3 centres collaboration

Antepartum Haemorrhage (APH), including Placenta Praevia, Abruption and Vasa Praevia

Table of contents

 

Download Quick guide (pdf)

 

Aim

This guideline aims to provide consistent advice for the evidence-based management of antepartum haemorrhage (APH) across the three level six (tertiary) maternity services in Victoria. This will be of significant benefit to the women being treated and for the primary and secondary service providers, who receive advice and support from these tertiary maternity centres.

It is anticipated that this guideline will be used as a basis for the development of local guidelines, which will take into account local service provision and the needs of the local population.

Comparison of International Guidelines

To compile this guideline, international guidelines from obstetric groups were used to compare facets of care pertaining to antepartum haemorrhage, diagnosis and treatment.

An evidence-based model has been extrapolated from the consensus of opinion between these international guideline groups. Where opinion was absent or equivocal, the highest level of evidence from systematic reviews has been used.

Published guidelines from each of the three tertiary centres, namely Mercy Hospital for Women, The Royal Women's Hospital and Southern Health's Monash Medical Centre were gathered, then compared and contrasted against the international model.

Following an iterative consultation process among key stakeholders, a consensus of opinion was gained in most instances. In cases of conflicting points of view, a variance process was initiated, whereby the Co-Chairs of the 3centres Collaboration made the final decision.

Search and Appraisal

The following methods of search and appraisal were used:

An Ovid platform database selection was made using Medline, Embase, Cochrane library and the Clinicians Health channel to access on-line journals and databases for systematic reviews of evidence or the results of randomised controlled trials.

Guidelines developed by specific, international guideline groups were also searched via the Internet.

Search terms used were; “Guidelines”, “antepartum haemorrhage (hemorrhage)”, “placenta praevia (previa)”, “placental abruption”, “placentae abruptio”, “vasa praevia (previa)” and “vaginal bleeding”.

The basis of international guideline selection was: The publication after the year 2000 and international guidelines published by obstetric and gynaecology professional bodies.

The areas of clinical care covered in this guideline include:

  • definition and incidence of APH
  • causes of APH outlined
  • emergency management of a major APH
  • causes and specific management of APH
    • Placenta Praevia
    • Abruption
    • Vasa Praevia
    • Cervical and lower genital tract bleeding
  • quick reference guides

Definition and Incidence of APH

Obstetric haemorrhage (both antepartum and postpartum haemorrhage) is one of the leading causes of maternal mortality in the developed world.

Antepartum haemorrhage (APH) is defined as any bleeding from the genital tract after the 20th week of pregnancy and before the onset of labour. Some of the causes of antepartum haemorrhage might also cause intrapartum bleeding, such as an abruption or placenta praevia.

Antepartum haemorrhage complicates 2-5% of all pregnancies. It is associated with increased rates of perinatal morbidity and mortality and contributes to significant healthcare costs.1

Classification of APH

Classification of an APH is according to the site of bleeding and is commonly defined as follows:

Placenta Praevia (Accounts for about 30% of APH cases) and it is bleeding from a placenta located in the lower uterine segment.

Placental abruption (Accounts for about 25% of APH) is bleeding from a normally situated placenta. This may be a marginal bleed (bleeding from the placental edge or margin) or in association with significant placental separation.

Vasa Praevia is a rare condition in which umbilical blood vessels traverse the fetal membranes of the lower uterine segment, unsupported by the umbilical cord or the placenta. Bleeding from these vessels is almost always associated with rupture of the fetal membranes.

Cervical and lower genital tract bleeding (Accounts for about 45% of APH) includes bleeding from any site within the genital tract and include:

Cervical lesions such as an ectropion, dysplasia, cervicitis, polyps or carcinoma.

Cervical bleeding in pregnancy may occur spontaneously, or follow sexual intercourse, a clinical examination or Pap smear. Bleeding from the lower genital tract is uncommon.

On occasion, bleeding from the urinary tract (haematuria) or ano-rectum (e.g. haemorrhoids) may be confused with an APH. Taking a complete history and conducting an appropriate clinical examination will greatly assist the clinician in making the correct diagnosis.

Regardless of the site of bleeding, women presenting with an APH may be broadly divided into two groups: Those with a major haemorrhage and those with an APH where immediate resuscitative measures are not required.

Emergency Management of a Major APH

The majority of women presenting with an APH will not require immediate resuscitation. However, the actual blood loss is often more than is immediately apparent from haemodynamic assessment (e.g. pulse and blood pressure). This is because otherwise healthy women are well able to compensate for acute loss without overt signs or symptoms of shock.

Early resuscitative measures are important, particularly if there has been substantive blood loss. These include control of bleeding, restoration of circulating blood volume for oxygenation of tissues and diagnosing and treating the underlying cause of the bleeding. The required urgency of assessment and the escalation of treatment will largely depend upon the amount of bleeding, haemodynamic stability of the woman, her degree of shock, gestation and general maternal and fetal wellbeing.

An important part of resuscitation in a major APH is replacing the blood cells lost, with the transfusion of blood products. All hospitals should have a massive transfusion protocol that may be initiated for women with a major APH. Also, all hospitals should have a protocol on the management of women who refuse blood products.

