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Antepartum haemorrhage
REVIEW
Antepartum haemorrhage
haemorrhage. The report does not distinguish the women who presented with APH, but three women were diagnosed with placental abruption and placenta praevia. The aim of this review is to define causes of APH and discuss management in accordance with recent guidelines and published evidence. The MBRRACE-UK report reminds us that APH and PPH are not only important causes of maternal mortality but also of maternal and perinatal morbidity. Therefore the early recognition and management of women presenting with genital tract blood loss is an important aspect of antenatal assessment. It is essential that the obstetrician be prepared for potential sequelae, and thorough antenatal, intrapartum, and postpartum planning is required.
Nadia Amokrane E R F Allen Anna Waterfield Shreelata Datta
Abstract Antepartum haemorrhage (APH) is bleeding from or into the genital tract occurring between 24 þ 0 weeks’ gestation until birth. It complicates 3e5% of pregnancies. The 2006e2008 report of the Confidential Enquiries into Maternal Deaths in the UK (CMACE) reported APH as the cause of death in four women. The high prevalence of APH, and its associated perinatal mortality and morbidity makes a thorough understanding of APH is essential for the practising obstetrician. The objective of this review is to consider the most common causes of APH (placenta praevia, placental abruption and local causes), together with their management.
Causes of APH Cervical and vaginal causes A common cause of APH is bleeding from the cervix. A cervical ectropion or ‘erosion’ is where the columnar epithelium that lines the cervical canal protrudes further onto vaginal surface of the cervix. This is more common in pregnancy, and is thought to be related to high oestrogen levels. The tissue of the ectropion is very friable and contact bleeding can occur, usually at sexual intercourse or even on passing hard stools. Ectropion can be easily diagnosed on speculum examination of the cervix. Cervicitis (inflammation or infection of the cervix) may be an under-diagnosed cause of bleeding in pregnancy and may be caused by sexually transmitted infections (STIs) such as chlamydia and gonorrhoea, which can present with abnormal vaginal bleeding. A high vaginal swab and screening for STIs should be undertaken. Treatment of STIs presenting in pregnancy is important, as they can be associated with preterm labour and neonatal morbidity. Bleeding or spotting can also occur from the vagina and vulva secondary to non-sexually transmitted infections such as thrush, folliculitis, and from trauma. Benign cervical polyps are a further cause of APH. If the bleeding does not clinically compromise the mother or fetus, and the polyp appears non-suspicious then these should not usually be removed in pregnancy. Cervical carcinoma presenting in pregnancy is uncommon and a detailed history at booking appointment should assess a woman’s smear history and history of previous cervical treatments. If a cervical carcinoma is suspected on assessment of the cervix then urgent referral to colposcopy is indicated.
Keywords antepartum haemorrhage; obstetric haemorrhage; placenta accreta; placenta praevia; placental abruption
Introduction Bleeding in pregnancy is a common reason for presentation to labour wards, maternity triage units, GP surgeries and early pregnancy centres in the UK. The management of bleeding in pregnancy varies according to gestation. In this review we specifically address antepartum haemorrhage (APH) which is defined as bleeding from the genital tract that occurs from viability onwards, defined here as greater than 24 weeks’ gestation. Obstetricians may see women with genital tract bleeding from 16 to 23 weeks’ gestation however management of this group of women may differ. APH and post-partum haemorrhage (PPH) are the leading causes of maternal death worldwide. In the UK, maternal deaths have continued to decrease. The recent MBRRACE-UK report published in December 2014 showed that maternal mortality in the UK had decreased from 11:100, 000 women between 2006 and 2008 to 10:10,000 between 2009 and 2012. Between 2009 and 2012, 17 mothers in the UK and Ireland died due to
Placental causes Placental abruption: abruptio placenta is the premature separation of a normally sited placenta from the uterus. Placental abruption can lead to maternal and fetal complications, and ultimately mortality. Bleeding occurs when the placenta starts to separate from the decidua basalis. The presentation of placental abruption usually includes pain (50%) and bleeding (70e80%) however, a concealed abruption (20% of cases) can present with no pain or bleeding. Premature labour is seen in nearly a third of cases of abruption, however, the contraction pains may be atypical in nature, with the patient describing severe unremitting pain. The incidence of placental abruption is reported between 0.26% and 0.80% in literature depending on the type of study
Nadia Amokrane MBChB is a Specialist Registrar in Obstetrics and Gynaecology at King’s College Hospital, London, UK. Conflicts of interest: none declared. E R F Allen MBBS BSc MRCOG is a Locum Consultant Obstetrician and Gynaecologist at King’s College London (PRUH), London, UK. Conflicts of interest: none declared. Anna Waterfield MRCOG is a Senior House Officer in Obstetrics and Gynaecology at King’s College Hospital, UK. Conflicts of interest: none declared. Shreelata Datta MBBS LLM BSc (Hons) MRCOG is a Consultant Obstetrician and Gynaecologist at King’s College Hospital, London, UK. Conflicts of interest: none declared.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Amokrane N, et al., Antepartum haemorrhage, Obstetrics, Gynaecology and Reproductive Medicine (2016), http://dx.doi.org/10.1016/j.ogrm.2015.11.009
REVIEW
and population. The biggest risk factor for abruption is a previous abruption with a 10-fold increased risk of abruption if there has been an abruption in the previous pregnancy. The risk increases to nearly 25% if a woman has had two previous abruptions. Although there is no single aetiology for placental abruption, a number of risk factors have been identified. These include hypertension and pre-eclampsia. Notably, when examining risk factors in a control population, chronic hypertension has a stronger association with abruption (OR 3.13) than preeclampsia (OR 1.73). Smoking is associated with a 90% increase in the risk of abruption. There is a three-fold increased risk in pregnancies complicated by prolonged rupture of membranes (PROM). Cocaine use has also been linked to a higher rate of placental abruption. However, despite numerous risk factors and associations, abruption is usually an unexpected event and the vast majority will occur in low risk pregnancies.
