Antepartum Haemorrhage
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Objectives
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- Assessment of fetal wellbeing ? Delivery
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- Rhesus prophylaxis, if appropriate
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Management details
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Resuscitation:
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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.
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An intravenous line (16G or larger) is established with Hartmann's solution
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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.
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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 30ml of urine per hour reflects adequate resuscitation.
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Diagnosis:
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The approach to diagnosis 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.
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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.
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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.
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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. Evidence of fetal or maternal compromise would suggest the need for urgent delivery rather than ultrasound.
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A Kleihauer test may help to establish the type of antepartum haemorrhage which has occurred, by determining the presence or absence of a feto-maternal haemorrhage.
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Rhesus prophylaxis:
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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).
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Possible Delivery
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In general terms tocolytic therapy is contraindicated in patients actively bleeding per vaginum.
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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 OPEN part of the ward closest to labour ward. Further management should include twice daily CTGs for at least 48 hours.
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A paediatrician should always be present at the delivery of any baby where significant antepartum haemorrhage has occurred during the pregnancy.
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Where immediate delivery is indicated:
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- Caesarean section is indicated.
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Placental Abruption
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If placenta praevia, vasa praevia and bleeding from the lower genital tract have been EXCLUDED the diagnosis of Placental Abruption may be made. Unless contraindicated for other reasons (eg. abnormal presentation, previous Caesarean section) induction of labour should be performed. This is performed in the standard fashion by amniotomy and oxytocin infusion, with the application of a fetal scalp clip for CTG monitoring. Increased bleeding or abnormal CTG development should be communicated to the consultant on-call and may indicate increase in the abruption and need for urgent delivery.
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The second stage should be shortened by an elective vacuum or forceps delivery and the third stage should be managed routinely, apart from the use of a Syntocinon infusion (40 IU of Syntocinon in 1 litre of Hartmann's solution infused over 2 hours). The placenta should be sent for histology.
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Uncertain diagnosis
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Where all other conditions for a vaginal birth are met, a vaginal examination should be performed in the Operating theatre under general anaesthesia. A large bore intravenous line (16G or larger) must be in-situ and running well, the cross-matched blood must be in the theatre suite, the staff and instruments necessary for an immediate Caesarean section must be in the theatre and ready (ie. instruments open, staff gowned and gloved), a urinary catheter must be in-situ with the bladder empty. Occasionally, the procedure may be performed without anaesthesia (but with the anaesthetist ready to induce anaesthesia immediately) - this is a Consultant to Consultant decision between the Obstetrician and the Anaesthetist. The lower uterine segment is examined through the vaginal fornices; if the placenta is not apparent in the lower segment then the examiners' fingers are passed through the cervix and, if placenta is not palpable and all other conditions are appropriate, an amniotomy is performed.
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