Bleeding antepartum
        Main and The Obgyn Clinic of Hvidovre (danish)
          Content:
          Assessment on arrival
          Abruptio placenta
          Palcenta previa

        Definition:
        Bleeding after 20 weeks of gestation.

        Assessment on Arrival:
        1. Maternal Condition:
          • Degree of Shock
          • Blood Pressure/Pulse
          • Active Bleeding
          • Abdominal palpation
          • Vaginal inspection, if appropriate
          • Hemoglobin
          • Platelet and Coagulation factor
          • Urine Output/proteinuria
        2. Fetal Condition:
          • Viability/Presence of Fetal Heart
          • Probable Gestational Age
          • Quality Fetal Heart (CTG)
        3. Ultrasound assessment:
          • Singleton presentation
          • Placental Site
          • Estimated Fetal Weight
        4. Probable Etiology:
          • Association with hypertension, trauma, etc.
        Resuscitation and Volume Replacements:
          In case of major obstetric haemorrhage
          • IV access 2 x 14 or 16 cannulas (se post part bleeding).
          • O2 BY MASK, 8 l/min.
          • Elevate legs
          • Blood for:
            • Cross match (6 units of blood)
            • Full blood count
            • Clotting screen (fibrinogen, APTT, PT,D-dimer, platelets)
            • Base line urea and electrolytes
        Foley catheter (monitor hourly urine output)
        Monitor (most optimal continuous monitoring): pulse, blood pressure, O2 saturation, ECG, pulse oximeter, central line

        Volume Replacement
        See bleeding post aprtuum : Suggestion for blood replacement and preparation for the use of Novoseven.

        Abruptio Placenta
        Clinical diagnosis and not a diagnosis based on ultrasound.

        Symptoms:
        Pain, uterine hypertonous, local or generalize.
        Uterine irritability, bleeding (15% concealed).

          Type I
          Slight vaginal bleeding and some uterine irritability is usually present. Maternal and fetal condition not affected.

          Type II
          Mild to moderate vaginal bleeding with living fetus, uterus is irritable and may be tetanic, signs of fetal distress, pulse rate may be elevated and coagulopathy (DIC) as well as pre-shock can develop.

          Type III
          1. Fetal death. Moderate to severe bleeding.(concealed bleeding: uterus Couve-laire), and
          2. uterus tetanic and fetal type and mother in shock with coagulopathy (DIC).

        II.Trimester Management/Inspection concerning affection on the cervix: erosion, polyp, cancer (contact bleeding), cervix dilatation (cervix insufficiency, labor). If recurrent bleeding on the cervix, colposcopy, Pap smear in a non-bleeding stage.

        III.Trimester - As above, but ruled out placenta previa/abruptio in case of preterm delivery consider gestational age.

        Management:
          Type I
            Admission under observation. IV access, CTG, expected management if mother and fetus are in good condition and there is no sign of tachycardia or coagulopathy. Eventually artificial rupture of the membranes if cervix is ripe and gestational > 35 weeks and/or if early labor to prevent further abruption.
          Type II
            Caesarean Section, eventually artificial rupture of the membranes in the waiting time. Vaginal delivery if delivery can be anticipated within 1-2 hours and fetal heart can carefully and constantly be monitored, if contraction are poor, augment labour with oxytocin.
          Type III
            Correction of hypovolemia and coagulopathy, cesarean section or induction by artificial rupture of membranes and cautious with IV Oxytocin.
            Postpartum Oxytocin infusion and control of coagulation factors in case of Type II and Type III. Careful monitoring of renal factor.
          Be prepared for post partum haemorrhage. Recurrance Risk is 15%.

        Placenta Previa
        Do not perform vaginal examination unless preparation have been made for immediate Caesarean section.

        Risk increased with age, parity and uterine surgery.

        Diagnosis: Unstable lie and mono-symptomatic bleeding. Ultrasound: Transvaginal is safe and is more accurate than transabdominal ultrasound in locating the placenta.

        II Trimester: 5-6% in late second trimester Potential placenta previa; cover internal os especially if > 1/3 of placenta is covered

        III Trimester: 0.1-0.5% in third trimester. Total: > 1 cm cover internal orifice. Marginal: < 1 cm from internal orifice. Low-lying placenta 1-3 cm from internal orifice.

        Treatment:
        < 1 cm from internal orifice always c/s
        1-2cm - a high percentage end by emergency c/s because of bleeding especially if thick placental margin
        > 2cm can expect normal delivery.

        Ruptured ulterus:
        • Restore blood volume
        • When stable immediately perform lapecstomy and deliver the baby and placenta.
        • If the uterus can be repaired with less operative risk than hysterectomy would entail and if the edges of tear are not necrotic, repair the uterus.
        • Otherwise perform subtotal hysterectomy or if tears extends ? cervix and vagina total hysterectomy may be requested.

        References:
        (1) Bhide A, et al. Placental edge to internal os distance in the late third trimester and mode of delivery in placenta previa. Br J Obstet Gynecol 2003; 110(9): 860-64.
        (2) Life savingshills manual Royal College of Obstetricians and Gynaecologist 2007
        (3) UpToDate 2005, Online 13.3

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