Maternal Care: Antepartum haemorrhage


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Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

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Maternal Care: Antepartum haemorrhage

  1. 1. 4 Antepartum haemorrhageBefore you begin this unit, please take the ANTEPARTUMcorresponding test at the end of the book toassess your knowledge of the subject matter. You HAEMORRHAGEshould redo the test after you’ve worked throughthe unit, to evaluate what you have learned. 4-1 What is an antepartum haemorrhage? An antepartum haemorrhage is any vaginal Objectives bleeding which occurs at or after 24 weeks (estimated fetal weight at 24 weeks = 500 g) and before the birth of the infant. A bleed before 28 When you have completed this unit you weeks is regarded as a threatened miscarriage as should be able to: the fetus is usually considered not to be viable. • Understand why an antepartum haemorrhage should always be regarded NOTE A fetus is viable from 28 weeks, or an estimated weight of 1000 g, if the duration as serious. of pregnancy is uncertain. Antepartum • Provide the initial management of a haemorrhage before the fetus is viable has patient presenting with an antepartum the same serious complications as that with a haemorrhage. viable fetus. In both cases, the management is the same except for fetal monitoring, which • Understand that it is sometimes is only done from 28 weeks (or 1000 g). necessary to deliver the fetus as soon as possible, in order to save the life of the 4-2 Why is an antepartum haemorrhage mother or infant. such a serious condition? • Diagnose the cause of the bleeding 1. The bleeding can be so severe that it can from the history and examination of the endanger the life of both the mother and patient. fetus. • Correctly manage each of the causes of 2. Abruptio placentae is a common cause antepartum haemorrhage. of antepartum haemorrhage and an important cause of perinatal death in • Diagnose the cause of a blood-stained many communities. vaginal discharge and administer appropriate treatment. Therefore, all patients who present with an antepartum haemorrhage must be regarded as
  2. 2. ANTEPAR TUM HAEMORRHAGE 101serious emergencies until a diagnosis has been 2. Assess the condition of the fetus. If themade. Further management will depend on fetus is viable but distressed, an emergencythe cause of the haemorrhage. delivery is needed. 3. Diagnose the cause of the bleeding, taking the clinical findings into account Any vaginal bleeding during pregnancy may be and, if necessary, the results of special an important danger sign that must be reported investigations. immediately. The initial management and diagnosis of a patient with vaginal bleeding is summarised in4-3 What advice about vaginal bleeding Flow diagram 4-1.should you give to all patients?Every patient must be advised that any vaginal 4-5 What symptoms and signs indicate thatbleeding is potentially serious and told that this the patient is shocked due to blood loss?complication must be reported immediately. 1. Dizziness is the commonest symptom of shock.4-4 What is the management of 2. On general examination the patientan antepartum haemorrhage? is sweating, her skin and mucousThe management consists of four important membranes are pale, and she feels coldsteps that should be carried out in the and clammy to the touch.following order: 3. The blood pressure is low and the pulse rate fast.1. The maternal condition must be evaluated and stabilised, if necessary. 4-6 How should you manage a shocked2. The condition of the fetus must then be patient with an antepartum haemorrhage? assessed.3. The cause of the haemorrhage must be When there are symptoms and signs to diagnosed. indicate that the patient is shocked, you must:4. Finally, the definitive management of an 1. Put up two intravenous infusions (‘drips’) antepartum haemorrhage, depending on with Balsol or Ringer’s lactate, to run in the cause, must be given. quickly in order to actively resuscitate theIt must also be decided whether the patient patient.should be transferred for further treatment. 