Primary Maternal Care: Antepartum haemorrhage


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Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from theory chapters and skills workshops from Maternal Care. This book complements the national protocol of antenatal care in South Africa. It covers: booking for antenatal care, assesing fetal growth and wellbeing, hypertensive disorders of pregnancy, antepartum haemorrhage, preterm labour, important medical conditions

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Primary 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? Objectives An antepartum haemorrhage is any vaginal bleeding which occurs at or after 24 weeks When you have completed this unit you (estimated fetal weight at 24 weeks = 500 g) and before the birth of the infant. A bleed before 28 should be able to: weeks is regarded as a threatened miscarriage as • Understand why an antepartum the fetus is usually considered not to be viable. haemorrhage should always be regarded as serious. 4-2 Why is an antepartum haemorrhage • Provide the initial management of a such a serious condition? patient presenting with an antepartum 1. The bleeding can be so severe that it can haemorrhage. endanger the life of both the mother and • Diagnose the most likely cause of fetus. the bleeding from the history and 2. Abruptio placentae is a common cause examination of the patient. of antepartum haemorrhage and an important cause of perinatal death in • Know how to manage a patient with a many communities. slight vaginal bleed mixed with mucus. • Diagnose the cause of a blood- Therefore, all patients who present with an antepartum haemorrhage must be regarded as stained vaginal discharge and provide serious emergencies until a diagnosis has been appropriate treatment. made. Further management will depend on the cause of the haemorrhage.
  2. 2. 88 PRIMAR Y MATERNAL CARE and, if necessary, the results of special Any vaginal bleeding during pregnancy may be investigations. an important danger sign that must be reported immediately. 4-5 What symptoms and signs indicate that the patient is shocked due to blood loss?4-3 What advice about vaginal bleeding 1. Dizziness is the commonest symptom ofshould you give to all patients? shock.Every patient must be advised that any vaginal 2. On general examination the patientbleeding is potentially serious and told that this is sweating, her skin and mucouscomplication must be reported immediately. membranes are pale, and she feels cold and clammy to touch.4-4 What is the management of 3. The blood pressure is low and the pulsean antepartum haemorrhage? rate fast.The management consists of 4 important 4-6 How should you manage a shockedsteps that should be carried out in the patient with an antepartum haemorrhage?following order: When there are symptoms and signs to1. The maternal condition must be evaluated indicate that the patient is shocked, you must: and stabilised, if necessary.2. The condition of the fetus must then be 1. Put up two intravenous infusions (‘drips’) assessed. with Balsol or Ringer’s lactate, to run in3. The cause of the haemorrhage must be quickly in order to actively resuscitate the diagnosed. patient.4. Finally, the definitive management of an 2. Insert a Foley’s catheter into the patient’s antepartum haemorrhage, depending on bladder, to measure the urinary volume the cause, must be given. and to monitor further urine output. 3. If blood is available, take blood for cross-It must also be decided whether the patient matching at the time of putting up theshould be transferred for further treatment. intravenous infusion and order 2 or more units of blood urgently. 4. Refer the patient to the hospital.THE INITIAL, EMERGENCYMANAGEMENT 4-7 What must you do if a patient presents with a life-threatening haemorrhage?OF ANTEPARTUM The maternal condition takes preference overHAEMORRHAGE that of the fetus. The patient, therefore, is actively resuscitated while arrangements areThe management must always be provided in made to transfer the patient to the hospital. Atthe following order: the hospital an emergency caesarean section1. Assess the condition of the patient. If the or hysterotomy will be performed. patient is shocked, she must be resuscitated immediately.2. Assess the condition of the fetus. If the fetus is viable but distressed, an emergency delivery is needed.3. Diagnose the cause of the bleeding, taking the clinical findings into account
  3. 3. ANTEPAR TUM HAEMORRHAGE 89DIAGNOSING THE CAUSE 4-9 How does a speculum examination help you determine the cause of the bleeding?OF THE BLEEDING 1. Bleeding through a closed cervical os confirms the diagnosis of a haemorrhage.4-8 Should you treat all patients 2. If the cervix is a few centimetres dilatedwith antepartum haemorrhage in with bulging membranes, or the presentingthe same way, irrespective of the part of the fetus is visible, this suggests thatamount and character of the bleed? the bleed was a ‘show’. 3. A blood-stained discharge in the vagina,No. The management differs depending on with no bleeding through the cervical os,whether the vaginal bleeding is diagnosed suggests a a ‘haemorrhage’ on the one hand, or a 4. Bleeding from the surface of the cervixblood-stained vaginal discharge or a ‘show’ caused by contact with the speculum (i.e.on the other hand. A careful assessment of contact bleeding) may indicate a cervicitisthe amount and type of bleeding is, therefore, or cervical intra-epithelial neoplasia (CIN).very important. 