1. Antepartum Hemorrhage Family Medicine Specialist CME University of Health Sciences

2. Objectives For antepartum hemorrhage: Describe and define the two major causes of bleeding in pregnancy Discuss the history and clinical examination for a patient presenting with bleeding in pregnancy Describe the management and care of a pregnant patient with bleeding

3. Clinical Case 20 year-old G3P1A1 female presents to the district hospital with vaginal bleeding. She is pregnant but is unsure of her dates as she got pregnant while breastfeeding. You can palpate a fetus in a breech position and the fetal heart rate is heard. What is the differential diagnosis? What questions are you going to ask her? What is your management plan for her?

4. Antepartum Hemorrhage Definition

5. Antepartum Hemorrhage Definition: Vaginal bleeding from 22 weeks to term or delivery.

6. Incidence and Etiology Incidence: – Occurs in 2% - 5% of all pregnancies Etiology: – Placental abruption (40%) – Placenta previa (20%) – Unclassified (35%) – Lower genital tract (5%)

7. Definition Placental Abruption Premature separation of the placenta from the uterine wall Placenta Previa Implantation of the placenta in the lower segment of the uterus either close to or over the internal cervical os Total/complete previa – entirely covers the os Partial previa – partially covers the os Marginal previa – placenta lying close to the os

8. Placenta Previa Classification Complete PreviaPartial PreviaMarginal Previa

9. Risk Factors Placental Abruption Idiopathic Maternal hypertension Prior abruption Abdominal trauma – MVA/Assault/Falls Substance Abuse - Maternal smoking/Alcohol/Cocaine Multiparity Advanced maternal age Uterine malformation Rapid uterine decompression - PROM Placenta Previa Prior cesarean section or uterine surgery Multiple gestation Advanced maternal age Multiparity Smoking Prior placenta previa

10. History Placental Abruption Abdominal pain Backache Prior hypertension Trauma Fall Assault Placenta Previa Prior uterine surgery or cesarean section Painless bleeding

11. Examination Placental Abruption Vital signs – Shock out of proportion to blood loss Uterus – tender, increased tone, irritable, contractions Normal fetal presentation Abnormal or absent fetal heart rate Placenta Previa Vital signs – Shock corresponds to blood loss Uterus – soft, not tender, no irritability or contractions Abnormal fetal presentation or high presenting part Normal fetal heart rate

12. Diagnosis Placental Abruption Ultrasound – Abdominal may be diagnostic but a negative ultrasound does not rule out abruption Placenta Previa Ultrasound – Definitive diagnosis Better with transvaginal ultrasound but can be made with abdominal ultrasound 75% of women will have a bleed in the early third trimester Must be at a hospital that can perform cesarean section

13. Clinical Management Call for HELP ABC’s -Airway/Breathing/Circulation Talk to the patient – explanation & plan Monitor vital signs Elevate legs/roll to side to avoid aspiration Obtain History and do Examination – NO CERVICAL EXAM UNTIL PREVIA RULED OUT Pelvic ultrasound to locate placenta Ausculate for fetal heart rate

14. Clinical Management - 2 Laboratory – CBC – Type and Screen/Crossmatch for blood – PT/PTT Provide oxygen to mother 2 Large bore IV’s 16/18 with Normal Saline or Ringer’s Lactate (1 L in 20 minutes) Reassess maternal & fetal status Transfer to facility where a cesarean section can per performed when patient stable

15. Clinical Management – 3 Unstable Patient Primary objective: – Fluid replacement – Delivery Simultaneously: – Oxygen to mother & O2 saturation – Active fluid resuscitation in 1 H - 2 larger bore IV’s rapidly infuse 2 L Normal saline/Ringer’s Lactate – Assessment of maternal vital signs/urine output – Continuously monitor fetal well-being

16. Clinical Management – 4 Unstable Patient Arrange for delivery – Transfer if required – Possible Cesarean section Placenta previa (partial or complete) Abruption with unstable maternal or fetal status

17. Clinical Management – 5 Stable Patient Maternal & fetal surveillance for 12 – 24 hours If abruption secondary to abdominal trauma – monitor for minimum of 4 hours after trauma Attention to maternal hemodynamic status – at risk for subsequent bleed If preterm, expectant management Transfer to higher risk facility if indicated

18. Bedside Clot test - Coagulopathy 2 mLs of venous blood in plain glass tube Hold tube in closed fist to keep it warm After 4 minutes, tip the tube slowly to see if clot is forming. Tip every minute until the blood clots and tube can be turned upside down Failure of a clot after 7 minutes or a soft clot suggests coagulopathy

19. Clinical Case 20 year-old G3P1A1 female presents to the district hospital with vaginal bleeding. She is pregnant but is unsure of her dates as she got pregnant while breastfeeding. You can palpate a fetus in a breech position and the fetal heart rate is heard. What is the differential diagnosis? What questions are you going to ask her? What is your management plan for her?

20. Conclusion Antepartum hemorrhage most often due to: – Placental abruption – Placenta previa Primary difference is presence or absence of abdominal pain Rapid diagnosis and appropriate treatment required to prevent maternal and neonatal mortality May need to transfer patient for appropriate care for mom and baby