2. Insert a Foley catheter into the patient’s bladder to measure the urinary volume and to monitor further urine output.THE INITIAL EMERGENCY 3. If blood is available, take blood for cross- matching at the time of putting up theMANAGEMENT intravenous infusion and order two orOF ANTEPARTUM more units of blood urgently. 4. Listen to the fetal heart:HAEMORRHAGE • If fetal distress is present and the fetus is assessed to be viable (28 weeks or anThe management must always be provided in estimated weight of 1000 g or more),the following order: then deliver by the quickest possible1. Assess the condition of the patient. If the method, usually by Caesarean section. patient is shocked, she must be resuscitated • If fetal distress is excluded, if the fetus immediately. is too preterm to be viable, or if there is an intra-uterine death, then more attention can be given to the history
  3. 3. 102 MATERNAL CARE History of vaginal Maternal condition? Not shocked bleeding Resuscitate Shocked No Yes A life-threatening Refer for urgent haemorrhage? Fetal stress? delivery Yes No Refer for urgent What type of Antepartum Speculum Caesarean section bleed? haemorrhage examination Blood mixed with No local mucus, or blood- Local cause, eg. cause stained discharge vaginitis or local found lesion Treat local Decide between: ‘Show’ or 1. Placenta praevia vaginitis cause of bleeding 2. Abruptio placentae and referFlow diagram 4-1: Initial management of a patient with vaginal bleeding
  4. 4. ANTEPAR TUM HAEMORRHAGE 103 and examination of the patient in If the maternal and fetal conditions are order to make a diagnosis of the cause satisfactory, then a careful speculum of the bleeding. examination should be done to exclude a local cause of the bleeding. Do not perform a4-7 What must you do if a patient presents digital vaginal examination, as this may causewith a life-threatening haemorrhage? a massive haemorrhage if the patient has a placenta praevia.The maternal condition takes preferenceover that of the fetus. The patient, therefore,is actively resuscitated while arrangements Do not do a digital vaginal examination untilare made to terminate the pregnancy by placenta praevia has been excluded.Caesarean section. 4-9 How does a speculum examination help you determine the cause of the bleeding?DIAGNOSING THE CAUSE 1. Bleeding through a closed cervical osOF THE BLEEDING confirms the diagnosis of a haemorrhage. 2. If the cervix is a few centimetres dilated with bulging membranes, or the presenting4-8 Should you treat all patients part of the fetus is visible, this suggests thatwith antepartum haemorrhage in the bleed was a ‘show’.the same way, irrespective of the 3. A blood-stained discharge in the vagina,amount and character of the bleed? with no bleeding through the cervical os,No. The management differs depending on suggests a vaginitis.whether the vaginal bleeding is diagnosed 4. Bleeding from the surface of the cervixas a ‘haemorrhage’ on the one hand, or a caused by contact with the speculum (i.e.blood-stained vaginal discharge or a ‘show’ contact bleeding) may indicate a cervicitison the other hand. A careful assessment of or cervical intra-epithelial neoplasia (CIN).the amount and type of bleeding is, therefore, 5. Bleeding from a cervical tumour orvery important. an ulcer may indicate an infiltrating carcinoma.1. Any vaginal bleeding at or after 24 weeks must be diagnosed as an antepartum haemorrhage if any of the following are 4-10 Can you rely on clinical findings to present: determine the cause of a haemorrhage? • A sanitary pad is at least partially In many cases the history and examination of soaked with blood. the abdomen will enable the patient to be put • Blood runs down the patient’s legs. into one of two groups: • A clot of blood has been passed. 1. Abruptio placentae.A diagnosis of a haemorrhage always suggests 2. Placenta praevia.a serious complication. There are some patients in whom no reason1. A blood-stained vaginal discharge will for the haemorrhage can be found. Such a consist of a discharge mixed with a small haemorrhage is classified as an antepartum amount of blood. haemorrhage of unknown cause.2. A ‘show’ will consist of a small amount of blood mixed with mucus. The blood- stained vaginal discharge or ‘show’ will be present on the surface of the sanitary pad but will not soak it.
