Antepartum Haemorrhage
Definition
Placenta Accreta/ Increta/ Percreta
Placenta Abruption
Epidemiology
Placenta Previa: 2% of pregnancies
Placenta Accreta (79%), Increta (14%), Percreta (7%): 0.5% of pregnancies (increasing due to more LUSCS)
Placenta Abruption: 4% of pregnancies
Risk Factors
Placenta Previa
Placenta Accreta
Placenta Abruption
Risk factors:
Clinical Features
Placenta Previa
Placenta Accreta
Placenta Abruption
Investigations
Previa
Imaging: TAUS --> TVUS
Accreta
Imaging: TAUS --> TVUS, MRI
Blood: ++ Mo AFP, Urinalysis (haematuria - invasion to bladder)
Management (NO PV EXAM!!)
Placenta Previa
Placenta Accreta
Placenta Abruption
Complications
Placenta Previa
Heavy placenta bleeding --> foetal hypoxia.
Placenta Accreta/ Abruption
DIC following haemorrhage due thromplastin released from damaged vessels
Source
Llewellyn-Jones. Fundamentals of Obstetrics and Gynaecology. 9th Ed 2010
UpToDate 2013
- PV bleeding >20/40
- Major: Implanted placenta in LUS, below foetus = vaginal birth impossible
- Minor: Vaginal birth possible
- Grade 1 = Close to internal os
- Grade 2 = Touching internal os
- Grade 3 = Partially covering internal os
- Grade 4 = Complete obstruction of internal os
Placenta Accreta/ Increta/ Percreta
- Accreta = Morbid adhesion of placenta, on a previous LUSCS scar
- Increta = invades myometrium
- Percreta = penetrate myotrium to serosa/ adjacent organs
Placenta Abruption
- Retroplacental bleeding (due damage)
Epidemiology
Placenta Previa: 2% of pregnancies
Placenta Accreta (79%), Increta (14%), Percreta (7%): 0.5% of pregnancies (increasing due to more LUSCS)
Placenta Abruption: 4% of pregnancies
Risk Factors
Placenta Previa
- Multiparous (3x)
Placenta Accreta
- Previous LUSCS + current placenta previa
Placenta Abruption
Risk factors:
- Previous abruption ++++
- Smoking (modifiable) ++
- GHTN/ Pre-eclampsia/ eclampsia +++
- Chorioamnionitis ++
Clinical Features
Placenta Previa
- Painless bleeding (not heavy)
- Contractions (10-20%)
- Recurrent (due to shearing forces from growing LUS - starts growing from 20/40 (Can Med Assoc J. Jan 1942; 46(1): 19–22).)
Placenta Accreta
- Massive bleeding (life-threatening)
Placenta Abruption
- Slight to massive bleeding
- Pain if moderate or worse bleeding
- Contractions
- Sx of shock
- Foetus alive if slight, dead if severe
Investigations
Previa
Imaging: TAUS --> TVUS
Accreta
Imaging: TAUS --> TVUS, MRI
Blood: ++ Mo AFP, Urinalysis (haematuria - invasion to bladder)
Management (NO PV EXAM!!)
Placenta Previa
- Admit, monitor blood loss, tranfuse if needed. If no bleeding 4-7d, d/c. LUSCS @ term
- If bleeding severe, oxytocin to control haemorrhage. If fail, deliver baby.
Placenta Accreta
- Emergency LUSCS to preserve mother's life
Placenta Abruption
- Admit, monitor blood loss. Tranfuse if needed (give amt of blood lost). D/C if bleeding stop
- US for foetal health, if foetus alive and bleeding mod, deliver
- Monitor urine output
- Prevent DIC. Venous blood monitoring q2h.
Complications
Placenta Previa
Heavy placenta bleeding --> foetal hypoxia.
Placenta Accreta/ Abruption
DIC following haemorrhage due thromplastin released from damaged vessels
Source
Llewellyn-Jones. Fundamentals of Obstetrics and Gynaecology. 9th Ed 2010
UpToDate 2013