Antepartum Hemorrhage - Causes, Diagnosis, and Treatment

Introduction:

Antepartum hemorrhage is one of the significant causes of death in maternal and perinatal periods. This bleeding is also one of the etiological factors for preterm babies getting born. The crucial step is to note the symptoms of clinical shock. Also, look for spotting, which refers to a slight blood stain or spot.

Minor bleeding is blood loss of fewer than fifty milliliters. Major hemorrhage is blood loss of 50 to 1000 ml and no symptoms of clinical shock. Massive hemorrhage means blood loss more significant than 1000 ml and clinical shock symptoms. Recurrent antepartum bleeding means more than one episode of bleeding. And this bleeding occurs in the second part of the pregnancy.

What Are the Causes of Antepartum Hemorrhage?

When the placenta covers the opening of the cervix of the mother, it is called the placenta previa. This is the primary cause of antepartum hemorrhage. The diagnosis can be made 28 weeks after the lower uterine segment is formed. This is classified as

• Type 1 - Low lying.

• Type 2 - Marginal-anterior and posterior.

• Type 3 - Partial.

• Type 4 - Complete.

The causative factors for placenta previa are the previous history of the same;

• History of cesarean section.

• History of abortions.

• Maternal age greater than 35 years.

• Two to five pregnancies.

• Endometritis (inflammation of the endometrium).

• Manual placenta removal.

• Curettage (procedure to remove tissue from the inner surface of the uterus).

How Is Placenta Previa Clinically Classified?

The placenta previa is clinically classified as major and minor.

1. Minor is type 1 and type 2 anterior, delivered vaginally.

2. Major is type 2 posterior; type 3 and 4 are delivered through a cesarean section.

The loss of attachment of the placenta from the uterus (womb) is called placental abruption. It is classified as

• External Abruption: Also known as relatively concealed abruption. The placenta does not detach completely from the uterine wall.

• Concealed Abruption: The blood is trapped between the placenta and uterine wall.

The causative factors for the placental abruption include the previous history of:

• Mother being hypertensive.

• Maternal age is greater than 35 years.

• Abdominal injury.

• Smoking or alcohol abuse.

• Shortened umbilical cord.

• Fibroids.

• Severe blood loss from the fetus due to breakage of fetal vessels is known as vasa praevia.

• The predisposing factors are the umbilical cord inserts on the chorioamnionitis membrane but not on the placental mass is known as velamentous insertion.

• History of more than two gestations.

• The diagnosis is by fast fetal beating of the heart.

• Vaginal bleeding without pain.

• The crucial step is to check the fetal heart rate after the breakage of the membrane.

• The other causes of antepartum hemorrhage are vulvovaginal varicosities which involves varicose veins formed at the outer surface of female genitals called the vulva, tumors of the genital tract, genital infections, and blood in the urine.

What Are the Complications of Antepartum Hemorrhage?

Complications to the Mother:

• Excessive bleeding.

• More susceptible to infections.

• Shock.

• Damage to the renal tubular cells.

• Disseminated intravascular coagulation is excessive bleeding or clotting.

• Uncontrolled bleeding postpartum.

• Mentally disturbed.

• Complications during blood transmission.

Complications to the Fetus:

• Decreased oxygen supply to the fetus.

• Growth retardation of the fetus.

• Premature fetus.

• Death of the fetus.

How to Clinically Assess Antepartum Hemorrhage?

1. Check whether the mother and fetus are in good condition.

2. Check the duration of vaginal bleeding and the mother's heart condition.

3. Case history must be taken after the mother's condition is stable.

• Ask regarding the pain along with bleeding.

• If the pain is continuous, then placental abruption.

• If the pain is intermittent, then labor.

4. Check if the fetal movements are less (the fetus does not move but has a heartbeat) and if there is any breakage of fetal membranes (breakage of amniotic sac before thirty-seven weeks).