Prompt assessment is imperative. Members of the treating team including an experienced obstetrician, anaesthetist, haematologist and other assistance as needed may carry out the following actions simultaneously.

The following principles will assist in the prompt assessment and management of a major APH:

History and initial assessment

  • assess the woman's general condition - Record pulse, blood pressure, temperature, respiratory rate and oxygen saturation level. NB. A healthy adult may maintain vital signs within the normal range until shortly before a critical point is reached and then suddenly and rapidly deteriorate.
  • record history – Expected due date, history of any bleeding in pregnancy, other relevant history e.g. recent trauma. 
  • check blood group, Rhesus and antibody screen, ultrasound scan results for placental site.
  • note blood loss (amount, consistency and colour). It has been shown that practitioners often underestimate the volume of blood loss, particularly when blood loss is large.2
  • considerable blood loss may be contained within the uterus (concealed), therefore the volume of visible blood may not be an accurate representation of the total amount of blood being lost. A tense tender uterus may signify the presence of concealed blood.
  • if there has been a severe abruption (tense, tender uterus with a fetal death in utero), consider an early blood transfusion. 
  • additional support – Midwives, obstetric staff, anaesthetist, haematologist and neonatologist.

Basic Life Support

  • if required, establish an airway and administer oxygen therapy or assist ventilation.
  • infuse fluids at approximately the rate that blood is being lost. In initial resuscitation, fluid replacement with crystalloid is as effective as with colloid.3
  • insert an in-dwelling urinary catheter with urometer. Record hourly urine output.
  • if blood component therapy is indicated and consented to, advice should be sought from a haematologist regarding appropriate therapy.
  • in the absence of a massive transfusion protocol or specialist haematology advice, consider the following:

Fluid replacement and fluid balance

  • IV access. One or two size 16 gauge or larger bore cannulae. 
  • infuse fluids at approximately the rate that blood is being lost. In initial resuscitation, fluid replacement with crystalloid is as effective as with colloid.
  • insert an in-dwelling urinary catheter with urometer. Record hourly urine output.
  • if blood component therapy is indicated and consented to, advice should be sought from a haematologist regarding appropriate therapy.
  • in the absence of a massive transfusion protocol or specialist haematology advice, consider the following:

If maternal haemodynamic state can only be improved by delivery, this should be considered, irrespective of gestational age.

Emergency management summary box

 APH where immediate resuscitative measures are not required

 Initial Assessment

 The following history should be ascertained:

Presenting Features

  • timing and amount of blood loss – e.g. number of pads used with an estimation of the blood staining on each pad
  • associated features – e.g. abdominal pain and contractions
  • provoking factors – e.g. trauma or sexual intercourse
  • fetal movements since the bleeding has started

Current Pregnancy

  • previous episodes of bleeding in the current pregnancy
  • review of any ultrasound examinations performed earlier in pregnancy, particularly noting placental site recorded on a 20 week (or later) scan

Past obstetric, gynaecological, medical and surgical history.

Examination

An examination should be performed, checking the following:

  • the woman's general condition - record pulse, blood pressure and temperature. For a non major APH, the vital signs should be within the normal ranges.
  • abdominal Palpation – checking for uterine tenderness and symphysis-fundal height, fetal lie and presentation.
  • vaginal examination with a speculum only, to assess the site of bleeding.

 Blood investigations 

  • collect blood for: Full blood count (FBC), blood group and cross-match at least two units in case the bleeding escalates to a major APH, coagulation profile to detect any unsuspected thrombocytopaenia, Kleihauer-Betke test or flow cytometry for an estimation of feto-maternal haemorrhage and confirm amount of Anti-D immunoglobulin required if the woman is Rhesus negative. 

 Fetal well-being assessment 

  • cardiotocogragh (CTG) or hand held Doppler, if an appropriate gestation has been reached. If not reached, fetal well-being can be confirmed with an ultrasound scan.

Ultrasound scan

  • ultrasound scan for placental location, to exclude placenta praevia.
  • an ultrasound scan is not the investigation of choice to diagnose a placental abruption. Unless there is substantive placental separation, and this will be clinically apparent, a placental abruption is not likely to be seen on ultrasound.

Medications

  • the need for analgesia should raise concerns of a moderate or severe placental abruption, or that the woman is in labour. Offer analgesia and antiemetics if required.
  • give corticosteroids if gestation is less than 34 weeks. (Two doses of Betamethasone 11.4mg, 24 hours apart).
  • administer 625iu Anti-D, as an intramuscular injection, if the woman is Rhesus D negative. Additional doses of Anti-D immunoglobulin may be required if the Kleihauer-Betke test indicates a large feto-maternal haemorrhage.
  • if birth is imminent at a gestation less than 30 weeks gestation, consider a magnesium sulphate infusion for fetal neuroprotection.4

Documentation and communication

  • accurately document fluid input and output.
  • accurately document events and interventions performed, as contemporaneously as possible.
  • communication and explanations to the woman, her partner and family should be prompt, frequent and in a style and manner that they will understand.