5. Bleeding from a cervical tumour or1. Any vaginal bleeding at or after 24 weeks an ulcer may indicate an infiltrating must be diagnosed as an antepartum carcinoma. haemorrhage if any of the following are present: 4-10 Can you rely on clinical findings to • A sanitary pad is at least partially determine the cause of a haemorrhage? soaked with blood. In many cases the history and examination of • Blood runs down the patient’s legs. the abdomen will enable the patient to be put • A clot of blood has been passed. into one of 2 groups: A diagnosis of a haemorrhage always suggests a 1. Abruptio placentae (placental abruption). serious complication. 2. Placenta praevia.2. A blood-stained vaginal discharge will There are some patients in whom no reason consist of a discharge mixed with a small for the haemorrhage can be found. Such a amount of blood. haemorrhage is classified as an antepartum3. A ‘show’ will consist of a small amount haemorrhage of unknown cause. of blood mixed with mucus. The blood- stained vaginal discharge or ‘show’ will be 4-11 What is the most likely cause present on the surface of the sanitary pad of an antepartum haemorrhage but will not soak it. with fetal distress?If the maternal and fetal conditions are Abruptio placentae is the commonest causesatisfactory, then a careful speculum of antepartum haemorrhage leading to fetalexamination should be done to exclude a local distress or an intra-uterine death. However,cause of the bleeding. Do NOT perform a sometimes there may be very little or nodigital vaginal examination, as this may cause bleeding even with a severe abruptio placentae.massive haemorrhage if the patient has aplacenta praevia. An antepartum haemorrhage with fetal distress or fetal death is almost always due to abruptio Do not do a digital vaginal examination until placentae. placenta praevia has been excluded.
  4. 4. 90 PRIMAR Y MATERNAL CARE4-12 What is the most likely cause of a life- 3. Absence of fetal movements following thethreatening antepartum haemorrhage? bleeding.A placenta praevia is the most likely causeof a massive antepartum haemorrhage that 4-16 What do you expect to findthreatens the woman’s life. on examination of the patient? 1. The general examination and observations show that the patient is shocked, oftenANTEPARTUM BLEEDING out of proportion to the amount of visible blood loss.CAUSED BY ABRUPTIO 2. The patient usually has severe abdominalPLACENTAE pain. 3. The abdominal examination shows the following:4-13 What is abruptio placentae? • The uterus is tonically contracted, hardAbruptio placentae (placental abruption) and tender, so much so that the wholemeans that part or all of a normally implanted abdomen may be rigid.placenta has separated from the uterus before • Fetal parts cannot be of the fetus. The cause of abruptio • The uterus is bigger than the patient’splacentae remains unknown. dates suggest. • The haemoglobin concentration is low, indicating severe blood loss.4-14 Which patients are at increased 4. The fetal heart beat is almost always absentrisk of abruptio placentae? in a severe abruptio placentae.Patients with: These symptoms and signs are typical of a1. A history of an abruptio placentae in a severe abruptio placentae. However, abruptio previous pregnancy. (There is a 10% chance placentae may present with symptoms and of recurrence after an abruptio placentae signs which are less obvious, making the in a previous pregnancy and a 25% chance diagnosis difficult. after 2 previous pregnancies with an abruptio placentae.) The diagnosis of severe abruptio placentae can2. Pre-eclampsia (gestational proteinuric usually be made from the history and physical hypertension), and to a lesser extent any examination. of the other hypertensive disorders of pregnancy.3. Intra-uterine growth restriction.4. Cigarette smoking. ANTEPARTUM5. Poor socio-economic conditions. BLEEDING CAUSED BY6. A history of abdominal trauma, e.g. a fall or kick on the abdomen. PLACENTA PRAEVIA4-15 What symptoms point to a 4-17 What is placenta praevia?diagnosis of abruptio placentae? Placenta praevia means that the placenta is1. An antepartum haemorrhage which implanted either wholly or partially in the is associated with continuous, severe lower segment of the uterus. The placenta may abdominal pain. extend down to, or cover the internal os of the2. A history that the blood is dark red with cervix. When the lower segment starts to form clots. or the cervix begins to dilate, the placenta
