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Antepartum hemorrhage

Last updated: November 4, 2020

Summary

Antepartum hemorrhage is a serious complication of pregnancy occurring within the third trimester. It is associated with significant maternal and fetal morbidity and mortality. Common causes of antepartum hemorrhage are bloody show associated with labor, placental previa, and placental abruption. Rare causes include vasa previa and uterine rupture. Symptoms of placental abruption typically include lower abdominal pain, vaginal bleeding, and rigid uterus. Placenta previa and vasa previa on the other hand typically manifest prior to rupture of membranes or after rupture of membranes respectively, with painless vaginal bleeding and fetal distress. Uterine rupture, which occurs during labor, is discussed in a separate article. In cases of severe hemorrhage, patients may present with signs of hypovolemic shock. Fetal symptoms include signs of fetal stress, such as decelerations on heart monitoring and decreased fetal movements. The diagnosis is primarily clinical and is confirmed via transabdominal or transvaginal ultrasound. The treatment approach depends on maternal symptoms and fetal vitality. A conservative approach with continuous monitoring is advised for asymptomatic patients carrying a healthy fetus, while an emergency cesarean delivery is indicated in patients with acute symptoms and a live, distressed fetus.

Overview

Differential diagnosis of antepartum bleeding
Condition Onset Pain Additional symptoms Risk factors
Placental abruption
  • Usually mild to moderate abdominal pain
Placenta previa
  • Painless
Vasa previa
  • Painless
Uterine rupture
  • Severe abdominal pain

Stillbirth

  • Cramping abdominal pain
Bloody show
  • Associated regular uterine contractions and cervical changes
  • A small amount of blood or blood-tinged mucus that is usually passed prior to labor or in early labor.
  • N/A
Cervical trauma
  • Sudden, typically caused by sexual intercourse
  • Mild to moderate pelvic pain depending on the extent of damage
  • Bruised and tender cervix without evidence of active bleeding
  • N/A

Placental abruption

Definition

  • The partial or complete separation of the placenta from the uterus prior to delivery; subsequent hemorrhage occurs from both maternal and fetal vessels.

Epidemiology

Etiology

Clinical features

Following placental separation of more than 30%, there is a sudden onset of the following symptoms:

In cases of retroplacental hemorrhage, patients may present with signs of hypovolemic shock without evident vaginal bleeding!

Diagnostics

Placental abruption is a clinical diagnosis.

Rapid diagnosis and immediate treatment are vital for the survival of both mother and child!

Treatment

General approach

  • Hemodynamic control: monitor vital signs, maintain airways, volume resuscitation, type and crossmatch blood
  • Correct coagulopathy if necessary
  • RhD prophylaxis in RhD negative mothers
  • See also peripartum hemorrhage.

Specific approach according to severity

Complications

Abruptio placentae is characterized by the “abrupt” onset of painful bleeding.

References:[2][3][4]

Placenta previa

Definition

  • Presence of the placenta in the lower uterine segment; ; can lead to partial or full obstruction of the neck of the uterus with high risk of hemorrhage (rupture of placental vessels) and birth complications

Epidemiology

Risk factors [6]

Classification [7]

  • Placenta previa: placenta that covers the internal os either partially or completely
    • Previously, this category included marginal previa (placenta reaching the internal os), partial previa (placenta partially covering the internal os), and complete previa (placenta completely covering the internal os); these terms have been excluded from the new classification.
  • Low-lying placenta: : lower edge of the placenta lies less than 2 cm from the internal cervical os

Clinical features

  • Sudden, painless, bright red vaginal bleeding
  • Usually occurs during the 3rd trimester (before rupture of the membranes), stops spontaneously after 1–2 hours, and recurs during birth
  • Often causes preterm delivery (∼ 45% of cases)
  • Soft, nontender uterus
  • Usually no fetal distress

In contrast to placental abruption, bleeding in patients with placenta previa is painless.

Diagnostics

Treatment [8]

Vaginal delivery should never be attempted outside the operating room in a patient with placenta previa.

In placenta previa, we receive a “preview” of the placenta through the cervical os.

References:[9][10][11][12][13][14]

Vasa previa

Definition

  • Condition in which the fetal vessels are located in the membranes near the internal os of the cervix, putting them at risk of injury if the membranes rupture

Epidemiology

  • 1/2500 births

Etiology

In most cases, at least one of the following risk factors is present.

Clinical features

Diagnostics

  • Transabdominal or transvaginal ultrasound with color Doppler shows fetal vessels overlying the internal os and decreased blood flow within fetal vessels.

Treatment

References:[15]

References

  1. Ananth CV, Keyes KM, Hamilton A, et al. An international contrast of rates of placental abruption: an age-period-cohort analysis.. PLoS ONE. 2015; 10 (5): p.e0125246. doi: 10.1371/journal.pone.0125246 . | Open in Read by QxMD
  2. Ananth CV, Kinzler WL. Placental abruption: Clinical features and diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/placental-abruption-clinical-features-and-diagnosis?source=see_link.Last updated: January 4, 2017. Accessed: February 17, 2017.
  3. Oyelese Y, Ananth CV. Placental abruption: Management. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/placental-abruption-management.Last updated: March 2, 2016. Accessed: April 25, 2017.
  4. Briggs GG, Nageotte M. Diseases, Complications, and Drug Therapy in Obstetrics: A Guide for Clinicians. ASHP ; 2009
  5. Jauniaux E, Grønbeck L, Bunce C, Langhoff-Roos J, Collins SL. Epidemiology of placenta previa accreta: a systematic review and meta-analysis. BMJ Open. 2019; 9 (11): p.e031193. doi: 10.1136/bmjopen-2019-031193 . | Open in Read by QxMD
  6. Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-analysis of observational studies. The Journal of Maternal-Fetal & Neonatal Medicine. 2003; 13 (3): p.175-190. doi: 10.1080/jmf.13.3.175.190 . | Open in Read by QxMD
  7. Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal Imaging. Journal of Ultrasound in Medicine. 2014; 33 (5): p.745-757. doi: 10.7863/ultra.33.5.745 . | Open in Read by QxMD
  8. Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period. Am J Obstet Gynecol. 2018; 218 (1): p.B2-B8. doi: 10.1016/j.ajog.2017.10.019 . | Open in Read by QxMD
  9. Lockwood CJ, Russo-Stieglitz K. Clinical features, diagnosis, and course of placenta previa. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/clinical-features-diagnosis-and-course-of-placenta-previa?source=see_link.Last updated: November 30, 2016. Accessed: February 17, 2017.
  10. Gibbs RS. Danforth's Obstetrics and Gynecology. Lippincott Williams & Wilkins ; 2008
  11. Beckmann CRB. Obstetrics and Gynecology. Lippincott Williams & Wilkins ; 2010
  12. Hacker NF, Gambone JC, Hobel CJ. Hacker & Moore's Essentials of Obstetrics and Gynecology E-Book. Elsevier Health Sciences ; 2015
  13. Sakornbut E, Leeman L, Fontaine P. Late Pregnancy Bleeding. Am Fam Physician. 2007; 75 (8): p.1199-1206.
  14. Lockwood CJ, Russo-Stieglitz K. Management of placenta previa. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/management-of-placenta-previa.Last updated: March 3, 2017. Accessed: June 24, 2017.
  15. Lockwood CJ, Russo-Stieglitz K. Velamentous umbilical cord insertion and vasa previa. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/velamentous-umbilical-cord-insertion-and-vasa-previa.Last updated: November 22, 2016. Accessed: April 25, 2017.