nonobstetric causes

a) Cervicitis
b) Cervical cancer or dysplasia
c) Cervical polyps
d) Cervical eversion
e) Cervical erosion
f) Vaginal laceration
g) Vaginitis
h) Vaginal varicosities
i) Vaginal trauma E.g. sexual, object

 Nonobstetric causes usually result in relatively little blood loss and little
threat to mother or fetus.
 An exception is invasive carcinoma of the cervix.
 Most serious hemorrhages (2-3% of pregnancies) lose more than 800mL
of blood and are due to premature separation of the placenta or placenta
previa.
 Less common but still dangerous causes of bleeding are circumvallate
placenta, abnormalities of the blood clotting mechanism, and uterine
rupture
 Bleeding from the peripheral portion of the intervillous space, or
marginal sinus rupture, is a debatable cause of bleeding
 Extrusion of cervical mucus ("bloody show") is the most common cause
of bleeding in late pregnancy.
 Bleeding from vasa praevia is the only cause of pure fetal hemorrhage,
but fortunately it is rare.
 If fetal bleeding is suspected, the presence of nucleated red cells in the
vaginal blood may be seen or the presence of fetal hemoglobin may be
confirmed by elution (The removal of antibodies absorbed onto the
erythrocyte surface) or electrophoretic techniques.

Treatment

Principles of Management

 A vaginal or rectal examination must not be performed until placenta

previa has been ruled out and until preparations are complete for
management of massive hemorrhage and maternal or perinatal
complications.
 Vaginal or rectal examination is extremely hazardous because of the
possibility of provoking an uncontrollable, catastrophic hemorrhage.

Management of Bleeding

 The 3 general management options are immediate delivery, continued

labor, or expectant management, depending on the diagnosis.
 If the fetus is immature, the patient should be treated expectantly unless
additional complications appear (e.g. continuing bleeding, fetal distress,
labor, or spontaneous rupture of the membranes).
 In about 90% of cases, third-trimester bleeding will subside within 24
hours.
 Nonobstetric causes of bleeding in late pregnancy usually result only in
spotting that does not increase with activity.
 There are no uterine contractions, and the definitive diagnosis is usually
made by speculum examination, Papanicolaou smear, culture, or
colposcopy.
 Only in advanced cancer is there a poor maternal prognosis.
 Vaginal lacerations and varices may require repair but have a good
prognosis.
 Most infections causing bleeding clear readily when treated with
appropriate agents.
 Benign neoplasias and eversions require simple treatment and have a
good prognosis

Life-Threatening Hemorrhage Associated With Hypovolemic Shock

 Early recognition of hypovolemia is essential.

 Signs and symptoms of hypovolemic shock include pallor, clammy skin,
syncope, thirst, dyspnea, restlessness, agitation, anxiety, confusion,
falling blood pressure, tachycardia, thready pulse, and oliguria.
 Nonreassuring fetal heart tracing will occur as the patient decompensates
 Most healthy gravidas remain hemodynamically stable until
approximately 1500 mL (25%) of their blood volume is lost.
 If adequate treatment is not provided, the patient will rapidly
decompensate.
 In the unstable patient, the standard ABCDs of resuscitation should be
initiated
 Place the patient in Trendelenburg position with a left tilt.
 This will maximize venous return by preventing the gravid uterus from
compressing the inferior vena cava.
 Two large-bore (16-gauge or larger) intravenous catheters should be
placed and fluid replacement with crystalloid (normal saline or Ringer's
lactate) initiated.
 Hetastarch or other colloid plasma expanders can be given while blood
products are being cross-matched.
 In this case, the "D" in the ABCDs stands for continuous fetal monitoring
using Doppler ultrasound while the mother is being stabilized.

Blood Transfusion

 When clinically indicated, whole blood or packed red blood cells

(PRBCs) should be administered rapidly.
 When using packed cells, it is important to be aware of the potential for
dilution coagulopathy.
 After 4 units of PRBCs are transfused, a coagulation panel in addition to
calcium and potassium levels should be obtained and electrolytes
replenished if needed.
 If fluid overload is a concern, such as in the preeclamptic patient,
cryoprecipitate can be used in place of fresh-frozen plasma.