Question 30

28, G1P0 at 32 weeks, c/o painless, vaginal spotting 3/7, then no more bleeding, no trauma or fall.

O/e - Vitals stable, P/A - soft, SFH 32cm, uterus not tender

USG - Parameters normal, FH present

Most appropriate management

A. IM Dexa
B. Repeat USG 2 weeks
C. Admit
D. Advise for rest
E. FBC

Antepartum Hemorrhage

Definition: Bleeding from/in to the genital tract ≥24 weeks of pregnancy

Causes:
1) Placenta Previa
2) Placenta Abruption
3) Local causes (vulva/vagina/cervix)
4) Vasa Previa
5) Uterine rupture
6) Unexplained APH (Indeterminate APH)

 Amount often underestimated (e.g. concealed placental abruptions)

o Assess for signs of clinical shock
o Signs of fetal compromise

Clinical assessment in woman presenting with APH

1) If there is no maternal compromise – a full history should be taken

- Onset
- Duration of bleeding
- Associated symptoms
2) Identify risk factor
3) Fetal movement and auscultate fetal heart
4) Previous cervical smear history to assess possibility of neoplastic lesion on the cervix as
cause of bleeding

Abdominal palpation:

- Tenderness or signs of acute abdomen

- Abruptions: Tense and ‘woody’’
- Assess for uterine contractions
- Presenting parts: abnormal lie/floating head (PP), palpable fetal parts: uterine rupture
Speculum examination:

- Identify cervical dilatations

- Visualize lower genital tract cause of bleeding

Digital vaginal examination:

- Should not be performed until ultrasound has excluded PP

Placenta Previa

Risk factor:

PP type 1: 2.0 – 5.0 cm from internal os

PP type 2: < 2.0cm from internal os – not covering it
Symptoms:

 Majority: asymptomatic
 Others: most common symptoms: vaginal bleeding – painless, bright red, vary in amount

Management:

1) Bleeding? – Admission
2) Antenatal steroid – single course recommended between 34 - 35+6 weeks of gestation and
before 34 weeks if at higher risk of premature delivery

Method of delivery: should be discussed after assessment at 36 weeks but generally if minor PP,
vaginal birth may be attempted if fetal head is below leading edge of placenta (PP type 2 anterior)

Timing:

Indications for delivery before 37 weeks of gestation in a case of placenta praevia are:

 onset of labour (not able to be suppressed)

 fetal distress
 severe growth restriction
 intrauterine death
 severe bleed (threatening maternal health).

Placenta abruption

Def: Premature separation of placenta from uterine wall

- can be @ as low as 20weeks gestation

Risk factor:

Abruption in previous pregnancy

Pre- eclampsia
Fetal growth restriction
Non vertex presentation
Polyhydramnios
Advanced age
Multiparity
Low BMI
Assisted pregnancy
Intrauterine infection
PROM
Abdominal trauma
Smoking and drug use during pregnancy
1st trimester bleeding
Maternal thrombophilia

Presentation:
 - vaginal bleeding – dark blood, can be concealed, revealed or mixed
- abdominal pain – constant
- uterine tenderness
- uterine contractions
- fetal distress/demise
- DIVC – non clotting vaginal bleeding, bleeding from drip sites, skin bruising
- Maternal circulatory shock

Diagnosis: clinical suspicion

Management:

Depends on gestation, signs and symptoms, mother’s cardiovascular status, evidence of fetal
compromise
Vasa Previa

Def: fetal vessels crossing the internal cervical os through the free placental membranes.

Supected when bleeding during ARM or SROM – fetal haemorrhage, exsanguination or death