Antepartum Hemorrhage

 

 

 

Causes and Risk Factors

 

Obstetrical causes of bleeding include:

 

Differential diagnosis includes:

 

 

 

Signs, Symptoms, and Diagnosis

 

  • history
  • physical exam
  • lab investigations
  • diagnostic imaging

History

Amount and frequency of bleeding (how many pads, etc)

When did it start?

Gestational age?

Any pain?

Has it happended before?

Any intercourse prior to symptoms

 

Past obstetrical history (previa, abruption)

 

Any fluid mixed in (watery vs frank blood)

Contractions present?

 

 

Medical history

  • cervical infection
  • polyps

Physical Exam

Vitals:

  • pulse
  • blood pressure

Palpate the lie of the baby and for contractions

Sterile speculum exam to assess for:

  • visible source of blood
  • pooling of fluid or blood
  • dilated cervix

Lab Investigations

 

Bloodwork:

  • CBC to assess hemoglobin and to set a baseline
  • type and screen
  • liver enzymes
  • Kleihauer
  • coag (PTT, INR) to assess DIC

 

Amniotic fluid analysis:

  • microscopic examination (arborization rather than ferning)
  • fetal fibronectin or nitrosine cannot be done in the presence of blood

Diagnostic Imaging

 

Ultrasound can be done to assess for

  • placental placement
  • amniotic fluid volume

 

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Pathophysiology

 

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Treatments

 

A large-bore IV (14-18G) should be started, with fluids (normal saline, Ringer's lactate as indicated by hemodynamic status).

Treatment depends on suspected cause of hemorrhage, stability of mother, and age of fetus. The first decision is where to monitor the decision.

Tocolytics should be considered but are not given to women who are actively bleeding.

Steroids (ie betamethasone) should be given to increase fetal lung maturity if gestational age is low.

RhoGam should be given if there is mismatch.

Pain control with

 

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Consequences and Course

 

 

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Resources and References