suggest that transvaginal scanning in suspected placenta praevia cases is unsafe. Women with a low-lying placenta at 20 weeks should be followed up in the third trimester, usually at 32e36 weeks. However, if women have had a previous Caesarean section and have a low-lying placenta, then a placenta accreta should be suspected. If major placenta praevia is suspected in the third trimester, then this significantly raises the risk of morbidity and preterm delivery. However the diagnosis of placenta praevia should be considered in any patient who presents with painless, fresh vaginal bleeding or bleeding after intercourse. The most likely symptom from a placenta praevia is painless bleeding in contrast to abruption where pain is likely to copresent. The bleeding is usually fresh, red and the amount of APH can vary. The patient may also present with fresh bleeding in early labour, with the onset of labour and cervical dilatation triggering the bleed or vice versa.
Placenta praevia, placenta accreta, increta and placenta percreta: placenta praevia is the insertion of the placenta partially or entirely within the lower segment of the uterus after 32 weeks. If the placenta does not cover the internal os then it is described as a minor praevia and if it partially or fully covers the os then it is classified as a major praevia. A morbidly adherent placenta such as a placenta accreta, increta or percreta invades through the decidua basalis. In placenta accreta the chorionic villi attach to the myometrium. In placenta increta the placenta has invaded into the myometrium; in placenta percreta the placenta invades through the myometrium and breaches the uterine serosa. Placenta percreta may then invade other organs such as the bladder. The incidence of low-lying placenta can be up to 28% at the routine 20 week anomaly ultrasound scan, but the majority of these will have migrated higher by the following scan, usually at 32 weeks or later. The incidence of true placenta praevia at term is approximately 3%. There are several hypotheses about the aetiology of placenta praevia. One theory is that the position of the placenta depends on the site of implantation of the discoid trophoblast when the pregnancy is developing and from where the placenta will arise. A further theory postulates that areas of deficient endometrium from procedures such as caesarean sections, surgical management of miscarriage and myomectomies may affect how the placenta attaches in these cases. The risk factors for placenta praevia include multiparity, increasing maternal age, smoking, previous praevia and surgical procedures that may result in deficient endometrium (Table 1). The number of previous Caesarean sections also increases the risk of placenta praevia. In well-resourced settings such as in the UK, the majority of placenta praevia cases may be picked up on ultrasound scan at 20 weeks. Currently the UK National Screening Committee does not recommend screening for placenta praevia however, alongside the RCOG, they support most local practice of identifying women by ultrasound whose placenta lies near the internal os at the routine 20 week scan. Evidence shows that at the second trimester scan about 26e60% of women with a low lying placenta on abdominal ultrasound would be reclassified with a more accurate transvaginal scan. There have been no reports to
Other causes Uterine rupture: uterine rupture is a rare event that is defined as loss of the full thickness of the uterine wall integrity. It usually occurs during labour in a woman with a previous Caesarean section or myomectomy. Within this group the risk is still small; the incidence of uterine rupture has been estimated at 7 per 10,000 planned vaginal births after Caesarean section. Uterine rupture may present with CTG abnormalities, pain or APH. Early recognition and quick stabilisation of the mother and baby is required as mortality and morbidity is high.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
Vasa praevia: vasa praevia is a rare obstetric complication where fetal blood vessels cross the internal cervical os. As the incidence is rare (between 1 in 2000 and 1 in 6000 pregnancies) it is not currently screened for during routine ultrasound. The risk of APH mainly comes with rupture of the membranes or labour, as a direct consequence of tearing of the blood vessels. The fetus can be comprised quickly and management if diagnosed or suspected is usually by immediate category 1 Caesarean section.