  5. 5. 104 MATERNAL CARE4-11 What is the most likely cause of the other hypertensive disorders ofof an antepartum haemorrhage pregnancy.with fetal distress? 3. Intra-uterine growth restriction. 4. Cigarette smoking.Abruptio placentae is the commonest cause 5. Poor socio-economic conditions.of antepartum haemorrhage leading to fetal 6. A history of abdominal trauma, e.g. a falldistress. However, sometimes there may be or kick on the abdomen.very little or no bleeding even with a severeabruptio placentae. 4-15 What symptoms point to a diagnosis of abruptio placentae? An antepartum haemorrhage with fetal distress 1. An antepartum haemorrhage which or fetal death is almost always due to abruptio is associated with continuous severe placentae. abdominal pain. 2. A history that the blood is dark red with4-12 What is the most likely cause of a life- clots.threatening antepartum haemorrhage? 3. Absence of fetal movements following the bleeding.A placenta praevia is the most likely causeof a massive antepartum haemorrhage thatthreatens the patient’s life. 4-16 What do you expect to find on examination of the patient? 1. The general examination and observationsANTEPARTUM BLEEDING show that the patient is shocked, oftenCAUSED BY ABRUPTIO out of proportion to the amount of visible blood loss.PLACENTAE 2. The patient usually has severe abdominal pain. 3. The abdominal examination shows the4-13 What is abruptio placentae? following:Abruptio placentae (placental abruption) • The uterus is tonically contracted, hardmeans that part or all of the normally and tender, so much so that the wholeimplanted placenta has separated from the abdomen may be rigid.uterus before delivery of the fetus. The cause of • Fetal parts cannot be palpated.abruptio placentae remains unknown. • The uterus is bigger than the patient’s dates suggest. • The haemoglobin concentration is low,4-14 Which patients are at increased indicating severe blood loss.risk of abruptio placentae? 4. The fetal heartbeat is almost always absentPatients with: in a severe abruptio placentae.1. A history of an abruptio placentae in a These symptoms and signs are typical of a previous pregnancy. (There is a 10% chance severe abruptio placentae. However, abruptio of recurrence after an abruptio placentae placentae may present with symptoms and in a previous pregnancy and a 25% chance signs which are less obvious, making the after two previous pregnancies with an diagnosis difficult. abruptio placentae.) The management of abruptio placentae is2. Pre-eclampsia (gestational proteinuric summarised in flow diagram 4-2. hypertension) and, to a lesser extent, any
  6. 6. ANTEPAR TUM HAEMORRHAGE 105 Antepartum haemmorhage with symptoms or signs of abruptio placentae Shocked Maternal condition? Not shocked Fetal heart No Rupture Resuscitate Vaginal delivery present? membranes Yes Yes No Vaginal Fetus viable? examination Cervix 9 cm or more dliated and No Caesarean fetal head section engaged? Yes Vaginal deliveryFlow diagram 4-2: Management of a patient with an abruptio placentae
  7. 7. 106 MATERNAL CARE 4-19 What should you do if the The diagnosis of severe abruptio placentae can fetal heartbeat is absent? usually be made from the history and physical examination. 1. Active resuscitation of the mother is a priority and should have been started as part of the initial emergency management:4-17 What would you do if the fetal • Two intravenous infusion lines areheartbeat was still present? usually needed, one of which can be aIf the fetal heartbeat is still present with an central venous pressure line inserted inabruptio placentae, there will usually be signs the antecubital fossa.of fetal distress. The infant will die in utero if • Two units of fresh frozen plasma,not delivered immediately. and at least four units of whole blood are usually needed for effective4-18 How should you decide on resuscitation.the method of delivery if the fetal 2. A Foley catheter is inserted into theheartbeat is still present? bladder. 3. The pulse rate and blood pressure must1. If the symptoms and signs are typical of an be checked every 15 minutes until the abruptio placentae, a vaginal examination patient’s condition stabilises, and half- should be done. hourly thereafter. The urinary output must2. If the cervix is at least 9 cm dilated, and the be recorded hourly. presenting part is well down in the pelvis, 4. The membranes are then ruptured, then the membranes should be ruptured following which cervical dilatation and and the infant delivered vaginally. If these delivery of the fetus usually occur quickly. conditions are not present, an emergency 5. Pain relief in the form of pethidine or Caesarean section should be done. morphine and promethazine (Phenegan)3. If the fetus is not viable, it should be or hydroxyzine (Aterax) should be given delivered vaginally if the diagnosis is once the patient is adequately resuscitated. abruptio placentae.4. While preparations for delivery are being 4-20 Why is it important to remember that made, the mother must be resuscitated many patients with abruptio placentae and intra-uterine resuscitation of the fetus have underlying pre-eclampsia? started. However, salbutamol or nifedipine must not be given to a patient who shows 1. Signs of shock may be present even with any evidence of shock. a normal blood pressure. These patients,5. When there is doubt about the diagnosis, nevertheless, need active resuscitation. specifically when placenta praevia cannot 2. After resuscitation a hypotensive patient be excluded on history and examination, may become hypertensive, so much so that then a digital vaginal examination should dihydralazine (Nepresol) may have to be not be done. If fetal distress is present and given parenterally or nifedipine (Adalat) the fetus is viable, a Caesarean section orally. must be done. If there is neither fetal 3. Magnesium sulphate must be given if the distress nor severe vaginal bleeding, the patient develops imminent eclampsia. possibility of a placenta praevia must be investigated. An ultrasound examination NOTE These patients are haemodynamically very or vaginal examination in theatre must unstable. Although initially they also require active resuscitation, they quickly become then be done. fluid overloaded, resulting in pulmonary oedema. Renal complications, such as acute tubular necrosis, commonly occur.