While it has been common clinical practice to routinely admit women who have experienced an APH, there is no high level evidence to support this practice.

Dependant upon the underlying cause of the bleeding, women who have experienced an APH that is non life-threatening, who are clinically stable, and dependant upon the underlying cause of the bleeding, may be discharged and reviewed on an outpatient basis. This decision will be based upon the judgement of an experienced clinician, in consultation with the woman and also in view of her individual circumstances. i.e. distance from an appropriate hospital, home support, telephone and transportation access. 

APH Footnotes

  1. Konje JC, Taylor DJ. Bleeding in late pregnancy.  In: James DK, et al.  High risk pregnancy management options, 3rd ed. Philadelphia: Elsevier 2006.
  2. Martel MJ et al, Hemorrhagic shock. SOGC Clinical Practice Guidelines. J Obstet Gynaecol Can 2002;24(6):504-11
  3. Perel P, Roberts I, Pearson M. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic reviews 2007, Issue 4. Art. No.: CD000567. DOI: 10.1002/14651858.CD000567.pub3
  4. NHMRC.Antenatal Magnesium Sulphate Prior to Preterm Birth for Neuroprotection of the Fetus, Infant and Child: National Clinical Practice Guidelines 2010 Feb.
    Available at: www.adelaide. edu.au/arch/antenatalMagnesium_SulphateGuidelines.pdf 

APH Additional references sourced

  • ACOG Educational bulletin. Hemorrhagic shock. Number 235. April 1997.
  • Bose P et al, Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG. 2006 Aug;113(8):919-24.
  • Brace V, Kernaghan D, Penney G. Learning from adverse clinical outcomes: major obstetric haemorrhage in Scotland, 2003–05. BJOG 2007;114:1388–1396.
  • Dildy GA et al, Estimating Blood Loss: Can Teaching Significantly Improve Visual Estimation? Obstet Gynecol 2004;104:601–6.
  • Doyle LW et al, Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database of Systematic Reviews 2009, Issue 1.

Placenta Praevia

Definition and Diagnosis

Placenta praevia is when the placenta is inserted wholly or partly into the lower segment of the uterus in the third trimester of pregnancy.

The diagnosis of placenta praevia is made by transvaginal ultrasound, where the distance between the inferior edge of the placenta and the internal cervical os is measured.

If the placenta lies over the cervical os, it is considered a major placenta praevia; otherwise it is considered a minor placenta praevia. This diagnosis has evolved from the original clinical (I–IV) grading system.

Trans-vaginal or trans-labial ultrasound is the preferred method for localisation of a low-lying placenta. They have been shown to be significantly more accurate than using trans-abdominal sonography and it is safe to perform, even in the presence of bleeding. It is easier to identify an anterior than a posteriorly located placenta praevia. This is because the fetus often obscures the leading edge of a posterior placenta.

When a woman is found to have a low lying placenta that reaches or overlaps the cervical os at her 18-20 week morphology ultrasound scan, a further trans-vaginal ultrasound scan in later pregnancy is required, to confirm the diagnosis of placenta praevia. The timing of the second ultrasound scan for placental localisation should be:

  • in cases of asymptomatic suspected minor placenta praevia - follow-up imaging can be arranged for 32 to 36 weeks. The earlier the ultrasound scan is performed the more likely it is to find an ongoing placenta praevia however, a later scan may lead to unnecessary clinical uncertainty.

  • in cases with asymptomatic suspected major placenta praevia, a trans-vaginal ultrasound scan should be performed at 30-32 weeks. This is to clarify the diagnosis, to check for the presence of a vasa praevia, and to allow planning for third-trimester management and delivery.

  • women who are symptomatic - should be managed individually according to their needs.

Incidence

A low lying placenta occurs in 5% of pregnancies at 16-18 weeks gestation but are evident in only 0.5% pregnancies at term.1  The change of placental position results from the formation of the lower uterine segment and which moves the placenta upwards with the expanding uterus. The incidence of placenta praevia is higher in women with a previous caesarean section and increases in prevalence with each caesarean section.

Presentation

Women with a placenta praevia generally present in the following ways:

  • with an antepartum haemorrhage.
  • as a finding on ultrasound in an asymptomatic woman.
  • with a fetal malpresentation or a high mobile presenting part in late pregnancy.
  • with vaginal bleeding in labour

Effects of placenta praevia

The most common pregnancy complication arising from a placenta praevia is intermittent vaginal bleeding. About 70-80% of women with a placenta praevia will have at least one episode of vaginal bleeding, irrespective of whether the placenta praevia major or minor.3 Bleeding may also lead to maternal anaemia and so it is worthwhile ensuring and maintaining adequate maternal haemoglobin levels and iron stores. Bleeding is more likely to occur in the third trimester when the lower uterine segment is developing or during contractions with cervical dilatation, which is thought to cause shearing forces, leading to disruption of the placental attachment. Bleeding can also be provoked by a digital examination or intercourse.4

From the second trimester, a placenta praevia may be associated with vasa praevia and therefore localisation of the fetal vessels on a follow up ultrasound scan is advised.1

Bleeding caused by a placenta praevia may lead to maternal (as documented above) and fetal effects, such as hypoxia related to decreased blood supply to the placental bed, which leads to an abnormal cardiotocograph. Bleeding will lead to the need to deliver the fetus in a small number of cases.

