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11.3 Antepartum Haemorrhage (APH)

Table of Contents

It is the bleeding from the birth canal after the 28th week of gestation. The main forms are placenta praevia and abruption placenta.

11.3.1 Placenta Praevia

It is an obstetric complication in which the placenta embeds itself partially or wholly in the lower segment of the uterus.

Diagnostic criteria

  • Sudden onset of bright red fresh painless bleeding after 28 weeks of gestation

Management

  • If asymptomatic – Bed rest and follow up every 2 weeks
  • If complete placenta praevia
    • Admit for fetal lung maturation ≥ 24 weeks of gestation
    • Deliver by Cesarean section at 37–38 weeks of gestation
    • 30–60mg of elemental iron and 400µg (0.4mg) folic acid supplements
    • Do FBC and Blood group and cross match, blood coagulation tests
    • Monitor fetal heart rate
    • Ultrasound for fetal wellbeing and localization of the placenta
  • If >34 weeks of gestation and minimal hemorrhage and no uterine contractions: Expectant management
  • If there is uterine contractions;
    • Complete placenta praevia or malpresentation: Deliver by Cesarean section.
    • Partial or marginal placenta praevia: Carefully perform amniotomy for vaginal delivery if the head is engaged.

Major Recommendations

If <34 weeks of gestation

  • Fetal lung maturation give
    B: Dexamethasone 6 mg IM every 12 hours for 48 hourly
  • If there is uterine contractions tocolyse with
    C: Nifedipine short acting (PO) 20mg start, then continue with
    C: Long acting nifedipine 20mg 8 hourly
  • If premature rupture of membrane:
    A: Ampicillin 2g start dose, then
    A: Amoxicillin tabs 500mg 8 hourly for 5–7 days, while close monitoring for bleeding
  • In case of any hemorrhage, the patient should report to the doctor for immediate action
    • Avoid vaginal examination
    • For any risk of premature delivery, the patient must be managed in a center with neonatal care facilities

11.3.2. Placental Abruption

It is bleeding from the placental site due to premature separation of a normally situated placenta from 28 weeks of gestation.

Diagnostic Criteria

  • Vaginal bleeding: May pass dark blood or clots. Sometimes bleeding can be concealed
  • Abdominal pain is moderate to severe but may be absent in small bleeds
  • The uterus is enlarged and very tender, painful and sometimes hard
  • Fetal demise or fetal distress may be present
  • Uterine lower segment tender on vaginal examination

Investigations

  • Ultrasound: Fetal wellbeing, localize retro placental clot
  • Full blood count and cross–match
  • Renal function test and electrolytes
  • Liver function tests
  • Proteinuria if pre-eclampsia is suspected
  • Fibrinogen tests if available
  • Coagulation profile

NOTE: The diagnosis of placental abruption is mainly clinical.

Management

Maternal resuscitation

  • Insert large bore 2 IV lines and give Normal Saline/Ringers Lactate.
  • Transfusion if necessary
  • Give oxygen 6L/min
  • Insert a urinary catheter to monitor input/output
  • If Disseminated Intravascular Coagulation: Give fresh frozen Plasma 1 Unit/hour, give packed cells 2–4 units
  • Monitor blood pressure, pulse, bleeding, hourly, full blood count, clotting profile every 2 hours

Obstetrical Management

  • If the fetus is alive and viable: emergency Caesarean section
  • If the fetus is dead: Normal vaginal delivery is preferable
  • Perform artificial rupture of membrane,
  • If no spontaneous labor: induce with uterotonics (Oxytocin infusion 5IU in dextrose 5% 500 ml beginning with 10 drops/min)
  • Do active management of third stage of labor and uterine massage
  • Emergency Caesarean section should be considered if:
    • Worsening of maternal condition
    • Failure/Non progressing vaginal delivery
  • Prophylactic antibiotics: Ampicillin IV 2g start, if necessary

11.3.3 Postpartum Haemorrhage (PPH)

It is loss of more than 500 ml of blood from the genital tract in the first 24 hours after vaginal delivery and more than 1000 ml after Caesarean section.

Prevention

The use of uterotonics for the prevention of PPH during the third stage of labour is recommended for all births. (Strong recommendation, moderate quality evidence)

Pharmacological Treatment

A: Oxytocin 10 IU IM

OR

C: Ergometrine 0.25mg IM

OR

A: Misoprostol 600μg PO start

Note
Caution should be exercised when opting for ergot derivatives for the prevention of PPH as these medicines have clear contraindications in women with hypertensive disorders. Thus, it is probably safer to avoid the use of ergot derivatives in unscreened populations
Misoprostol ( 600µg PO) is regarded an effective medicine for the prevention of PPH

Prevention of PPH – Cord management and Uterine massage

  • Controlled cord traction (CCT) is recommended for vaginal births
  • In settings where skilled birth attendants are unavailable, CCT is not recommended
  • Late cord clamping (performed approximately 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care.
  • Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin.

Prevention of PPH in Caesarean sections

  • Oxytocin (IV or IM) is the recommended uterotonic drug for the prevention of PPH in Caesarean section
  • Cord traction is the recommended method for the removal of the placenta in Caesarean section

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