  8. 8. ANTEPAR TUM HAEMORRHAGE 1074-21 At your initial assessment of • Are grande multiparas, i.e. who arethe patient, how would you know para 5 or higher.whether or not there is underlying • Have had a previous Caesarean section.pre-eclampsia present? 2. With regard to their present obstetric history, patients who:By finding protein in the patient’s urine. • Have a multiple pregnancy. • Have had a threatened abortion, Abruptio placentae with pre-eclampsia is a serious especially in the second trimester. condition with a high risk of maternal death. • Have an abnormal presentation.4-22 What complication should 4-26 What in the history of the bleedingyou watch for after delivery? suggests the diagnosis of placenta praevia?Postpartum haemorrhage, as this is common 1. The bleeding is painless and bright red inafter abruptio placentae. colour. 2. Fetal movements are still present after the bleed.4-23 What action should you take toprevent postpartum haemorrhage? 4-27 What are the typical findings1. Syntometrine 1 ampoule should be given on physical examination in a intramuscularly, if the patient is not patient with placenta praevia? hypertensive. Only oxytocin is used in a hypertensive patient. 1. General examination may show signs that2. In addition, 20 units of oxytocin are put in the patient is shocked, and the amount the intravenous infusion bottle. of bleeding corresponds to the degree3. The uterus is rubbed up well. of shock. The patient’s haemoglobin4. The patient is carefully observed for concentration is normal or low depending bleeding. on the amount of blood loss and the time interval between the haemorrhage and the haemoglobin measurement. However, theANTEPARTUM first bleed is usually not severe. 2. Examination of the abdomen shows that:BLEEDING CAUSED BY • The uterus is soft and not tender toPLACENTA PRAEVIA palpation. • The uterus is not bigger than it should be for the patient’s dates.4-24 What is placenta praevia? • The fetal parts can be easily palpated, and the fetal heart is present.Placenta praevia means that the placenta is • There may be an abnormalimplanted either wholly or partially in the lower presentation. Breech presentation orsegment of the uterus. It may extend down to, oblique or transverse lies are commonlyor cover the internal os of the cervix. When present.the lower segment starts to form or the cervix • In cephalic presentations, the head isbegins to dilate, the placenta becomes partially not engaged and is easily balottableseparated and this causes maternal bleeding. above the pelvis.4-25 Which patients have thehighest risk of placenta praevia? The diagnosis of placenta praevia can usually be1. With regard to their previous obstetric made from the history and physical examination. history, patients who:
  9. 9. 108 MATERNAL CARE4-28 Do you think that engagement 4-32 What is the further management afterof the head can occur if there is making the diagnosis of placenta praevia?a placenta praevia present? 1. If the patient is not bleeding actively,No. If there is 2/5 or less of the fetal head further management depends on thepalpable above the pelvic brim on abdominal gestational age:examination, then placenta praevia can be • With a gestational age of less than 38excluded and a digital vaginal examination can weeks, the patient is hospitalised andbe done safely. The first vaginal examination managed conservatively until 38 weeksmust always be done carefully. or until active bleeding starts. • If the fetus is viable (28 weeks or more) but the gestational age is less Two fifths or less of the fetal head palpable than 34 weeks, steroids must be given above the pelvic brim excludes the possibility of to stimulate fetal lung maturity as placenta praevia. delivery may become necessary within a few days.4-29 What do you understand • With a gestational age of 38 weeks orby a ‘warning bleed’? more, the fetus should be delivered. The further management of a patientThis is the first bleeding that occurs from a when her pregnancy has reached 36 weeksplacenta praevia, when the lower segment depends on the grade of placenta praevia.begins to form at about 34 weeks, or even 2. A patient who is actively bleeding must beearlier. delivered irrespective of the gestational age, because this is a life-threatening condition4-30 Are there any investigations that can for the patient. An emergency Caesareanconfirm the diagnosis of placenta praevia? section or hysterotomy must be done.1. If the patient is less than 38 weeks pregnant The management of a patient with a placenta and not bleeding