Fetal effects of placenta praevia, that are seen in the longer term, may include intrauterine growth restriction (IUGR), due to abnormal placental implantation and vascularisation in the area of the uterus destined to be the lower segment; and a higher incidence of premature prelabour rupture of the membranes (PPROM), which is thought to be as a result of the blood affecting the integrity of the membranes.

Triggers for delivery caused by placenta praevia (i.e. in addition to other routine reasons) can be summarised as:

Short Term

  • maternal - Haemodynamic instability
  • fetal – Abnormal Cardiotocograph

Longer Term

  • fetal – Progressive intrauterine growth restriction
  • fetal – preterm, prelabour rupture of membranes
  • fetal – The presence of a vasa praevia
  • adequate gestation gained to balance the risk of further bleeding against prematurity.

Hospital or home management for women with placenta praevia?

Women with a placenta praevia and active vaginal bleeding require hopsitalization.

Traditionally women with an asymptomatic placenta praevia, that is without vaginal bleeding, have been admitted to hospital at 34 weeks gestation or earlier. However, several studies have suggested that, in the absence of active bleeding, it is safe and appropriate for women with a placenta praevia, either major or minor, to be managed on an outpatient basis and that inpatient care is not necessary.

Although not based on any high quality evidence, some clinicians make decisions regarding inpatient versus outpatient management on a variety of individualized factors, including: 

Gestation Age.

Bleeding History including:

  • severity, frequency, how recent

Home Issues such as:

  • likelihood of obtaining rest
  • carer continuously in attendance
  • absence of sexual intercourse and trauma

Ability to obtain timely treatment in the event of catastrophic haemorrhage.

Hospital proximity with respect to:

  • ability to transport immediately to hospital
  • resuscitation and massive transfusion capability
  • immediate caesarean section if needed


Management of birth, route and timing

Management recommendations for women with placenta praevia are based upon clinical and ultrasound findings.

Where the placenta is not overlying the internal os, recommendations should consider:

  • likelihood of a placenta accreta (e.g. in cases of previous caesarean section)
  • considerations with respect to immediate caesarean section (birth within 15 minutes)
  • presence of a vasa praevia
  • placental edge proximity to the internal os
  • availability of high volume blood transfusion: this may be limited by local factors or the presence of anti-red cell antibodies
  • individual considerations such as acceptability of blood transfusion, acceptability of an elective caesarean section

Vaginal versus caesarean birth

When the placental edge lies greater than 20 mm away from the internal cervical os, women may be suitable for a trial of labour.

A distance of 0-20mm from the cervical os, does not absolutely preclude a vaginal birth but, because it is associated with a likelihood of significant intrapartum bleeding, an elective caesarean section should be considered in these women.5

Caesarean section for placenta praevia

Where possible and if the woman is clinically stable, the timing of a caesarean section should be deferred until after 39 weeks to improve neonatal morbidity. However, in a major placenta praevia, planning for a caesarean section at 37-38 weeks may avoid the possibility that an emergency caesarean may be needed due to the onset of labour before the scheduled caesarean section at 39+ weeks. About 25% women scheduled for a caesarean section at 39-40 weeks will present in labour before then.6 This may present unacceptable risks of severe bleeding and subsequent maternal and neonatal sequelae in women with a placenta praevia.

It is imperative that the woman and her family are unambiguously counselled regarding the risks associated with having a placenta praevia, including the possible need and consent for blood transfusion and/or hysterectomy.

Contemporaneous documentation to support the outcome of these discussions would be prudent.

Caesarean section procedure

Consultant obstetric staff should be in attendance in theatre, or immediately available, at the time of surgery as the risk of haemorrhage is greatest at this time.

Usually a routine Pfannenstiel skin incision is adequate for delivery.

If the lower segment has not developed or if there is a known placenta accreta, a vertical skin incision should also be considered, at the discretion of the experienced obstetrician involved.

If faced with a situation of massive haemorrhage at the time of caesarean section, clinicians may need to consider: bimanual compression, hydrostatic balloon catheterisation or uterine packing. Additional 

surgical techniques to consider include compression sutures such as the B-Lynch suture, uterine or internal iliac artery ligation or hysterectomy. Arterial embolisation has been reported and is useful in selected cases, as long as the iliac vessels have not been ligated during surgery.

The choice of these techniques will be dependant upon the resources and specific expertise available at the time of the operation.

Anaesthesia

The type of anaesthesia will be made in consultation with the anaesthetist, obstetrician and the woman.

The safety of regional anaesthesia has been proven and is widely practiced.

When prolonged surgery is anticipated in women with prenatally diagnosed placenta accreta, general anaesthesia may be preferable.