• Examination of the vital signs (pulse, blood pressure, body temperature, respiration rate)

• On abdominal examination, a tender or stiff feel indicates abruption. Bleeding is not associated with pain - placenta previa. The non-tender, soft feel of the uterus indicates bleeding from the placenta.

• Check for dilation of the cervix (opening of the cervix during childbirth).

• Vaginal examination (a pelvic exam where the clinician inserts one or two gloved fingers of one hand into the vagina and presses on the lower abdomen with another hand). The vagina is the part that extends external genitalia to the cervix.

What Are the Investigations to Assess Antepartum Hemorrhage?

• Complete Blood Test: Complete blood picture of the mother is taken to evaluate overall health and detect various disorders.

• Clotting and Bleeding Time: This test shows how long the blood clots take to stop bleeding. The bleeding time normal range is two to seven minutes, and the clotting time normal range is eight to fifteen minutes.

• Ultrasonography: The use of high-frequency ultrasound waves to record images of internal organs.

• Blood Type: Classification of blood based on the presence or absence of antibodies.

• Transvaginal Ultrasound: Color doppler transvaginal sound. Ultrasound test to look through the vagina.

• Cardiotocography: It is done to record the fetal heart rate.

• Kleihauer Test: Kleihauer test is done in case of negative rhesus, abdominal trauma, and abnormal cardiotocography.

• Liver and Renal Test: For bleeding more significant than 50 ml, functional liver and renal function tests must be done.

What Is the Treatment for Antepartum Hemorrhage?

Management of Bleeding Before the Full Term:

• They can be discharged after counseling if there is only slight spotting and no longer bleeding.

• If the delivery is mostly before the entire term, then a single course of Corticosteroid medications is given for six days.

• Conservative management is until the mother's situation stabilizes at twenty-four to twenty-six weeks.

Placenta Previa Treatment:

• Placenta previa occurs in less than thirty-seven weeks of gestation. Doctors recommend bed rest and checking all vital signs if the mother and fetus are stable, with no excessive bleeding. Ultrasonography, steroids, and everyday cardiotocography are studied to record fetal movements. If everything is under control, then plan for delivery after 37 weeks. There is a chance for normal delivery for type 1 and type 2 anterior categories of placenta previa. If there is progress without bleeding, proceed with vaginal delivery without complications.

• If the bleeding continues, then cesarean delivery should be opted for.

• Type 2 posterior, type 3 and type 4 categories of placenta previa proceed with cesarean delivery.

• Four units of blood transfusion if there is uncontrolled bleeding.

Placental Abruption Treatment:

• Hospital admission is a requisite for treating placental abruption.

• Then check for proper airway, breathing, and circulation. Record the vital signs and also examine the urinary output.

• Check for vaginal bleeding. Repeated cardiotocography (a technique used to monitor fetal heart rate) for fetal heart rate.

• Transfuse four units of blood if there is excessive blood loss.

• Recommend Dexamethasone medication if the delivery is before the full term. Dexamethasone improves the condition of fetal lungs before full-term delivery.

• If there is a chance of fetal death, then vaginal delivery is recommended.

• Cesarean delivery may be considered if maternal or fetal health is deteriorating.

• A hysterectomy is done if there is uncontrolled bleeding. Hysterectomy means the removal of a part or the whole uterus. The uterus is the womb where the fetus grows.

What Is the ICD Code for Antepartum Hemorrhage?

• 046,90 is billable or specific ICD-10-CM (International Classification of Diseases) for reimbursement purposes.

Conclusion:

Antepartum hemorrhage is a critical complication. Utmost care should be taken to prevent excessive bleeding, and the health of the mother and the fetus should be considered before proceeding with any treatment procedure. A multidisciplinary approach and preparation are crucial enough to provide safer treatment modalities. A clear and standard checklist of the correct treatment must be followed in an emergency. Ultimately the health of the mother and fetus are essential factors before coming to any conclusion regarding treatment.

Appropriate antenatal care and do not ignore any warning signs of bleeding during gestation. Correct case history is a must to prevent such complications. The best intensive care unit and blood banks must be nearby to provide timely treatment.