In this section
APH Antepartum haemorrhage is the term applied to any event where more than 15 mL blood is passed per vaginum in the 2nd half of pregnancy.
PIPER Paediatric Infant Perinatal Emergency Retrieval
Depending upon the clinical state of the patient, normal resuscitative measures should be taken. In the case of Placental Abruption, there may be a large occult component to the blood loss, with the result that plasma expansion/blood replacement must be greater than is expected from the perceived loss.
An intravenous line (16G or larger) is established with Hartmann's solution
At the time of insertion of the cannula, blood is collected for haemoglobin estimation, blood grouping and cross-matching (2 or more units of whole blood), and clotting profile (including a measure of fibrinolysis, such as Fibrin Degradation Products [FDPs] or D-dimer), base line electroloytes and creatinine. If any evidence of Disseminated Intravascular Coagulopathy (DIC) and/or Fibrinolysis is found Fresh Frozen Plasma and Platelet packs should be ordered as well.
An indwelling Foley catheter is inserted and a strict and accurate fluid balance is instituted; if urinary output remains low a Central Venous line should be inserted and further volume replacement guided by the CVP readings. Production of 30 mL of urine per hour reflects adequate resuscitation.
A CTG should be commenced.
The approach to management depends upon whether or not delivery is considered necessary at the time of admission. Generally, if the gestation is greater than 37 weeks delivery is indicated - earlier if there is evidence of fetal or maternal compromise.
The admission history should take particular notice of any potential cause of the haemorrhage and whether or not the patient appears to be in labour. The clinical notes should be scrutinised for ultrasound evidence of placental localisation and for the patient's blood group and blood group antibodies.
A gentle sterile speculum examination is performed to exclude bleeding from the lower genital tract and to note the presence or otherwise of ruptured membranes. An Apts test (Thevarajah modification) should be performed on the blood passed per vaginum; this involves adding 1-2 drops (or more) of the blood or blood-stained fluid to 20 drops of 10% Sodium Hydroxide - fetal Hb remains pink, whilst maternal Hb turns a yellow or yellow-brown colour.
Unless a recent ultrasound report detailing the location of the placenta is available, an urgent ultrasound scan is performed to localise the placenta - the degree of urgency is determined by the presence or absence of persistent bleeding. However evidence of fetal or maternal compromise would suggest the need for urgent delivery rather than ultrasound.
A Kleihauer test may also help to establish the type of antepartum haemorrhage which has occurred, by determining the presence or absence of a feto-maternal haemorrhage.
Anti-D gamma globulin should be administered to all Rhesus negative women, with the dose being determined by a Kleihauer test (to give an estimate of the size of the feto-maternal haemorrhage).
In general terms tocolytic therapy is contraindicated in patients actively bleeding per vaginum. Steroids should be administered to women presenting preterm, unless a course has already been completed earlier in the pregnancy.
Where bleeding has settled, the gestation is less than 37 weeks, and there is no evidence of fetal or maternal compromise the patient may be transferred to the ward closest to labour ward. Further management should include twice daily CTGs for at least 48 hours.
If placenta praevia, vasa praevia and bleeding from the lower genital tract have been excluded, the presumptive diagnosis of placental abruption is made by exclusion. If the gestation is greater than 37 weeks, and if there is no other contraindication such as a malpresentation or a previous caesarean section, induction of labour should be performed. This is performed in the standard way by amniotomy and oxytocin infusion, with application of a fetal scalp clip and continuous CTG monitoring. Increasing bleeding or the development of an abnormal CTG could indicate an increase in the extent of the abruption, and urgent delivery should be considered. The second stage should be shortened by an elective vacuum or forceps delivery and the third stage actively managed, but with the addition of a Syntocinon infusion in recognition of the increased risk of postpartum haemorrhage (40IU of Syntocinon in 1 litre of Harmann’s solution, infused over 2 hours).
In most cases, the diagnosis of an abnormally situated placenta can be made by ultrasound with confidence. If the diagnosis remains uncertain after 37 weeks, a vaginal examination should be performed in the Operating Theatre, either under general anaesthesia, or without anaesthesia but with the anaesthetist ready to induce anaesthesia immediately if needed. A large bore (16G or larger) intravenous line must be in situ and running well, the cross-matched blood in the theatre suite, the staff and instruments necessary for an immediate caesarean section ready (i.e. instruments opened, staff gowned and gloved), and a urinary catheter in situ. The lower uterine segment is first palpated through the vaginal fornices, and if the placenta is not apparent, the examiner’s fingers are passed through the cervix. On excluding placenta praevia, a forewater amniotomy is performed to induce labour.
A paediatrician should always be present at the delivery of any baby where significant antepartum haemorrhage has occurred during the pregnancy. The placenta should also be sent for histology.
The occurrence of significant bleeding, with or without associated uterine tenderness or threatened labour, is associated with an increased likelihood that delivery will occur soon, and if the pregnancy has not reached a gestation to enable safe delivery on site, transfer should occur to a centre with a higher level of resources. In some cases known to have a low-lying placenta, short-term tocolysis may be advised by the PIPER Perinatal consultant to facilitate safe transport.
As is cases of transfer of women in preterm labour, it is important to ascertain by gentle speculum examination that the cervix has not dilated significantly prior to transfer of care to the paramedics. If there is any doubt regarding the feasibility of safe transfer, the PIPER Perinatal consultant should be contacted again to discuss the case.
In some cases of recurrent small bleeds associated with a known placenta praevia, in the absence of threatened preterm labour, and if the woman is already in a centre with 24x7 obstetric medical staff cover, it may be reasonable to manage her expectantly in the peripheral unit.