Antepartum bleeding
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Antepartum bleeding | |
---|---|
Other names | Antepartum haemorrhage (APH), prepartum haemorrhage |
Specialty | Obstetrics |
Antepartum bleeding, also known as antepartum haemorrhage (APH) or prepartum hemorrhage, is genital bleeding during
It can be associated with reduced fetal birth weight.[3] Use of aspirin before 16 weeks of pregnancy to prevent pre-eclampsia also appears effective at preventing antepartum bleeding.[4]
In regard to treatment, it should be considered a medical emergency (regardless of whether there is
Classification
The total amount of blood loss and signs of circulatory shock due to blood determine the severity of the antepartum haemorrhaging. There are 4 degrees of antepartum haemorrhaging:[5]
Stage | Amount of Blood Loss |
---|---|
Spotting | Stains, streaking, or spotting of blood |
Minor Haemorrhage | Less than 50mL |
Major Haemorrhage | 50-1000mL without signs of circulatory shock |
Massive Haemorrhage | Greater than 1000mL with or without signs of circulatory shock |
Causes
Placenta praevia
Placenta praevia refers to when the placenta of a growing foetus is attached abnormally low within the uterus. Intermittent antepartum haemorrhaging occurs in 72% of women living with placenta praevia.[6] The severity of a patient's placenta praevia depends on the location of placental attachment;
Type | Location of Placental Attachment |
---|---|
Type 1 | Lower segment of uterus, no attachment to the cervix |
Type 2 | Touching but not covering the internal orifice of the cervix |
Type 3 | Partially covering the internal orifice of the cervix |
Type 4 | Completely covering the internal orifice of the cervix |
Types 1 and 2 are classified as minor placental praevia as these typically result in minor antepartum haemorrhaging. Types 3 and 4 are referred to as major placental praevia due to the risk of heavy haemorrhaging in the case of a rupture due to the location of placental attachment.
Abnormal placentation
During pregnancy the layer of endometrium that attaches directly to developing
Type | Depth of Chorionic Villus |
---|---|
Placenta Accreta |
Attached to outermost portion of the myometrium |
Placenta Increta | Invading the myometrium |
Placenta Percreta | Invading past the myometrium into the perimetrium |
In placenta percreta, the
Placental abruption
Vasa praevia
Abnormal placental shape
- Circumvallate placenta
A
- Bilobed Placenta
A bilobed placenta has a cleavage in the middle dividing it into two lobes with membranous vessels branching in between. The exposed connecting membranous vessels present risk of rupturing due to limited protection from
- Multilobed or Succenturiate Placenta
When a placenta has multiple lobes which are distal and not of equal size this is referred to as a succenturiate placenta. Distal lobes are connected by a placental artery and vein extending from the main placenta, which tends to be centrally located and is the largest in mass.[20] At the time of contraction or delivery the connecting placental arteries and veins may rupture resulting in significant haemorrhaging. Incidences of vasa previa and haemorrhaging in the presence of a succenturiate placenta are highly increased.[21]
- Fetal blood (can be distinguished with Apt test)
Minor causes
Cervical ectropion
There are 2 types of
Vaginal infection
The presence of severe vaginal infections at the time of pregnancy may cause minor antepartum haemorrhaging. For example, the presence of chlamydia, thrush, cervicitis or other infections are all irritants to the vaginal and cervical lining, causing bleeding from those surfaces where the infection is severe.[23]
Cervical canal and distal genital tract
Most cases of Antepartum haemorrhaging originate from within the
Endometriosis
Estimates of the frequency of endometriosis in women range between 6-15% across several sources. In a 30-year reproductive and pregnancy outcome study of 14,000+ women, those with endometriosis had a significantly increased risk of antepartum haemorrhage during pregnancy.[25]
Diagnosis
Differential diagnosis
- GI bleed - haemorrhoids, inflammatory bowel disease
See also
- Obstetrical haemorrhage
References
- ^ patient.info » PatientPlus » Antepartum Haemorrhage
- ^ The Royal Women's Hospital > antepartum haemorrhage Archived 2010-01-08 at the Wayback Machine Retrieved on Jan 13, 2009
- S2CID 218855273.