actively, an ultrasound praevia is summarised in flow diagrams 4-3 examination must be done in order to and 4-4. localise the placenta.2. If the patient is 38 or more weeks pregnant, 4-33 When a patient with placenta and not bleeding actively: praevia is less than 38 weeks pregnant • If ultrasonology is available, an and is being managed conservatively, ultrasound examination can be done in what amount of bleeding would indicate order to localise the placenta. that you should deliver the fetus? • If ultrasonology is not available, a digital vaginal examination can be done 1. Any sudden, severe haemorrhage. in theatre with everything ready for a 2. Any continuous, moderate bleeding, such Caesarean section. that the drop in the patient’s haemoglobin concentration requires a blood transfusion.4-31 What action should you take if aroutine ultrasound examination early in 4-34 How will you further manage a patientpregnancy shows a placenta praevia? who has been treated conservatively?In most cases, the position of the placenta 1. With a grade 3 or 4 placenta praevia, amoves away from the internal os of the Caesarean section should be done at 36cervix as pregnancy continues. A follow-up weeks.ultrasound examination must be arranged at a 2. With a grade 2 placenta praevia, agestational age of 32 weeks. Caesarean section should be done at 38 weeks.
  10. 10. ANTEPAR TUM HAEMORRHAGE 109 Antepartum haemorrhage with Maternal condition? symptoms or signs of placenta praevia Resuscitate Shocked Not shocked Caesarean Yes No section if fetus ltrasound Fetal distress? examination viable Continuing Yes Caesarean Yes lacenta bleeding with a ospitalise section praevia? fall in b? No No A of No ocal See flow ed rest to unknown cause? diagram V weeks cause Yes reat local causeFlow diagram 4-3: Management of a patient with a placenta praevia before 36 weeks
  11. 11. 110 MATERNAL CARE lacenta praevia of weeks or more rade of placenta praevia? rade with rade or bleeding or rade with engaged head and rade of placenta placenta unengaged head praevia uncertain covering internal or rade no bleeding cervical os ait for ait for Caesarian weeks or spontaneous section bleeding onset of labour Careful vaginal examination lacental tissue palpable in lower segment? Yes No Caesarean Rupture membranes section and deliver vaginallyFlow diagram 4-4: Management of a patient with a placenta praevia at 36 weeks or more
  12. 12. ANTEPAR TUM HAEMORRHAGE 1113. With a grade 1 placenta praevia which ability as the upper segment to contract bleeds now, and a presenting part that and retract after delivery. Therefore, remains high above the pelvis, a Caesarean the same measures taken with abruptio section should be done at 38 weeks. placentae must be taken to prevent4. With a grade 1 placenta praevia, which postpartum haemorrhage. does not bleed and where the fetal head is engaged (2/5 or less palpable above the brim), you can wait for the spontaneous ANTEPARTUM onset of labour. The first vaginal examination must be done very carefully. HAEMORRHAGE OF UNKNOWN CAUSE4-35 How do you go about doing avaginal examination in theatre? 4-38 When would you suspect1. The theatre sister must be scrubbed up an antepartum haemorrhage with her trolley ready. of unknown cause?2. The anaesthetist must be ready with his drugs drawn up so that, if necessary, he can In patients who fulfill all the following proceed immediately with the induction of requirements: anaesthesia. 1. Less severe antepartum bleeding, without3. A careful digital examination must be signs of shock, and when the fetal done. First feel in all four vaginal fornices: condition is good. • If there is soft tissue between the 2. When the history and examination do not examining finger and the fetal skull, suggest a severe abruptio placentae. then placenta praevia is diagnosed. 3. When local causes have been excluded on • If the fetal skull is easily felt in all four speculum examination. fornices, then a careful examination is 4. When placenta praevia has been excluded done through the cervix. by an ultrasound examination. • If placental tissue is felt, then a Caesarean section should be done. If 4-39 What should you do to exclude not, the membranes can be ruptured other causes of bleeding if you do with the aim of allowing a vaginal not have ultrasound facilities ? delivery. 1. Abruptio placentae can usually be excluded on history and examination.4-36 If the fetus is alive, why is urgent 2. Local causes are excluded on speculumdelivery of less importance in placenta examination.praevia than in abruptio placentae? 