Thromboprophylaxis

As with any pregnant woman who is hospitalised for lengthy periods, these women are at a greater risk of thromboembolism. Regular mobilisation is encouraged and the use of thromboembolic stockings is advised. Prophylactic anticoagulation should be reserved for those at high risk of thromboembolism. 

Placenta accreta, percreta, increta

When placenta accreta is thought to be likely, consultant anaesthetic and obstetric input are vital in planning and conducting the delivery. The place of delivery should be in a level 6 (Tertiary) hospital or where adequate resources and expertise are available.

Cross-matched blood should be available and colleagues from other specialties/subspecialties such as neonatology, urology, gynaecological oncology, intensive care and interventional radiology, may be alerted to be on standby or to attend as needed.

Surgical management choices to be considered:

  1. Vaginal delivery of the baby and awaiting spontaneous delivery of the placenta while giving the usual regimen of oxytocics. If this option is chosen, the woman must have been previously counselled, and the surgeon must be prepared to proceed promptly to hysterectomy if needed and the anaesthetist prepared for massive transfusion in the event of possible heavy bleeding while the hysterectomy is being undertaken.
  2. Delivery of the baby followed immediately by an elective hysterectomy. If this option is chosen, the woman must have been previously counselled, and the anaesthetist prepared for massive transfusion in the event of possible heavy bleeding while the hysterectomy is being undertaken.
  3. Delivery of the baby via a uterine incision distant from the placenta, full repair of the uterus and conservative management.

In approximately 75% of women, the placenta will be successfully reabsorbed.  One quarter will still require a hysterectomy because of uncontrollable bleeding, which may be delayed up to several weeks.  This has serious implications if the woman is returning to a remote area with little facility to cope with sudden severe haemorrhage.7

Further surgical options for the experienced clinician to consider are:

  • Ureteric stents: In women with suspected placenta accreta for whom a caesarean hysterectomy is planned, ureteric stent placement is associated with reduced ureteric injury.8
  • Vascular occlusive balloon catheters: The placement of vascular occlusive balloon catheters in the common iliac arteries (under radiological guidance) may offer good haemostatic control during a caesarean hysterectomy and thereby reduce maternal blood loss and morbidity.

Placenta praevia Footnotes

  1. Neilson JP. Interventions for suspected placenta praevia. Cochrane Database of Systematic Reviews 2003, Issue 2.
  2. Gilliam M, Rosenberg D, Davis F. The likelihood of placenta praevia with greater number of caesarean deliveries and higher parity. Obstet Gynecol. 2002;99:967–80.
  3. Love CDB, Wallace EM. Pregnancies complicated by placenta praevia: what is the appropriate management? BJOG Sept 1996, vol 103, pp.864-867
  4. Gagnon R, Morin L, et al, Guidelines for the management of vasa previa. J Obstet Gynaecol Can 2009 Aug;31(8):748-53.
  5. Oppenheimer L, and the Society of Obstetricians and Gynaecologists of Canada. Diagnosis and management of placenta previa. J Obstet Gynaecol Can. 2007;29:261-266.
  6. Kirkeby Hansen et al, Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. Downloaded from bmj.com on 3 March 2009
  7. Sentilhes L, Ambroselli C, et al, Maternal Outcome After Conservative Treatment of Placenta Accreta, Obstetrics & Gynecology: March 2010 - Volume 115 - Issue 3 - pp 526-534
  8. Eller A, Porter T, Soisson P, Silver R. Optimal management strategies for placenta accreta. BJOG 2009;116:648–654.

 

Placenta praevia additional references sourced

  • Clement D, Kayem G, Cabrol D. Conservative treatment of placenta percreta: a safe alternative. Eur J Obstet Gynaecol Reprod Biol 2004;114:108–9.
  • Courbiere B, Bretelle F, Porcu G, Gamere M, Blanc B. Conservative treatment of placenta accreta. J Gynecol Obstet Biol Reprod 2003;32:549–54.
  • Konje JC, Taylor DJ. Bleeding in late pregnancy.  In: James DK, Steer PJ, Weiner CP, Gonik B, editors.  High risk pregnancy management options, 3rd ed. Philadelphia: Elsevier 2006.
  • Ouellet A, Sallout B, Oppenheimer LW. Conservative v surgical management of placenta accreta; a systematic review of the literature and case series. Am J Obstet Gynecol 2003:189:S130.
  • RCOG. Placenta praevia and placenta praevia accreta: Diagnosis and management. Guideline No.23 Oct. 2005. Accessed from: www.rcog.org.au
  • Love CDB, Fernando KJ, Sargent L, Huges RG. Major placenta praevia should not preclude out-patient management. Eurpoean Journal of Obstetrics, Gynecology & Reproductive Biology. 117(1):24-9, 2004 Nov 10.

Placental abruption

Definition

Abruption is an antepartum haemorrhage from placental separation from the myometrial wall. The bleeding may be may be revealed, when blood escapes through the vagina, or concealed, when the bleeding occurs behind the placenta, with no evidence of bleeding from the vagina. When there is revealed bleeding it is also likely that there is a significant concealed proportion of bleeding. There are degrees of abruption that will reflect the range of maternal and fetal compromise.