- PMID 29305829.
- ^ Antepartum Haemorrhage. (2015). Perth, Western Australia: Department of Health Western Australia, pp.3-6.
- ^ Love, C. and Wallace, E. (1996). Pregnancies complicated by placenta praevia: what is appropriate management?. BJOG: An International Journal of Obstetrics and Gynaecology, 103(9), pp.864-867.
- ^ Royal College of Obstetricians & Gynaecologists. (2018). Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis and Management (Green-top Guideline No. 27). [online] Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg27/ [Accessed 27 Apr. 2018].
- ^ Better Health Channel. (2018). Placenta Previa. [online] Available at: https://www.betterhealth.vic.gov.au/health/healthyliving/placenta-previa [Accessed 27 Apr. 2018].
- ^ Gest, T. (2018). Placenta and Extraembryonic Membranes. [online] The University of Michigan Medical School - Anatomy. Available at: https://www.med.umich.edu/lrc/coursepages/m1/embryology/embryo/06placenta.htm [Accessed 31 May 2018].
- ^ Silver, R. (2015). Abnormal Placentation. Obstetrics & Gynecology, 126(3), pp.654-668.
- ^ Smith, Z., Sehgal, S., Van Arsdalen, K. and Goldstein, I. (2014). Placenta Percreta With Invasion into the Urinary Bladder. Urology Case Reports, 2(1), pp.31-32.
- ^ Nielsen, T., Hagberg, H. and Ljungblad, U. (1989). Placenta previa and Antepartum Hemorrhage after Previous Cesarean Section. Gynecologic and Obstetric Investigation, 27(2), pp.88-90.
- ^ American Pregnancy Association. (2018). Placental Abruption: Risks, Causes, Symptoms and Treatment. [online] Available at: http://americanpregnancy.org/pregnancy-complications/placental-abruption/ [Accessed 27 Apr. 2018].
- ^ Better Health Channel. (2014). Placental Abruption. [online] Available at: https://www.betterhealth.vic.gov.au/health/healthyliving/placental-abruption [Accessed 27 Apr. 2018].
- ^ TIKKANEN, M. (2010). Placental abruption: epidemiology, risk factors and consequences. Acta Obstetricia et Gynecologica Scandinavica, 90(2), pp.140-149.
- ^ Derbala, Y., Grochal, F. and Jeanty, P. (2007). Vasa Praevia. Journal of Prenatal Medicine.
- ^ Ruiter, L., Kok, N., Limpens, J., Derks, J., de Graaf, I., Mol, B. and Pajkrt, E. (2015). Incidence of and risk indicators for vasa praevia: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology, 123(8), pp.1278-1287.
- ^ Hermann, Z. (1963). Circumvallate Placenta, a Cause of Antepartum Bleeding, Premature Delivery, and Perinatal Mortality. Obstetrics & Gynecology, 22(6), pp.798-802.
- ^ Rathburn, K. and Hildebrand, J. (2017). Placenta, Abnormalities.
- ^ Antepartum haemorrhage or bleeding in the second half of pregnancy. (2013). p.14.
- ^ Suzuki, S. and Igarashi, M. (2007). Clinical significance of pregnancies with succenturiate lobes of placenta. Archives of Gynecology and Obstetrics, 277(4), pp.299-301.
- ^ Cervical ectropion (cervical erosion). (2015). Guy's and St Rhomas' NHS Foundation Trust, pp.1-2.
- ^ Mater Patient Information. (2018). Antepartum haemorrhage - Mater Patient Information. [online] Available at: http://brochures.mater.org.au/brochures/mater-mothers-hospital/antepartum-haemorrhage [Accessed 27 Apr. 2018].
- ^ Antepartum haemorrhage or bleeding in the second half of pregnancy. (2013). p.11.
- ^ Saraswat, Lucky (2015). "ESHRE2015: Endometriosis associated with a greater risk of complications in pregnancy". endometriosis.org. European Society of Human Reproduction and Embryology. Retrieved 14 February 2024.