3. With a gestational age of 38 weeks or more,Compared with abruptio placentae, intra- a vaginal examination is done in theatre touterine death is uncommon in placenta confirm or exclude placenta praevia.praevia. However, a serious vaginal bleed due 4. If the gestational age is less than 38to placenta praevia may still necessitate an weeks, the patient must be admitted toimmediate delivery to save the mother’s life. hospital and close attention paid to fetal movements, especially in the first 24 hours.4-37 Why do patients with a placenta NOTE If available, antenatal fetal heartpraevia have an increased risk of rate monitoring should be done onpostpartum haemorrhage? admission to hospital and every six1. The placenta was implanted in the lower hours during the first 24 hours. segment which does not have the same
  13. 13. 112 MATERNAL CARE4-40 What is the most likely cause NOTE Antepartum haemorrhage could also beof an antepartum haemorrhage due to vasa praevia. This rare cause of antepartumof unknown cause? haemorrhage occurs when the vessels of the umbilical cord cross the membranes near toA small abruptio placentae that does not cause the internal os. When the membranes rupture, aany other signs or symptoms. If the placental small amount of continuous bright red bleedingseparation is going to extend, it will usually occurs. The blood is from the fetal circulationhappen within the first 24 hours following and, therefore, the fetus can bleed to death.the bleed. Therefore, the patient must be If the cervix is almost fully dilated, the fetus can be delivered vaginally. If not, a Caesareanhospitalised and closely observed during this section must be done. The presence of fetalperiod for signs of fetal distress. blood is confirmed by performing the sodium hydroxide (Apt) test: Add one drop of blood to4-41 How should you manage nine drops of 1% sodium hydroxide in a glassa patient with an antepartum test tube. Read at one minute. If the blood ishaemorrhage of unknown cause? fetal, the mixture remains pink. However, if the blood is maternal, the mixture becomes brown.1. The patient must be hospitalised.2. Careful attention must be given to fetal movements, especially during the first 24 REFERRAL OF A PATIENT hours. WITH AN ANTEPARTUM NOTE If available, a cardiotocogram must be recorded on admission and then every HAEMORRHAGE six hours during the first 24 hours.3. If there is no further bleeding in the next 4-43 How should you decide whether 48 hours, the patient can be discharged. a patient can be managed locally or She must abstain from coitus for the rest of whether she should be transferred? her pregnancy.4. As a high-risk pregnancy, the patient must 1. Clinics and level 1 hospitals which do not have weekly follow-ups and is advised to have blood available must refer all patients report immediately if there is any decrease with an antepartum haemorrhage. in fetal movements, or further bleeding. No 2. Level 1 hospitals which have blood digital vaginal examination must be done. available, and level 2 hospitals, must manage5. The patient must be allowed to go into patients with the following problems: spontaneous labour at term. • A life-threatening bleed from placenta praevia. • Fetal distress present with a viable fetus. A patient with an antepartum haemorrhage of • Abruptio placentae with a live, viable unknown cause must be closely observed for fetal fetus. distress during the first 24 hours after the bleed. 3. Abruptio placentae with a dead fetus must be managed in at least a level 2 hospital, because of the risk of clotting defects.4-42 Why is an antepartum 4. A patient with abruptio placentae andhaemorrhage of unknown cause pre-eclampsia must be referred to a level 3always regarded in a serious light? hospital as this patient is at high risk ofThere is the possibility that abruptio placentae pulmonary oedema and acute tubularmay be present. If the abruptio placentae going to extend, intra-uterine death may 5. A patient with a grade 3 or 4 placentaresult. The risk of such an event is greatest praevia and a viable fetus of less thanduring the 24 hours following the bleed. 34 weeks, who is going to be managed
