26/3 Antepartum Haemorrhage Overview and Management Notes

Overview of Antepartum Haemorrhage (APH)

• Definition: Significant bleeding from 24 weeks of pregnancy until the time of birth.

• Change of definition by ACOG and Royal College of Obstetricians and Gynaecologists (RCOG) from 20 weeks to 24 weeks.

Key Causes of Antepartum Haemorrhage

• Two primary causes:

• Placenta Previa

  • Definition: Placenta is located low in the uterus and may cover the cervical opening.

  • Classification:

  • Grade 1: Low-lying placenta, not covering the internal os (≥ 4-5 cm away).

  • Grade 2: Near the internal os but not covering it.

  • Grade 3: Partially covers the internal os, risk of bleeding during labor.

  • Grade 4: Completely covers the internal os, usually requires cesarean delivery.

  • Management: Regular scans (20 & 32 weeks) to monitor placental positioning.

  • Symptoms: Painless vaginal bleeding, especially later in pregnancy.

• Placental Abruption

  • Definition: Premature separation of the normally positioned placenta from the uterus.

  • Types of bleeding:

  • Revealed: External bleeding is evident.

  • Concealed: No visible bleeding but internal bleeding occurs.

  • Combined: Both revealed and concealed bleeding coexist.

  • Symptoms: Painful vaginal bleeding, tense uterus upon palpation, potentially leading to preterm labor.

  • Causes: Trauma, hypertension, pre-eclampsia.

Classification of Hemorrhage

• Division of hemorrhage into three categories:

• Minor Haemorrhage: Less than 50 mL.

• Major Haemorrhage: Approximately 500 mL with no signs of shock.

• Massive Haemorrhage: More than 1000 mL, may or may not have signs of shock.

• Management varies according to hemorrhage type and patient’s hemodynamic stability.

Clinical Examples and Case Studies

• Discussion of individual cases demonstrating recurrent bleeding patterns in patients.

• Highlighting the need for thorough assessments, including ultrasounds, to understand the underlying causes of bleeding.

• Importance of close monitoring and intervention when necessary to prevent adverse outcomes for mother and fetus.

Guidelines and References

• Check local healthcare guidelines for managing Antepartum Haemorrhage specific to regions (e.g., Northland, Taranaki, Rotorua).

• Emphasizing the importance of continual education and awareness about changes in definitions and management strategies in obstetric care, including consultations for recurrent APH.

Definition of Antepartum Haemorrhage (APH)

• Significant bleeding from or into the genital tract after 24 weeks of pregnancy until the time of birth. It reflects potential risks for both the mother and fetus.

Local Definition of APH

• According to Te Whatu Ora I Te Toka Tumai, APH is defined similarly, emphasizing regional parameters informing the management strategy and standards of care. This local definition aligns with global perspectives yet includes considerations specific to community practices.

APH from Placental Origin

• APH can arise from placental-related issues such as placenta previa or placental abruption.

  • Placenta Previa: The placenta is positioned low in the uterus, potentially covering the cervical opening leading to painless bleeding.

  • Placental Abruption: Refers to the premature detachment of the placenta from the uterine wall, often resulting in painful bleeding and a tense uterus.

Acute Assessment: Diagnosis

• Essential steps include:

  • Clinical evaluation of the mother: vital signs, level of consciousness, and signs of shock.

  • Ultrasound examination to determine placental location and assess fetal wellbeing.

  • Blood tests as indicated (e.g., hemoglobin levels, type and crossmatch).

Collaborative Care: Referral Guidelines (Te Whatu Ora, 2023)

• Referral to specialized care may be necessary based on assessment outcomes, severity of hemorrhage, or detection of high-risk conditions such as severe preeclampsia or fetal distress.

• Continuous interdisciplinary communication is crucial to ensure coordinated care for the mother and fetus. Regular monitoring and re-evaluation strategies should be in place for all cases of APH.