Placental abruption is associated with a high maternal and neonatal morbidity and mortality.

 Incidence

Placental abruption complicates around 1% of pregnancies.

Risk factors

Risk factors for placental abruption include:

  • Factors predisposing to an abruption such as chronic hypertension, preeclampsia, thromobphilia, previous placental abruption, smoking, cocaine use.
  • Chorioamnionitis
  • Sudden reduction in size of an over-distended uterus e.g. rupture of the membranes in association with polyhydramnios, between births of multiple pregnancies
  • Trauma e.g. motor vehicle accident. A woman involved in trauma, such as an MVA, should be evaluated for abruption. An abruption may occur in the absence of direct abdominal trauma or, an abruption may become apparent several hours or days after the trauma.

Diagnostic features

A placental abruption most commonly presents with bleeding associated with a variable degree of abdominal pain.  This is in contrast to the painless bleeding of placenta praevia or bleeding from the cervix or lower genital tract. However, some placental abruption can also be painless.  Abruption should be high on the differential diagnosis list whenever abdominal pain occurs in the second half of pregnancy. Back pain may also be another common symptom.

Where the abruption is substantive, the uterus may be tender on palpation or may feel hard or tense. Fetal parts might not be felt through the tense uterus. Symptoms, signs and clinical examination finding of preterm labour may also coexist with abruption.

In some cases fetal demise may be the only indication of an abruption or could be accompanied by any of the previously listed symptoms.

Initial management

A detailed history should be taken if possible, to ascertain if the woman has any risk factors for abruption, including predisposing factors for placental insufficiency or any recent trauma A detailed routine history should be taken. 

The revealed blood loss should be estimated and clinical signs (blood pressure, pulse) evaluated. Urine output should be at least 30 mL/hour.  An indwelling urinary catheter with a urometer will assist with accurate measuring of output.

The following principles should guide the need for blood transfusion:

  • Revealed loss is likely to underestimate total blood loss
  • In the presence of a typical severe abruption (with fetal death), the woman may require 4-6 units of blood due to the concealed haemorrhage.
  • Considerable further blood loss should be anticipated around the time of birth. Blood replacement should be directed towards stabilising the maternal condition so that the woman is capable of sustaining further blood loss. (See management of a major APH)

An abruption should be considered if there has been recent abdominal trauma. In this situation, fetal monitoring should be carried out for a minimum of 4 hours.1

If there are uterine contractions, abnormal fetal heart rate tracings, vaginal bleeding, uterine tenderness, or rupture of the membranes, further evaluation and/or delivery are indicated as determined by gestational age and individual circumstances.

Investigations

Maternal investigations:

  • Palpation: Contractions are often frequent with a short resting period between the contractions. 
  • Haemoglobin, coagulation studies to exclude disseminated intravascular coagulopathy as a consequence of large blood loss. Note that Fibrinogen levels rise in pregnancy therefore ‘normal’ or low fibrinogen levels and a prolonged prothrombin time are suggestive of disseminated intravascular coagulation (DIC).
  • Ultrasound: In severe abruptions, there may be evidence of a retroplacental haematoma, increased placental thickness or echogenicity however, ultrasound is not the investigation of choice as there may be no ultrasound findings in the presence of an abruption.
  • Kleihauer –Betke test or flow cytometry as a measure of feto-maternal haemorrhage.

Fetal investigations:

  • Cardiotocograph.

Abruption on-going management

Corticosteroids and Magnesium Sulphate

Should be given for fetal lung maturation in pregnancies less than 34 weeks gestation, Two doses of Betamethasone 11.4mg, 24 hours apart, if delivery is not planned within the next 12 hours.

Magnesium sulphate should be considered for neuroprotection in pregnancies where delivery is planned at less than 30 weeks gestation.2

Timing of Birth

Factors that should be taken into consideration:

  • Gestational age
    • Severity of abruption as judged by: The volume of revealed blood loss and clinical signs and symptoms of haemorrhagic shock.
    • Features of concealed blood loss such as abdominal pain & tenderness
  • Fetal well-being e.g. cardiotocography
  • Co-existent conditions that may have be associated with the abruption such as preeclampsia or placental insufficiency of unknown origin.

For women at or near term, even if the current abruption appears to be minimal, delivery is recommended in view of fetal maturity. This is due to the risk of further, possibly catastrophic placental abruption.

At premature (32-37 weeks) gestations, conservative management can be considered for what appears to be only a minor placental abruption.  However, if there is substantive revealed blood loss, significant uterine tenderness, evidence of coagulopathy or fetal compromise, delivery should be expedited.     

At very premature (28-32 weeks) and extreme preterm (less than 28 weeks) gestations, conservative management may considered, even in the presence of substantive revealed bleeding or significant uterine tenderness – but only if both maternal and fetal conditions are stable. The timing of birth must weigh the risks of the maternal condition and prematurity, against those of continuing the pregnancy.