  5. 5. ANTEPAR TUM HAEMORRHAGE 91becomes partially separated and this causes oblique or transverse lies are commonlymaternal bleeding. present. • In cephalic presentations, the head is4-18 Which patients have the not engaged and is easily balottablehighest risk of placenta praevia? above the pelvis.1. With regard to their previous obstetric The diagnosis of placenta praevia can usually be history, patients who: made from the history and physical examination. • Are grande multiparas, i.e. who are para 5 or higher. • Have had a previous caesarean section. 4-21 Do you think that engagement2. With regard to their present obstetric of the head can occur if there is history, patients who: a placenta praevia present? • Have a multiple pregnancy. No. If there is 2/5 or less of the fetal head • Have had a threatened abortion, palpable above the pelvic brim on abdominal especially in the second trimester. examination, then placenta praevia can be • Have an abnormal presentation. excluded and a digital vaginal examination can be done safely. The first vaginal examination4-19 What in the history of the bleeding must always be done carefully.suggests the diagnosis of placenta praevia?1. The bleeding is painless and bright red in Two fifths or less of the fetal head palpable colour. above the pelvic brim excludes the possibility of2. Fetal movements are still present after the placenta praevia. bleed. 4-22 What do you understand4-20 What are the typical findings by a ‘warning bleed’?on physical examination in apatient with placenta praevia? This is the first bleeding that occurs from a placenta praevia, when the lower segment1. General examination may show signs that begins to form at about 34 weeks, or even the patient is shocked, and the amount earlier. of bleeding corresponds to the degree of shock. The patient’s haemoglobin 4-23 Are there any investigations that can concentration may be normal if done at the confirm the diagnosis of placenta praevia? time of the haemorrhage or low depending on the amount of blood loss and the time An ultrasound examination must be done in interval between the haemorrage and the order to localise the placenta, if the patient is haemoglobin measurement. However, the not bleeding actively. fisrt bleed is usually not severe.2. Examination of the abdomen shows that: 4-24 What action should you take if a • The uterus is soft and not tender to routine ultrasound examination early in palpation. pregnancy shows a placenta praevia? • The uterus is not bigger than it should be for the patient’s dates. In most cases, the position of the placenta • The fetal parts can be easily palpated, moves away from the internal os of the and the fetal heart is present. cervix as pregnancy continues. A follow-up • There may be an abnormal ultrasound examination must be arranged at a presentation. Breech presentation or gestational age of 32 weeks.
  6. 6. 92 PRIMAR Y MATERNAL CARE4-25 What is the further management after 4-29 How does a patient describe a ‘show’?making the diagnosis of placenta praevia? As a slight vaginal bleed consisting of bloodRefer the patient to a hospital where she will mixed with admitted and managed conservatively until36 to 38 weeks depending on the severity of 4-30 How should you manage a patientthe bleed or until active bleeding starts. with a history of a blood-stained vaginal discharge or a ‘show’?4-26 When you refer a patient, what 1. After getting a good history andprecautions should you take to ensure ensuring that the condition of thethe safety of the patient in transit? fetus is satisfactory, a careful speculum1. A shocked patient should have 2 examination should be done. intravenous infusion lines with Balsol 2. The speculum is only inserted for 5 cm, or Ringer’s lactate running in fast. A carefully opened, and then introduced doctor should accompany the patient if further until the cervix can be seen. possible. If not possible, a registered nurse 3. Any bleeding through a closed cervical os or trained person from the ambulance indicates an antepartum haemorrhage. service should accompany her. 4. A ‘show’ is the most likely cause, if the2. A patient who is no longer bleeding, should cervix is a few centimetres dilated, with also have an intravenous infusion, and be bulging membranes, or if the presenting accompanied by a registered nurse or a part of the fetus is visible. trained person from the ambulance service. 5. A vaginitis is the most likely cause, if a blood-stained discharge is seen in the4-27 When would you suspect antepartum haemorrhageof unknown cause? 4-31 How should you treat a blood-stained discharge due to vaginitis in pregnancy?In patients who have all the following factors: 1. Organisms identified on the cervical1. Mild antepartum haemorrhage when cytology smear are the most likely cause of there are no signs of shock and the fetal the vaginitis. condition is good. 2. If no organisms are identified on the2. When the history and examination do not cytology smear, or a smear was not done, suggest a severe abruptio placentae. then Trichomonas vaginalis is most3. When local causes of bleeding have been probably present. excluded on a speculum examination.4. When placenta praevia has been excluded To treat a Trichomonal vaginitis, both the by an ultrasound examination. patient and her partner should receive a single dose of 2 g metronidazole (Flagyl) orally.A BLOOD-STAINED 4-32 Should metronidazole be used during pregnancy?VAGINAL DISCHARGE Metronidazole should not be used in the first trimester of pregnancy, unless it is absolutely4-28 How does a patient describe a necessary, as it may cause congenitalblood-stained vaginal discharge? abnormalities in the fetus. The patient and herAs a vaginal discharge mixed with a small partner must be warned that metronidazoleamount of blood. causes severe nausea and vomiting if it is taken with alcohol. The risk of congenital