Unexplained APH Some women will present with bleeding that cannot be attributed to any of the above causes. The RCOG Greentop Guideline references a number of studies over the last four decades that demonstrate that pregnancies with unexplained APH are at higher risk of preterm birth and stillbirth. A recent retrospective, observational study noted that pregnancies complicated by APH of unknown aetiology are at a higher risk of preterm birth, lower birthweight, induction of labour, and neonatal unit admissions. Repeated presentations with unexplained APH in pregnancy should raise suspicion and the pregnancy should be monitored as high risk, with the need for additional ultrasound scans for fetal growth. Healthcare providers should be aware that maternal trauma, including domestic violence, can result in APH, possibly from placental abruption. A third of domestic violence is known to start or escalate in pregnancy. A retrospective study of 2070 women subjected to physical violence in pregnancy found an increased odds ratio of APH in this cohort, compared with controls, of 3.79 (95% CI 1.38e10.40). Women who present with
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Amokrane N, et al., Antepartum haemorrhage, Obstetrics, Gynaecology and Reproductive Medicine (2016), http://dx.doi.org/10.1016/j.ogrm.2015.11.009
REVIEW
multidisciplinary team including a senior obstetrician, anaesthetist, and senior midwife. Input is also frequently required from blood transfusion technicians, haematologists, neonatologists, and porters. Obstetric units will usually have fixed protocols for the management of massive obstetric haemorrhage that should be activated if a woman presents with or develops massive haemorrhage. These protocols should be actively rehearsed in annual skills training in order to prepare for such cases. The RCOG Greentop Guideline defines the severity of APH, as outlined in Table 2. However, it should be remembered that the amount of blood lost can be underestimated, particularly as the amount of blood seen on vaginal examination may not be an accurate representation of the total blood lost. The initial assessment of a woman with APH should include the ABC approach to stabilise the patient (Table 3) and assess the total estimated blood loss. However, it is important to remember that not all blood loss is revealed, so the clinical features of blood loss are extremely important (e.g. grade of shock) to formulating appropriate management plans. Patients with major or massive obstetric haemorrhage should be managed in left lateral tilt to reduce hypotension secondary to uterine compression of the inferior vena cava. Resuscitation and stabilization of the mother is the key priority. Following the initial survey and after commencing resuscitation, the cause and extent of the APH should be assessed by history taking and carrying out a full examination. Abdominal examination may illicit a ‘woody’ or tense uterus, which is characteristically seen in placental abruption or it may show the patient is contracting and could be in labour. If a patient with known placenta praevia presents with bleeding, then a digital examination or speculum examination is not necessary. A digital examination or speculum may be indicated where placenta praevia has been excluded to check for a cause for the APH and to assess cervical dilatation. The diagnosis of vasa praevia should be considered when the APH has been associated with rupture of membranes.
Risk factors for placenta praevia Risk factors Placenta praevia
Placental abruption
Vasa praevia
Uterine rupture
Uterine rupture
Large placental area (multiple pregnancy) Advanced maternal age High parity Uterine scar (caesarean section, myomectomy) Previous placenta praevia Smoking, cocaine use Placental pathology Previous placental abruption Hypertension Pre-eclampsia Smoking, cocaine use Premature rupture of membranes Coagulopathies Multiple gestation Advanced maternal age Abdominal trauma Velamentous insertion of umbilical cord Succenturiate, bilobe placenta Multiple gestation IVF pregnancy Multiparity Congenital uterine anomalies Uterine scar (secondary to caesarean section, myomectomy etc) Maternal age Abnormal placentation Uterine distension (multiple gestation, polyhydramnious, macrosomia) Gestation >40 weeks Obstructed labour
Table 1
Investigations The RCOG guideline recommends that all patients with APH should have a full blood count (FBC) and a group and save. A Kleihauer test is also necessary for all Rhesus negative women. Women who present with major or massive haemorrhage should also have liver and renal function blood tests and a coagulation screen including fibrinogen. They also may benefit from a bedside blood check such as a Hemacue since the FBC may not give an accurate immediate estimate of blood loss.
APH and other signs suggestive of domestic violence or, who disclose violence, should be identified and managed appropriately by a multidisciplinary team who have been specially trained in domestic violence to safeguard pregnant women.
Diagnosis and management of APH Women who present with major haemorrhage and signs of shock should be seen in a maternity unit with involvement of a
RCOG definition of APH severity Description
Blood volume
Spotting Minor haemorrhage Major haemorrhage Massive haemorrhage
Staining, streaking or blood spotting noted on underwear or sanitary protection Blood loss less than 50 ml that has settled Blood loss of 50e1000 ml, with no signs of clinical shock Blood loss greater than 1000 ml and/or signs of clinical shock
Table 2
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Amokrane N, et al., Antepartum haemorrhage, Obstetrics, Gynaecology and Reproductive Medicine (2016), http://dx.doi.org/10.1016/j.ogrm.2015.11.009
REVIEW
Resuscitation pathway for major APH Assessment A(irway) B(reathing)
C(irculation)
D(isabilty) E(xposure)
F(etus)
Management Check patency Respiratory rate Oxygen saturations 10e15L via non rebreathing mask Heart rate Capillary refill time Blood pressure IV access (consider x 2 16 gauge cannulas) IV fluid resuscitation crystalloid/colloid/blood Assess blood loss Consider catheterisation (input/output monitoring) Glasgow coma score Abdominal examination Speculum Vaginal examination CTG Auscultation FHR Ultrasound
Method used gestation dependent
Table 3
be hospitalised until elective delivery although there is no evidence to support this. In accordance with the RCOG Green-top guideline, women with placenta praevia in the third trimester should be counselled about the risks of preterm delivery and obstetric haemorrhage. The place and package of care should be individualised to meet the needs of each patient. If care is at home, the woman should be within close proximity to the hospital, have a constant companion at home, and be aware of when she should attend hospital immediately.
Even with bedside haemoglobin checks and laboratory FBC, it should be noted that after acute major blood loss these tests can be misleading during or soon after the initial haemorrhage. Therefore, initial diagnosis and management of APH should be based on clinical criteria and observations. After stabilizing the mother, the fetal heart rate should be checked. There is no clear guidance or evidence to support monitoring fetuses during APH as there may be transient abnormalities with the CTG. Clinical judgement is essential to make a decision regarding mode and timing of delivery based on likely diagnosis and the maternal and fetal status. For example, if an abruption is suspected and there is an abnormal CTG then the CTG findings are likely to be associated with fetal hypoxia and so delivery would be indicated for fetal benefit. Ultrasound can be used to determine placental site, or to check fetal growth, liquor and Doppler studies once the bleeding has settled. It is not recommended as a diagnostic tool to diagnose abruption as the reported sensitivity is only between 25 and 50%. Generally most clinicians currently do not recommend tocolysis if a patient is actively bleeding. The RCOG recommends a single course of steroids between 24 and 34 weeks if delivery is likely to be preterm.