Mode of birth

If either the fetus or woman are unstable, delivery should take place promptly, with concurrent stabilisation of both. This is usually by caesarean section unless vaginal delivery is imminent and can be achieved safely. In significant abruptions, neonatal morbidity is improved if the decision to delivery time for caesarean section is less than 20 minutes, therefore unnecessary delay should be avoided.

If the abruption is significant but the woman is stable and the CTG is normal, then vaginal delivery can be attempted. Often the woman is having contractions, but if she is not in active labour, induction usually results in delivery. Continuous electronic fetal heart rate monitoring is strongly recommended, as is the availability of blood products in the event of catastrophic bleeding.

Tocolysis

For women with abruption who are bleeding and contracting, tocolysis is controversial and should only be used with caution by experienced clinicians.

Conservative management after a placental abruption

Place of Management

In all cases, the woman will be initially admitted to hospital and many will remain as inpatients until birth.  However, after a period of assessment, some women may be discharged home and monitored as an outpatient providing that:

  • The initial bleeding has completely abated and there is no evidence of ongoing haemorrhage. 
  • Clinical features were those of a minor placental abruption (low volume revealed blood loss and minimal uterine tenderness)
  • Fetal well-being is reassuring

Fetal Surveillance

All pregnancies that have had a placental abruption require intensive fetal surveillance. The woman should be carefully advised with respect to the observation of fetal movements and the reporting of any decrease in fetal activity. 

A regimen of regular cardiotocography and serial ultrasound scans is appropriate and should be tailored according to the clinical condition.

Fetal demise following a severe placental abruption

If the woman is not in active labour, the labour can be induced by routine methods, providing her condition remains stable. If the maternal condition is worsening, caesarean delivery may be indicated.

In a woman refusing the administration of all blood products but without overt DIC, a caesarean section may avoid the catastrophic situation of a later vaginal birth with massive haemorrhage, DIC and a patient refusing all blood products.  In contrast, if DIC is already established, the conventional wisdom is to avoid adding to the risk of bleeding at the  surgical site to the risk of bleeding at the placental site. 

Postpartum Haemorrhage following a Placental Abruption

Postpartum haemorrhage is relatively common following a placental abruption and may occur as a consequence of both a bleeding disorder (thrombocytopenia +/- DIC) and uterine atony.  The latter may occur in association with a “couvelaire” uterus – where blood has suffused into the myometrium, giving the serosal surface a mottled black appearance. Utero-tonic agents such as oxytocin, ergometrine and prostaglandin analogues may be given, according to the usual contraindications.  Platelets and clotting factors should be replaced.

In severe cases, where bleeding is unresponsive to delivery, utero-tonic administration, platelet and clotting factor replacement surgical measures can be life saving. The following can be considered, according to individual circumstances and local expertise:

  • Balloon tamponade (e.g. Bakri)
  • Compression sutures (e.g. B-Lynch)
  • Surgical ligation of the uterine arteries or the hypogastric arteries
  • Selective embolisation of these vessels may arrest this life-threatening haemorrhage.
  • Hysterectomy

Abruption Follow-up

Placental pathology may help elucidate the aetiology and pathophysiology of the abruption. Abnormalities such as placental thrombosis, perivillous fibrin deposition, infarction and decidual abnormalities may be found.

Women who have had a placental abruption should be screened for both congenital and acquired thrombophilias.  If the Protein S level is low, it should be repeated after an interval of 6 weeks, as the abnormally low level may be a transient impact of pregnancy. Women who smoke or engage in recreational drug use, should be advised of the strong association with placental abruption.

Abruption Footnotes

  1. Oyelese, Yinka MD. ACOG, Obstetrics & Gynecology: October 2006 - Volume 108 - Issue 4 - pp 1005-1016
  2. Doyle LW et al, Magnesium Sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database of Systematic Reviews 2009, Issue 1. 

 

Abruption additional references sourced

  • BMJ-Best Practice www.bestpractice.bmj.com/best-practice.

  • Hillemanns P, et al, Crash emergency cesarean section: decision-to-delivery interval under 30 min and its effect on Apgar and umbilical artery pH. Arch Gynecol Obstet. 2005 Dec;273(3):161-5.

  • Martel MJ, MacKinnon KJ, Arsenault MY, Bartellas E, Klein MC, Lane CA, Sprague AE, Wilson AK; Clinical Practice Obstetrics Committee and Executive and Council, Society of Obstetricians and Gynaecologists of Canada. Hemorrhagic shock. J Obstet Gynaecol Can 2002;24(6):504-11.

  • Martí-Carvajal AJ, Comunián-Carrasco G, Peña-Martí GE. Haematological interventions for treating disseminated intravascular coagulation during pregnancy and postpartum. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD008577. DOI: 10.1002/14651858.CD008577.

  • Neilson JP. Interventions for treating placental abruption. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD003247. DOI: 10.1002/14651858.CD003247.

Vasa praevia

Definition

Vasa praevia is a condition in which the umbilical vessels, unsupported by either the umbilical cord or placental tissue, traverse the fetal membranes of the lower segment above the cervix.

