Makindo Medical Notes

Related Subjects: |Antepartum haemorrhage |Postpartum haemorrhage |Acute Haemorrhage |Placenta praevia |Placenta abruption

With placental abruption, blood loss may not always be visible per vaginam and can be dangerously underestimated.

About

• Antepartum haemorrhage is defined as any vaginal bleeding after 24 weeks of gestation up until the birth of the infant.
• Placental abruption refers to the separation of the placenta from the uterine wall before the baby is born.
• It is a leading cause of antepartum haemorrhage (bleeding before delivery).

Aetiology

• Occurs in 1-2% of pregnancies, where bleeding occurs into the decidua basalis (the maternal part of the placenta).
• Blood loss can be severe and rapid due to the high uterine blood supply, which is 600-800 mL/min at term.

Risk Factors for Abruption

• Pre-eclampsia
• Chorioamnionitis
• Cocaine use
• Race: Higher risk in Black women than White women
• Male fetus
• Hypertension
• Polyhydramnios (excess amniotic fluid)
• Smoking
• Trauma (e.g., from a car accident or fall)

Clinical Features

• Vaginal bleeding (although sometimes blood loss is concealed).
• Severe, constant abdominal or back pain.
• Uterine contractions.
• Tense and tender uterus.
• Fetal distress (abnormal or absent fetal heartbeats).

Possible Differential Diagnoses

• Uterine rupture
• Appendicitis
• Chorioamnionitis

Causes of Antepartum Haemorrhage

Investigations

• Ultrasound scan (USS) can diagnose placental abruption in only 50% of cases. A clinical diagnosis is often made based on symptoms.

Management

• Supportive care: IV access, blood transfusion, and stabilization of the mother.
• Fetal viability: Assess the fetus to determine if it is still viable.
• Steroids: Administer corticosteroids to promote fetal lung maturity if preterm delivery is anticipated.
• Monitor for coagulopathy: Keep a close watch for signs of disseminated intravascular coagulation (DIC).
• Delivery: Vaginal delivery can be considered if both the mother and fetus are stable.
• Emergency C-section: If there is significant haemorrhage or fetal distress, an immediate caesarean section is required.

Complications

• Hemorrhagic shock: Severe blood loss can lead to shock.
• Disseminated intravascular coagulation (DIC): blood clots form throughout the body, leading to bleeding elsewhere.
• Acute tubular necrosis (ATN): Ischaemic damage to the maternal kidneys due to severe blood loss.
• Couvelaire uterus: Blood leaks into the uterine muscle, causing uterine atony and potential complications during delivery.