Blood products Managing severe antepartum haemorrhage frequently requires blood transfusion and considering delivery with surgical interventions to arrest the bleeding. If women require blood transfusion then individually cross-matched blood is ideal. Rarely, if blood loss is so excessive that the processing time for this would be clinically unacceptable then Group O Rhesus negative red cells should be utilised. Commencing red cell transfusion is based on clinical evaluation and haematological investigations, if available. If a coagulopathy develops then fresh frozen plasma (FFP) should be administered before one blood volume is lost. Haematological investigation and specialist advice should guide the further use of FFP, cryoprecipitate, and platelets in massive obstetric haemorrhage. The RCOG Green-top guideline on blood transfusion in obstetrics advises that cryoprecipitate may be indicated when there is bleeding with fibrinogen concentration below 1 g/L. The platelet count should be maintained at above 75 109/L. It is important that women who will refuse blood products in an emergency, including Jehovah’s witnesses, are identified in the antenatal period and referred to consultant-led care. These women are at higher risk of morbidity and mortality in the case of APH. The healthcare provider and patient should discuss what
Conservative management of placenta praevia Women with placenta praevia were previously advised to remain as inpatients from 34 weeks until elective delivery. Currently there is limited evidence to support either hospital-based or home-based care in the third trimester. Women with placenta praevia who have APH that resolves spontaneously without requiring immediate delivery are likely to remain in hospital until bleeding has completely ceased. With recurrent APH in the third trimester for any pathology, it is common practice for patients to
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Amokrane N, et al., Antepartum haemorrhage, Obstetrics, Gynaecology and Reproductive Medicine (2016), http://dx.doi.org/10.1016/j.ogrm.2015.11.009
REVIEW
audits and reviews are imperative for individual units to learn through previous experiences and near-misses. All maternity multidisciplinary team must be regularly updated in their obstetric haemorrhage protocols e both antenatal and postpartum. A
blood components and blood derivatives (for example clotting factor concentrates) would be acceptable to the woman in the event of serious blood loss, and also if autologous transfusion in the form of cell salvage can be used. There should be a signed advanced directive and all discussions clearly documented. Antenatally, any woman who would refuse blood transfusion or blood products should have their haemoglobin levels optimised. In the event of major APH or indeed PPH, a consultant obstetrician, anaesthetist and haematologist should be informed. If a woman who would refuse donor blood is diagnosed antenatally with placenta accreta or this is suspected, it is recommended that delivery is planned in a facility with access to interventional radiology. There is insufficient evidence on whether prophylactic catheter placement for balloon occlusion or embolisation is advantageous.
FURTHER READING Antepartum haemorrhage RCOG Green top guideline 63. 2011, https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_ 63.pdf. Anath CV, Savitz DA, Williams MA. Pracental abruption and its association with hypertension and prolonged rupture of membranes: a methodologic review and meta-analysis. Obstetrics Gynecol 1996 Aug; 88: 309e18. Blood transfusions in Obstetrics RCOG Green top guideline 47. https://www.rcog.org.uk/globalassets/documents/guidelines/ gt47bloodtransfusions1207amended.pdf. Knight M, Kenyon S, Brocklehurst P, et al., eds. on behalf of MBRRACEUK. Saving lives, improving mothers’ care e lessons learned to inform future maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009e12. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2014. Neilson JP. Interventions for suspected placenta praevia. Cochrane Database Syst Rev 2003 (2):CD001988. Neilson JP. Interventions for treating placental abruption. Cochrane Database Syst Rev 2003 (1):CD003247; reviewed 2009. Royal College of Obstetricians and Gynaecologists. Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management. Green-top Guideline No. 27. London: RCOG, 2011. Royal College of Surgeons. Code of practice for management of Jehovah witnesses. London: IBSA Press, 2002. Tikkanen M, Nuutila M, Hiilesmaa V, et al. Clinical presentation and risk factors of placental abruption. Acta Obstetricia Gynecol Scand 2006; 85: 700e5. http://dx.doi.org/10.1080/00016340500449915. Toivonen S, Heinonen S, Anttila M, et al. Reproductive risk factors, Doppler findings, and outcome of affected births in placental abruption: a population-based analysis. Am J Perinatol 2002; 19: 451e60.
Delivery techniques and post-partum care Placental abruption and placenta praevia can lead to ongoing bleeding after delivery. Bleeding should be managed according to normal post-partum haemorrhage protocols, with uterotonic agents and surgical interventions such as intrauterine balloons, B-Lynch suture, uterine artery embolization and hysterectomy as required. In cases of placenta accreta managed by Caesarean section, where the placenta fails to separate, managament options include leaving it in situ and proceeding to either elective hysterectomy or conservative management. There are no randomised control trials to compare approaches directly but case series show successful outcomes with both approaches. If the placenta is left in situ and the uterus is spared, conservative management involves prophylactic antibiotics and lengthy follow-up with beta-HCG measurement and imaging to ensure resolution. Women should be warned of the risk of persisting bleeding and infection.