  14. 14. ANTEPAR TUM HAEMORRHAGE 113 conservatively, should be managed in at 4. A ‘show’ is the most likely cause of the least a level 2 hospital with a neonatal discharge if the cervix is a few centimetres intensive care unit, or a level 3 hospital. dilated with bulging membranes, or if the presenting part of the fetus is visible.4-44 When you refer a patient, what 5. A vaginitis is the most likely cause, if aprecautions should you take to ensure blood-stained discharge is seen in thethe safety of the patient in transit? vagina.1. A shocked patient should have two 4-48 How should you treat a blood-stained intravenous infusion lines with discharge due to vaginitis in pregnancy? Plasmalyte B or Ringer’s lactate running in fast. A doctor should accompany 1. If a microscope is available, make a wet the patient if possible. If not possible, a smear of the discharge. The specific registered nurse should accompany her. organism causing the vaginitis can then be2. A patient who is no longer bleeding should identified and treated. also have an intravenous infusion and be accompanied by a registered nurse NOTE A wet smear of the discharge is whenever possible. made, in both saline and 2% potassium hydroxide and examined. 2. If a microscope is not available:A BLOOD-STAINED • Organisms identified on the cervicalVAGINAL DISCHARGE cytology smear are the most likely cause of the vaginitis. • If no organisms are identified on the4-45 How would a patient generally cytology smear, or a smear was notdescribe a blood-stained vaginal discharge? done, then Trichomonas vaginalis is most probably present.A patient would probably describe a blood-stained vaginal discharge as a vaginal To treat a Trichomonal vaginitis, both thedischarge mixed with a small amount of blood. patient and her partner should receive a single dose of 2 g metronidazole (Flagyl) orally.4-46 How would a patient generallydescribe a ‘show’? 4-49 Should metronidazole be used during pregnancy?A patient would probably describe a ‘show’as a slight vaginal bleed consisting of blood Metronidazole should not be used in the firstmixed with mucus. trimester of pregnancy, unless absolutely necessary, as it may cause congenital4-47 How should you manage a patient abnormalities in the fetus. The patient and herwith a history of a blood-stained partner must be warned that metronidazolevaginal discharge or a ‘show’? causes severe nausea and vomiting if it is taken with alcohol. The risk of congenital1. After getting a good history and abnormalities caused by alcohol may also be ensuring that the condition of the increased by metronidazole. fetus is satisfactory, a careful speculum examination should be done. 4-50 How do you manage a patient2. The speculum is only inserted for 5 cm, with contact bleeding? carefully opened, and then introduced further until the cervix can be seen. 1. When there is normal cervical cytology3. Any bleeding through a closed cervical os (Papanicolaou smear), the contact bleeding indicates an antepartum haemorrhage.
  15. 15. 114 MATERNAL CARE is probably due to a cervicitis. If it is 4. What should be done once the troublesome, the patient should be given condition of the patient and her a course of oral erythromycin 500 mg fetus have been assessed, and the six-hourly for seven days. patient resuscitated, if necessary?2. With abnormal cervical cytology, the The cause of the antepartum haemorrhage patient should be managed correctly. must be sought and managed. Cervical intra-epithelial neoplasia causes contact bleeding.4-51 What action should you take when the CASE STUDY 2bleeding is from a cervical ulcer or tumour? A patient who is 32 weeks pregnant,The patient most probably has an infiltrating according to her antenatal card, presentscervical carcinoma and should be correctly with a history of severe vaginal bleeding andmanaged. abdominal pain. The blood contains dark clots. Since the haemorrhage, the patient has NOTE When there is doubt about the not felt her fetus move. The patient’s blood diagnosis, a cytology smear and biopsy pressure is 80/60 mm Hg and the pulse rate of the lesion must be taken. The results should be obtained as soon as possible. 120 beats per minute. 1. What is your clinical diagnosis?CASE STUDY 1 The history is typical of an abruptio placentae.A patient who is 35 weeks pregnant presents 2. If the clinical examination confirms thewith a history of vaginal bleeding. diagnosis, what should be the first step in the management of this patient?1. Why does this patient need The patient’s blood pressure and pulse rateto be assessed urgently? indicate that she is shocked. Therefore, sheBecause an antepartum haemorrhage should must first be resuscitated.always be regarded as an emergency, until acause for the bleeding is found. Thereafter, the 3. What is the next step thatcorrect management can be given. requires urgent attention in the management of the patient?2. What is the first step