  7. 7. ANTEPAR TUM HAEMORRHAGE 93abnormalities caused by alcohol may also be 3. What must be done if the patient hasincreased by metronidazole. a rapid pulse rate and signs of shock? Put up two intravenous infusions (‘drips’) with4-33 How do you manage a patient Balsol or Ringer’s lactate, to run in quickly inwith contact bleeding? order to actively resuscitate the patient. InsertContact bleeding occurs if the cervix is a Foley’s catheter into the patient’s bladder, totouched (e.g. during sexual intercourse or measure the urinary volume and to monitorduring a vaginal examination). further urine output. If blood is available, take blood for cross-matching at the time of putting1. When there is normal cervical cytology up the intravenous infusion and order 2 or (Papanicolaou smear), the contact bleeding more units of blood urgently. is probably due to a cervicitis. If it is troublesome, the patient should be given 4. What is the next step in the a course of oral erythromycin 500 mg management of a patient with an 6 hourly for 7 days. antepartum haemorrhage?2. With abnormal cervical cytology, the patient should be correctly managed. The patient needs to be referred to hospital. Cervical intra-epithelial neoplasia causes contact bleeding. CASE STUDY 24-34 What action should you take when thebleeding 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 not felt her fetus move. The patient’s blood pressure is 80/60 mm Hg and the pulse rateCASE STUDY 1 120 beats per minute.A patient, who is 35 weeks pregnant, presents 1. What is your clinical diagnosis?with a history of vaginal bleeding. The history is typical of an abruptio placentae1. Why does this patient need and most likely she has an intra-uterine be assessed urgently? 2. If the clinical examination confirms theBecause an antepartum haemorrhage should diagnosis, what should be the first stepalways be regarded as an emergency, until a in the management of this patient?cause for the bleeding is found. Thereafter, thecorrect management can be given. The patient’s blood pressure and pulse rate indicate that she is shocked. Therefore, she2. What is the first step in the must first be of a patient with anantepartum haemorrhage? 3. What is the next step in the management of the patient, thatThe clinical condition of the patient must be requires urgent attention?assessed. Special attention must be paid tosigns of shock. The patient must then be referred to hospital.
  8. 8. 94 PRIMAR Y MATERNAL CARE4. What precautions should you take to CASE STUDY 4ensure the safety of the patient in transit?A shocked patient should have 2 intravenous A patient books for antenatal care at 30 weeksinfusion lines with Balsol or Ringer’s lactate gestation. When you inform her of the dangerrunning in fast. A doctor should accompany the signs during pregnancy, she says that she haspatient if possible. If not possible, a registered had a vaginal discharge for the past 2 weeks.nurse should accompany her. A patient who At times the discharge has been blood no longer bleeding, should also have anintravenous infusion, and be accompanied by 1. Has this patient had aa registered nurse or a trained person from the antepartum haemorrhage?ambulance service, whenever possible. The history suggests a blood-stained vaginal discharge rather than an antepartum haemorrhage.CASE STUDY 3 2. What is the most probable cause ofA patient is seen at the antenatal clinic at 35 the blood-stained vaginal discharge?weeks gestation with a breech presentation.The patient is referred to see the doctor the A vaginitis. This can usually be confirmed by afollowing week, for an external cephalic speculum examination.version. That evening she has a painless, brightred vaginal bleed. 3. What is the most likely cause of a vaginitis with a blood-stained discharge?1. What is your diagnosis? Trichomonas vaginalis. Therefore, if noThe history and the presence of an abnormal organisms were identified on the cervicallie suggest that the bleeding is the result of a cytology smear or a smear was not done,placenta praevia. Trichomonas vaginalis is presumed to be the cause of the vaginitis.2. Why is the history typicalof a placenta praevia? 4. How should you treat a patient with Trichomonal vaginitis?The bleeding is painless and bright red. Shealso has an abnormal lie. A single dose of 2 g metronidazole (Flagyl) is given orally to both the patient and her3. What do expect to find in partner. Both must be warned againstaddition to a breech presentation drinking alcohol for a few days after takingon abdominal examination? metronidazole.The uterus will be soft, with no tenderness andthe size will be appropriate for her gestationalage. The presenting part will be high.4. What should be the initialmanagement of the patient?The condition of the mother should firstbe assessed and the patient resuscitated, ifnecessary. The patient must then be referred tohospital.
  9. 9. ANTEPAR TUM HAEMORRHAGE 95 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: ÒShowÓ or 1. Placenta praevia cause of vaginitis 2. Abruptio placentae bleeding and referFlow diagram 4-I: Initial management of a patient with vaginal bleeding