Conclusion APH can be a traumatic and concerning event for women in pregnancy. Early recognition and management is therefore vital, together with a relevant postnatal debrief. The MBRRACE-UK report highlights that haemorrhage is still a significant contributor to UK maternal morbidity and mortality. Therefore, local
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Amokrane N, et al., Antepartum haemorrhage, Obstetrics, Gynaecology and Reproductive Medicine (2016), http://dx.doi.org/10.1016/j.ogrm.2015.11.009
Antepartum haemorrhage
haemorrhage. The report does not distinguish the women who presented with APH, but three women were diagnosed with placental abruption and placenta praevia. The aim of this review is to define causes of APH and discuss management in accordance with recent guidelines and published evidence. The MBRRACE-UK report reminds us that APH and PPH are not only important causes of maternal mortality but also of maternal and perinatal morbidity. Therefore the early recognition and management of women presenting with genital tract blood loss is an important aspect of antenatal assessment. It is essential that the obstetrician be prepared for potential sequelae, and thorough antenatal, intrapartum, and postpartum planning is required.
Nadia Amokrane E R F Allen Anna Waterfield Shreelata Datta
Abstract Antepartum haemorrhage (APH) is bleeding from or into the genital tract occurring between 24 þ 0 weeks’ gestation until birth. It complicates 3e5% of pregnancies. The 2006e2008 report of the Confidential Enquiries into Maternal Deaths in the UK (CMACE) reported APH as the cause of death in four women. The high prevalence of APH, and its associated perinatal mortality and morbidity makes a thorough understanding of APH is essential for the practising obstetrician. The objective of this review is to consider the most common causes of APH (placenta praevia, placental abruption and local causes), together with their management.
Causes of APH Cervical and vaginal causes A common cause of APH is bleeding from the cervix. A cervical ectropion or ‘erosion’ is where the columnar epithelium that lines the cervical canal protrudes further onto vaginal surface of the cervix. This is more common in pregnancy, and is thought to be related to high oestrogen levels. The tissue of the ectropion is very friable and contact bleeding can occur, usually at sexual intercourse or even on passing hard stools. Ectropion can be easily diagnosed on speculum examination of the cervix. Cervicitis (inflammation or infection of the cervix) may be an under-diagnosed cause of bleeding in pregnancy and may be caused by sexually transmitted infections (STIs) such as chlamydia and gonorrhoea, which can present with abnormal vaginal bleeding. A high vaginal swab and screening for STIs should be undertaken. Treatment of STIs presenting in pregnancy is important, as they can be associated with preterm labour and neonatal morbidity. Bleeding or spotting can also occur from the vagina and vulva secondary to non-sexually transmitted infections such as thrush, folliculitis, and from trauma. Benign cervical polyps are a further cause of APH. If the bleeding does not clinically compromise the mother or fetus, and the polyp appears non-suspicious then these should not usually be removed in pregnancy. Cervical carcinoma presenting in pregnancy is uncommon and a detailed history at booking appointment should assess a woman’s smear history and history of previous cervical treatments. If a cervical carcinoma is suspected on assessment of the cervix then urgent referral to colposcopy is indicated.
Keywords antepartum haemorrhage; obstetric haemorrhage; placenta accreta; placenta praevia; placental abruption
Introduction Bleeding in pregnancy is a common reason for presentation to labour wards, maternity triage units, GP surgeries and early pregnancy centres in the UK. The management of bleeding in pregnancy varies according to gestation. In this review we specifically address antepartum haemorrhage (APH) which is defined as bleeding from the genital tract that occurs from viability onwards, defined here as greater than 24 weeks’ gestation. Obstetricians may see women with genital tract bleeding from 16 to 23 weeks’ gestation however management of this group of women may differ. APH and post-partum haemorrhage (PPH) are the leading causes of maternal death worldwide. In the UK, maternal deaths have continued to decrease. The recent MBRRACE-UK report published in December 2014 showed that maternal mortality in the UK had decreased from 11:100, 000 women between 2006 and 2008 to 10:10,000 between 2009 and 2012. Between 2009 and 2012, 17 mothers in the UK and Ireland died due to
Placental causes Placental abruption: abruptio placenta is the premature separation of a normally sited placenta from the uterus. Placental abruption can lead to maternal and fetal complications, and ultimately mortality. Bleeding occurs when the placenta starts to separate from the decidua basalis. The presentation of placental abruption usually includes pain (50%) and bleeding (70e80%) however, a concealed abruption (20% of cases) can present with no pain or bleeding. Premature labour is seen in nearly a third of cases of abruption, however, the contraction pains may be atypical in nature, with the patient describing severe unremitting pain. The incidence of placental abruption is reported between 0.26% and 0.80% in literature depending on the type of study
Nadia Amokrane MBChB is a Specialist Registrar in Obstetrics and Gynaecology at King’s College Hospital, London, UK. Conflicts of interest: none declared. E R F Allen MBBS BSc MRCOG is a Locum Consultant Obstetrician and Gynaecologist at King’s College London (PRUH), London, UK. Conflicts of interest: none declared. Anna Waterfield MRCOG is a Senior House Officer in Obstetrics and Gynaecology at King’s College Hospital, UK. Conflicts of interest: none declared. Shreelata Datta MBBS LLM BSc (Hons) MRCOG is a Consultant Obstetrician and Gynaecologist at King’s College Hospital, London, UK. Conflicts of interest: none declared.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Amokrane N, et al., Antepartum haemorrhage, Obstetrics, Gynaecology and Reproductive Medicine (2016), http://dx.doi.org/10.1016/j.ogrm.2015.11.009
REVIEW
and population. The biggest risk factor for abruption is a previous abruption with a 10-fold increased risk of abruption if there has been an abruption in the previous pregnancy. The risk increases to nearly 25% if a woman has had two previous abruptions. Although there is no single aetiology for placental abruption, a number of risk factors have been identified. These include hypertension and pre-eclampsia. Notably, when examining risk factors in a control population, chronic hypertension has a stronger association with abruption (OR 3.13) than preeclampsia (OR 1.73). Smoking is associated with a 90% increase in the risk of abruption. There is a three-fold increased risk in pregnancies complicated by prolonged rupture of membranes (PROM). Cocaine use has also been linked to a higher rate of placental abruption. However, despite numerous risk factors and associations, abruption is usually an unexpected event and the vast majority will occur in low risk pregnancies.
