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Antepartum Haemorrhage - Treatment of Antepartum Haemorrhage

What is Antepartum Haemorrhage?

Antepartum Haemorrhage is defined as bleeding from the vagina after 24 weeks. The occurrence of multiple pregnancies, hypertensive disorders, diabetes mellitus and antepartum haemorrhage were significantly higher in group I than in the control group. In pregnancy bleeding is usually called antepartum haemorrhage and after the birth it is called postpartum haemorrhage. APH occurs in 2% of pregnancies and is an important cause of foetal and maternal death - 30% of maternal deaths are caused by APH, of which 50% are associated with avoidable factors. When antepartum haemorrhage of any type occurs, the diagnosis of placenta praevia should be suspected and hospital admission advised. Incidental antepartum haetnorrhage is haemorrhage which occurs from the genital tract but not from the site of the placenta or its implantation. Such haemorrhage may result from injury, infection, ulcers on the neck of the womb, polyps or, I1lOstcommonly, the onset of labour.

The diagnosis should be established by ultrasound imaging. Vaginal examination should be performed only in an operating theatre prepared for caesarean section, with blood crossmatched. There are only two indications for performing a vaginal examination:
• When there is serious doubt about the diagnosis
• When bleeding occurs in established labour.

Causes of Antepartum Haemorrhage

No definite cause is diagnosed in about 40% of all women who present with antepartum haemorrhage. Major causes are -

• Placenta praevia
• Abruptio placentae or accidental haemorrhage
• Uterine rupture
• Placenta praevia 31%
• Placental abruption 22%
• Vasa praevia (rare)
• Unclassified 47%
• Unknown aetiology.

Treatment of Antepartum Haemorrhage

• May need resuscitation measures if shocked.
• Admit to hospital, even if bleeding is only a very small amount. There may be a large amount of concealed bleeding with only a small amount of revealed vaginal bleeding.
• No vaginal examination should be attempted at least until a placenta praevia is excluded by ultrasound. May initiate torrential bleeding from a placenta praevia.
• Resuscitation can be inadequate because of under-estimation of blood loss and misleading maternal response. A young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs 2 .
• Take blood for full blood count and clotting studies. Cross match as heavy loss may require transfusion.
• Gentle palpation of the abdomen to determine gestational age of fetus, presentation and position.
• Fetal monitoring .
• Arrange urgent ultrasound.
• With every episode of bleeding, a Rhesus negative woman should have a Kleihauer test and be given prophylactic anti-D immunoglobulin 3 .

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