Antepartum Hemorrhage

00:01 Now let's discuss Antepartum Hemorrhage.

00:03 So there are several causes of Antepartum Hemorrhage.

00:07 But these are the most common.

00:09 Placenta previa, Placenta abruption, Vasa previa and then uterine rupture.

00:14 Let's talk about placenta previa first.

00:17 So placenta previa is a condition in which the placenta is in front of the baby covering the cervical os.

00:23 Now how do you if a patient has placenta previa? Well, there's a few things that they will present with.

00:28 The first and the most important is that they have painless vaginal bleeding.

00:33 You'll see this is different in some of the other presentations where there is pain associated with the vaginal bleeding.

00:39 For patients that have a placenta previa, you want to make sure that you do not perform a digital or speculum exam.

00:45 Doing so could disrupt the placenta and that mom could hemorrhage to death.

00:51 Because the placenta is in front of the cervix, our management delivery by C-section.

00:58 So let's move on to placental abruption.

01:01 Placental abruption happens when placenta prematurely separates from the uterus.

01:06 You can have a concealed or internal hemorrhage from that or you can have external bleeding if it's significant enough.

01:13 Now what are the causes of placental abruption? Hypertension is the most common.

01:18 But also trauma, cocaine or tobacco use or quick decompression of the uterus.

01:24 So for example, a mom that has polyhydramnios, extra fluid, when her water bag ruptures, the uterus decompresses very quickly.

01:33 And that can actually lead to placental abruption.

01:36 So vasa previa is a condition where the vessels traverse the cervical os.

01:41 As you can see in the picture, the vessels are in front of the fetal head.

01:45 Now this can be very traumatic for labor, specially if you have artificial rupture of membranes.

01:51 If you do this, you will actually start to make those vessels bleed and the baby can exsanguinate.

01:57 This is usually diagnosed on ultrasound.

02:02 And next is uterine rupture.

02:06 So with uterine rupture, the previous C-section scar made a hiss and the uterus can open up.

02:12 This is a cause of severe pain and also of heavy vaginal bleeding.

02:17 So let's go through a case.

02:20 A 19 year old Gravida 1 Para 0 female with an intrauterine pregnancy at 34 weeks and 2 days presents to labor and delivery with complaint of heavy vaginal bleeding.

02:31 It is associated with severe abdominal pain.

02:34 She has a history of drug abuse throughout her pregnancy.

02:37 On physical exam her blood pressure is 90 over 50 with a pulse of 120 and a fetal heart rate of 90 beats per minute.

02:45 What is the initial step in her management? Would it be, A. Order a urine toxicology.

02:52 B. Perform an emergency C-section C. Establish IV access with two large bore IV needles.

02:59 or D. Perform an ultrasound for location of the placenta.

03:02 The answer is C.

03:05 We always want to make sure we stabilize our patient.

03:08 And this patient she is actually going into shock.

03:10 Yes, she does use drugs and she probably is having a placental abruption from hypertension from the drugs.

03:18 But now she is actually in shock and that's why her blood pressure is low.

03:21 Her pulse rate is high.

03:23 So the first thing you want to do is assess your patient and resuscitate your patient before moving on to the cause of bleeding.

03:30 And that is why establishing an IV and starting IV fluids is the right answer in this case.