suggest that transvaginal scanning in suspected placenta praevia cases is unsafe. Women with a low-lying placenta at 20 weeks should be followed up in the third trimester, usually at 32e36 weeks. However, if women have had a previous Caesarean section and have a low-lying placenta, then a placenta accreta should be suspected. If major placenta praevia is suspected in the third trimester, then this significantly raises the risk of morbidity and preterm delivery. However the diagnosis of placenta praevia should be considered in any patient who presents with painless, fresh vaginal bleeding or bleeding after intercourse. The most likely symptom from a placenta praevia is painless bleeding in contrast to abruption where pain is likely to copresent. The bleeding is usually fresh, red and the amount of APH can vary. The patient may also present with fresh bleeding in early labour, with the onset of labour and cervical dilatation triggering the bleed or vice versa.
Placenta praevia, placenta accreta, increta and placenta percreta: placenta praevia is the insertion of the placenta partially or entirely within the lower segment of the uterus after 32 weeks. If the placenta does not cover the internal os then it is described as a minor praevia and if it partially or fully covers the os then it is classified as a major praevia. A morbidly adherent placenta such as a placenta accreta, increta or percreta invades through the decidua basalis. In placenta accreta the chorionic villi attach to the myometrium. In placenta increta the placenta has invaded into the myometrium; in placenta percreta the placenta invades through the myometrium and breaches the uterine serosa. Placenta percreta may then invade other organs such as the bladder. The incidence of low-lying placenta can be up to 28% at the routine 20 week anomaly ultrasound scan, but the majority of these will have migrated higher by the following scan, usually at 32 weeks or later. The incidence of true placenta praevia at term is approximately 3%. There are several hypotheses about the aetiology of placenta praevia. One theory is that the position of the placenta depends on the site of implantation of the discoid trophoblast when the pregnancy is developing and from where the placenta will arise. A further theory postulates that areas of deficient endometrium from procedures such as caesarean sections, surgical management of miscarriage and myomectomies may affect how the placenta attaches in these cases. The risk factors for placenta praevia include multiparity, increasing maternal age, smoking, previous praevia and surgical procedures that may result in deficient endometrium (Table 1). The number of previous Caesarean sections also increases the risk of placenta praevia. In well-resourced settings such as in the UK, the majority of placenta praevia cases may be picked up on ultrasound scan at 20 weeks. Currently the UK National Screening Committee does not recommend screening for placenta praevia however, alongside the RCOG, they support most local practice of identifying women by ultrasound whose placenta lies near the internal os at the routine 20 week scan. Evidence shows that at the second trimester scan about 26e60% of women with a low lying placenta on abdominal ultrasound would be reclassified with a more accurate transvaginal scan. There have been no reports to
Other causes Uterine rupture: uterine rupture is a rare event that is defined as loss of the full thickness of the uterine wall integrity. It usually occurs during labour in a woman with a previous Caesarean section or myomectomy. Within this group the risk is still small; the incidence of uterine rupture has been estimated at 7 per 10,000 planned vaginal births after Caesarean section. Uterine rupture may present with CTG abnormalities, pain or APH. Early recognition and quick stabilisation of the mother and baby is required as mortality and morbidity is high.
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Vasa praevia: vasa praevia is a rare obstetric complication where fetal blood vessels cross the internal cervical os. As the incidence is rare (between 1 in 2000 and 1 in 6000 pregnancies) it is not currently screened for during routine ultrasound. The risk of APH mainly comes with rupture of the membranes or labour, as a direct consequence of tearing of the blood vessels. The fetus can be comprised quickly and management if diagnosed or suspected is usually by immediate category 1 Caesarean section.