in the As the fetus is viable, it is of great importancemanagement of a patient with an to establish whether the fetus is still alive.antepartum haemorrhage? Therefore, it must be urgently establishedThe clinical condition of the patient must whether the fetal heartbeat is present or assessed. Special attention must bepaid to signs of shock. If shock is present, 4. How should you manage the patientresuscitation must be started urgently. if a fetal heartbeat is heard? A vaginal examination must be done. If3. What is the next step in the the cervix is 9 cm or more dilated and themanagement of a patient with an fetal head is on the pelvic floor, then theantepartum haemorrhage? membranes should be ruptured and the fetusThe condition of the fetus must be assessed. delivered vaginally as quickly as possible.The presence of fetal distress will influence the Otherwise, an emergency Caesarean sectionchoice of management. must be done as soon as the patient has been
  16. 16. ANTEPAR TUM HAEMORRHAGE 115resuscitated. Immediately before starting the 3. How should the patient be managedCaesarean section, make sure that the fetal if she should have a severe bleed?heartbeat is still present. An emergency Caesarean section must be done, as soon as the patient has been5. Should the above patient be adequately resuscitated.transferred to a level 2 or 3 hospitalfor delivery, if the fetus is still alive? 4. What investigations should be doneThe patient should be delivered in any hospital if the patient is not bleeding activelywhich has facilities for doing a Caesarean during your initial clinical examination?section. Moving the patient because the fetus A ultrasound examination must be done tois regarded as preterm may result in an intra- confirm the clinical diagnosis. After placentauterine death during transport. If necessary, praevia has been excluded, a careful speculumthe newborn infant can be transported to a examination should be done to exclude anylevel 2 hospital with a neonatal intensive care local cause for the bleeding.unit. The risk of a clotting defect is low if thefetus is still alive. 5. How should the patient be managed if she has had no further severe6. How should you manage this patient bleeding after the initial bleed?if a fetal heartbeat is not heard? She should be hospitalised and managedThe membranes should be ruptured and the conservatively until 36 or 38 weeks gestation,fetus delivered vaginally, if possible. or until she starts to bleed actively again. Depending on the degree of placenta praevia, a Caesarean section should be done at 36 or 38CASE STUDY 3 weeks or spontaneous labour can be awaited.A patient is seen at the antenatal clinic at 35weeks gestation with a breech presentation. CASE STUDY 4The patient is referred to see the doctor thefollowing week, for an external cephalic A patient books for antenatal care at 30 weeksversion. That evening she has a painless, bright gestation. When you inform her of the dangerred vaginal bleed. signs during pregnancy, she says that she has had a vaginal discharge for the past two weeks.1. What is your diagnosis? At times the discharge has been blood stained.The history and the presence of an abnormallie suggest that the bleeding is the result of a 1. Has this patient had aplacenta praevia. antepartum haemorrhage? The history suggests a blood-stained vaginal2. What should the initial discharge rather than an antepartummanagement of the patient be? haemorrhage.The condition of the mother should firstbe assessed and the patient resuscitated, if 2. What is the most probable cause ofnecessary. Then the fetal condition must be the blood-stained vaginal discharge?assessed. The patient’s abdomen should also be A vaginitis. This can usually be confirmed by aexamined, to determine whether the clinical speculum examination.signs support the diagnosis of placenta praevia.
  17. 17. 116 MATERNAL CARE3. How can the cause of the vaginalis is presumed to be the cause of thevaginitis be determined? vaginitis.During the speculum examination, a sample ofthe discharge should be taken and a wet smear 5. How should you treat a patientmade. Organisms seen on the wet smear are with Trichomonal vaginitis?probably the cause of the vaginitis. A single dose of 2 g metronidazole (Flagyl) is given orally to both the patient and her4. What is the most likely cause of a partner. Both must be warned againstvaginitis with a blood-stained discharge? drinking alcohol for a few days after taking metronidazole.Trichomonas vaginalis. Therefore, if amicroscope is not available, Trichomonas