Incidence 

 The reported incidence varies from 1 in 1275 to 1 in 5000 (0.08% - 0.02%). Vasa praevia usually occurs in association with velamentous insertion of the umbilical cord, bipartite placenta or succenturiate lobe. In the presence of a velamentous insertion of the cord with the placenta in the lower uterine segment, the incidence of vasa praevia has been reported to be 1 in 50.

Risk factors

Placenta praevia, low-lying placenta, and bilobate or succenturiate placenta.

Clinical presentation

When performing a third trimester ultrasound on a woman with a suspected placenta praevia, it is recommended that colour Doppler imaging is also performed specifically to detect the presence of fetal vessels.

 Vasa praevia will extremely rarely present with an “antepartum” haemorrhage.  Detection is more likely on vaginal examination with palpation of fetal vessel, vaginal bleeding at amniotomy or sudden severe abnormalities of the fetal heart rate in labour are more usual presentations.

Management

Antenatal diagnosis and prompt neonatal resuscitation have shown to improve outcomes and the safest form of delivery is caesarean section, prior to the onset of labour.

The optimal gestational age at delivery has not been established. Due to the high rate of fetal mortality, it has been recommended that delivery be considered by 35-36 weeks,1 but expert clinical judgement for individualized care is necessary.

In the event of vaginal bleeding with a known vasa praevia, if time permits, a rapid biochemical test for fetal haemoglobin could be conducted, followed by an urgent caesarean section if a confirmed result is returned. However, performing a CTG or listening to the fetal heart rate may be a quicker way in many situations, to infer the diagnosis and institute appropriate management. There is typically an initial tachycardia as the fetus first becomes hypovolaemic, soon followed by a sustained bradycardia and then fetal demise if delivery by caesarean section is not immediate.

Vasa Praevia Footnotes

  1. Gagnon R et al. SOGC Guidelines for the Management of Vasa Previa. No. 231 August 2009. International Journal of Gynecology & Obstetrics, Volume 108, Issue 1, Pages 85-89

 

Cervical and lower genital tract bleeding

Other causes of vaginal bleeding in late pregnancy include:

  • Heavy show / onset of labour – Bleeding associated with labour is not traditionally considered an Antepartum Haemorrhage. If the cervix is effaced or a dilated and other causes of bleeding are excluded, the bleed is likely to be a "show.”   
  • Cervical ectropion / dysplasia/ - Bleeding from the surface of the cervix caused by contact with the speculum and may indicate cervical pathology and warrant further investigation i.e. pap smear, colposcopy. Bleeding from the walls of the vagina may indicate a severe vaginitis.   
  • Genital Tract Polyps - Cervical polyps are usually apparent upon speculum examination. 
  • Vulval or vaginal varices - Will be apparent upon speculum examination. 
  • Trauma - Consider victims of domestic violence and sexual assault.  

Non genital tract causes:

  • Haematuria, anal or rectal bleeding. 
  • Unexplained bleeding.

Cervical and lower genital tract bleding references

  • Geneva Foundation for Medical Education and Research. Maternal Care Manual - Perinatal Education Programme.  Accessed from: www.gfmer.ch/PEP/MCM_Home.htm
  • Royal Women’s Hospital Clinical practice Guidelines. Accessed from www. thewomens.org.au

 

Appendix 1. APH quick reference guide

APH Quick reference guide

Appendix 2. APH clinical evidence tables

American College of Obstetricians and Gynecologists (ACOG)

Practice Bulletins summarise current information on techniques and clinical management issues for the practice of obstetrics and gynaecology. Practice Bulletins are evidence-based documents, and recommendations are based on the available evidence. The levels of evidence used are as follows:

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus American College of Obstetricians and Gynecologists.

Royal College of Obstetricians and Gynaecologists (RCOG)

Green-top Guidelines provide systematically developed recommendations, which assist clinicians and patients in making decisions about appropriate treatment for specific conditions. Green-top guidelines are concise documents, providing specific practice recommendations on focused areas of clinical practice. The Green-top guidelines are produced under the direction of the Guidelines and Audit Committee of the RCOG.

RCOG evidence grades:

A Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.

B Requires availability of well-conducted clinical studies but no randomised clinical trials on the topic of recommendation.

C Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality.

√Good practice point. Recommended best practice based on the clinical experience of the guideline development group.  

Classification of evidence levels:

Ia Evidence obtained from meta-analysis of randomised controlled trials.

Ib Evidence obtained from at least one randomised controlled trial.

IIa Evidence obtained from at least one well designed controlled study without randomisation.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.

IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

Royal College of Obstetricians and Gynaecologists UK 2006.  Available from: http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT10aManagementPreeclampsia2006.pdf (accessed July 2009)

 

The Society of Obstetricians and Gynaecologists of Canada (SOGC).

The levels of evidence are described as:

Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on Preventive Health Care

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence from well-designed controlled trials without randomization

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

A. There is good evidence to recommend the clinical preventive action

B. There is fair evidence to recommend the clinical preventive action

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making

D. There is fair evidence to recommend against the clinical preventive action

E. There is good evidence to recommend against the clinical preventive action

I. There is insufficient evidence (in quantity or quality) to make a recommendation; however,

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