Unexplained APH Some women will present with bleeding that cannot be attributed to any of the above causes. The RCOG Greentop Guideline references a number of studies over the last four decades that demonstrate that pregnancies with unexplained APH are at higher risk of preterm birth and stillbirth. A recent retrospective, observational study noted that pregnancies complicated by APH of unknown aetiology are at a higher risk of preterm birth, lower birthweight, induction of labour, and neonatal unit admissions. Repeated presentations with unexplained APH in pregnancy should raise suspicion and the pregnancy should be monitored as high risk, with the need for additional ultrasound scans for fetal growth. Healthcare providers should be aware that maternal trauma, including domestic violence, can result in APH, possibly from placental abruption. A third of domestic violence is known to start or escalate in pregnancy. A retrospective study of 2070 women subjected to physical violence in pregnancy found an increased odds ratio of APH in this cohort, compared with controls, of 3.79 (95% CI 1.38e10.40). Women who present with
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multidisciplinary team including a senior obstetrician, anaesthetist, and senior midwife. Input is also frequently required from blood transfusion technicians, haematologists, neonatologists, and porters. Obstetric units will usually have fixed protocols for the management of massive obstetric haemorrhage that should be activated if a woman presents with or develops massive haemorrhage. These protocols should be actively rehearsed in annual skills training in order to prepare for such cases. The RCOG Greentop Guideline defines the severity of APH, as outlined in Table 2. However, it should be remembered that the amount of blood lost can be underestimated, particularly as the amount of blood seen on vaginal examination may not be an accurate representation of the total blood lost. The initial assessment of a woman with APH should include the ABC approach to stabilise the patient (Table 3) and assess the total estimated blood loss. However, it is important to remember that not all blood loss is revealed, so the clinical features of blood loss are extremely important (e.g. grade of shock) to formulating appropriate management plans. Patients with major or massive obstetric haemorrhage should be managed in left lateral tilt to reduce hypotension secondary to uterine compression of the inferior vena cava. Resuscitation and stabilization of the mother is the key priority. Following the initial survey and after commencing resuscitation, the cause and extent of the APH should be assessed by history taking and carrying out a full examination. Abdominal examination may illicit a ‘woody’ or tense uterus, which is characteristically seen in placental abruption or it may show the patient is contracting and could be in labour. If a patient with known placenta praevia presents with bleeding, then a digital examination or speculum examination is not necessary. A digital examination or speculum may be indicated where placenta praevia has been excluded to check for a cause for the APH and to assess cervical dilatation. The diagnosis of vasa praevia should be considered when the APH has been associated with rupture of membranes.
Risk factors for placenta praevia Risk factors Placenta praevia
Placental abruption
Vasa praevia
Uterine rupture
Uterine rupture
Large placental area (multiple pregnancy) Advanced maternal age High parity Uterine scar (caesarean section, myomectomy) Previous placenta praevia Smoking, cocaine use Placental pathology Previous placental abruption Hypertension Pre-eclampsia Smoking, cocaine use Premature rupture of membranes Coagulopathies Multiple gestation Advanced maternal age Abdominal trauma Velamentous insertion of umbilical cord Succenturiate, bilobe placenta Multiple gestation IVF pregnancy Multiparity Congenital uterine anomalies Uterine scar (secondary to caesarean section, myomectomy etc) Maternal age Abnormal placentation Uterine distension (multiple gestation, polyhydramnious, macrosomia) Gestation >40 weeks Obstructed labour
Table 1
Investigations The RCOG guideline recommends that all patients with APH should have a full blood count (FBC) and a group and save. A Kleihauer test is also necessary for all Rhesus negative women. Women who present with major or massive haemorrhage should also have liver and renal function blood tests and a coagulation screen including fibrinogen. They also may benefit from a bedside blood check such as a Hemacue since the FBC may not give an accurate immediate estimate of blood loss.
APH and other signs suggestive of domestic violence or, who disclose violence, should be identified and managed appropriately by a multidisciplinary team who have been specially trained in domestic violence to safeguard pregnant women.
Diagnosis and management of APH Women who present with major haemorrhage and signs of shock should be seen in a maternity unit with involvement of a
RCOG definition of APH severity Description
Blood volume
Spotting Minor haemorrhage Major haemorrhage Massive haemorrhage
Staining, streaking or blood spotting noted on underwear or sanitary protection Blood loss less than 50 ml that has settled Blood loss of 50e1000 ml, with no signs of clinical shock Blood loss greater than 1000 ml and/or signs of clinical shock
Table 2
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Resuscitation pathway for major APH Assessment A(irway) B(reathing)
C(irculation)
D(isabilty) E(xposure)
F(etus)
Management Check patency Respiratory rate Oxygen saturations 10e15L via non rebreathing mask Heart rate Capillary refill time Blood pressure IV access (consider x 2 16 gauge cannulas) IV fluid resuscitation crystalloid/colloid/blood Assess blood loss Consider catheterisation (input/output monitoring) Glasgow coma score Abdominal examination Speculum Vaginal examination CTG Auscultation FHR Ultrasound
Method used gestation dependent
Table 3
be hospitalised until elective delivery although there is no evidence to support this. In accordance with the RCOG Green-top guideline, women with placenta praevia in the third trimester should be counselled about the risks of preterm delivery and obstetric haemorrhage. The place and package of care should be individualised to meet the needs of each patient. If care is at home, the woman should be within close proximity to the hospital, have a constant companion at home, and be aware of when she should attend hospital immediately.
Even with bedside haemoglobin checks and laboratory FBC, it should be noted that after acute major blood loss these tests can be misleading during or soon after the initial haemorrhage. Therefore, initial diagnosis and management of APH should be based on clinical criteria and observations. After stabilizing the mother, the fetal heart rate should be checked. There is no clear guidance or evidence to support monitoring fetuses during APH as there may be transient abnormalities with the CTG. Clinical judgement is essential to make a decision regarding mode and timing of delivery based on likely diagnosis and the maternal and fetal status. For example, if an abruption is suspected and there is an abnormal CTG then the CTG findings are likely to be associated with fetal hypoxia and so delivery would be indicated for fetal benefit. Ultrasound can be used to determine placental site, or to check fetal growth, liquor and Doppler studies once the bleeding has settled. It is not recommended as a diagnostic tool to diagnose abruption as the reported sensitivity is only between 25 and 50%. Generally most clinicians currently do not recommend tocolysis if a patient is actively bleeding. The RCOG recommends a single course of steroids between 24 and 34 weeks if delivery is likely to be preterm.
Blood products Managing severe antepartum haemorrhage frequently requires blood transfusion and considering delivery with surgical interventions to arrest the bleeding. If women require blood transfusion then individually cross-matched blood is ideal. Rarely, if blood loss is so excessive that the processing time for this would be clinically unacceptable then Group O Rhesus negative red cells should be utilised. Commencing red cell transfusion is based on clinical evaluation and haematological investigations, if available. If a coagulopathy develops then fresh frozen plasma (FFP) should be administered before one blood volume is lost. Haematological investigation and specialist advice should guide the further use of FFP, cryoprecipitate, and platelets in massive obstetric haemorrhage. The RCOG Green-top guideline on blood transfusion in obstetrics advises that cryoprecipitate may be indicated when there is bleeding with fibrinogen concentration below 1 g/L. The platelet count should be maintained at above 75 109/L. It is important that women who will refuse blood products in an emergency, including Jehovah’s witnesses, are identified in the antenatal period and referred to consultant-led care. These women are at higher risk of morbidity and mortality in the case of APH. The healthcare provider and patient should discuss what
Conservative management of placenta praevia Women with placenta praevia were previously advised to remain as inpatients from 34 weeks until elective delivery. Currently there is limited evidence to support either hospital-based or home-based care in the third trimester. Women with placenta praevia who have APH that resolves spontaneously without requiring immediate delivery are likely to remain in hospital until bleeding has completely ceased. With recurrent APH in the third trimester for any pathology, it is common practice for patients to
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audits and reviews are imperative for individual units to learn through previous experiences and near-misses. All maternity multidisciplinary team must be regularly updated in their obstetric haemorrhage protocols e both antenatal and postpartum. A
blood components and blood derivatives (for example clotting factor concentrates) would be acceptable to the woman in the event of serious blood loss, and also if autologous transfusion in the form of cell salvage can be used. There should be a signed advanced directive and all discussions clearly documented. Antenatally, any woman who would refuse blood transfusion or blood products should have their haemoglobin levels optimised. In the event of major APH or indeed PPH, a consultant obstetrician, anaesthetist and haematologist should be informed. If a woman who would refuse donor blood is diagnosed antenatally with placenta accreta or this is suspected, it is recommended that delivery is planned in a facility with access to interventional radiology. There is insufficient evidence on whether prophylactic catheter placement for balloon occlusion or embolisation is advantageous.
FURTHER READING Antepartum haemorrhage RCOG Green top guideline 63. 2011, https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_ 63.pdf. Anath CV, Savitz DA, Williams MA. Pracental abruption and its association with hypertension and prolonged rupture of membranes: a methodologic review and meta-analysis. Obstetrics Gynecol 1996 Aug; 88: 309e18. Blood transfusions in Obstetrics RCOG Green top guideline 47. https://www.rcog.org.uk/globalassets/documents/guidelines/ gt47bloodtransfusions1207amended.pdf. Knight M, Kenyon S, Brocklehurst P, et al., eds. on behalf of MBRRACEUK. Saving lives, improving mothers’ care e lessons learned to inform future maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009e12. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2014. Neilson JP. Interventions for suspected placenta praevia. Cochrane Database Syst Rev 2003 (2):CD001988. Neilson JP. Interventions for treating placental abruption. Cochrane Database Syst Rev 2003 (1):CD003247; reviewed 2009. Royal College of Obstetricians and Gynaecologists. Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management. Green-top Guideline No. 27. London: RCOG, 2011. Royal College of Surgeons. Code of practice for management of Jehovah witnesses. London: IBSA Press, 2002. Tikkanen M, Nuutila M, Hiilesmaa V, et al. Clinical presentation and risk factors of placental abruption. Acta Obstetricia Gynecol Scand 2006; 85: 700e5. http://dx.doi.org/10.1080/00016340500449915. Toivonen S, Heinonen S, Anttila M, et al. Reproductive risk factors, Doppler findings, and outcome of affected births in placental abruption: a population-based analysis. Am J Perinatol 2002; 19: 451e60.
Delivery techniques and post-partum care Placental abruption and placenta praevia can lead to ongoing bleeding after delivery. Bleeding should be managed according to normal post-partum haemorrhage protocols, with uterotonic agents and surgical interventions such as intrauterine balloons, B-Lynch suture, uterine artery embolization and hysterectomy as required. In cases of placenta accreta managed by Caesarean section, where the placenta fails to separate, managament options include leaving it in situ and proceeding to either elective hysterectomy or conservative management. There are no randomised control trials to compare approaches directly but case series show successful outcomes with both approaches. If the placenta is left in situ and the uterus is spared, conservative management involves prophylactic antibiotics and lengthy follow-up with beta-HCG measurement and imaging to ensure resolution. Women should be warned of the risk of persisting bleeding and infection.
Conclusion APH can be a traumatic and concerning event for women in pregnancy. Early recognition and management is therefore vital, together with a relevant postnatal debrief. The MBRRACE-UK report highlights that haemorrhage is still a significant contributor to UK maternal morbidity and mortality. Therefore, local
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