Primary Postpartum Haemorrhage

Max Brinsmead MB BS PhD
April 2015
When confronted with a pregnant patient
who is bleeding after 20w
There are five questions that need
urgent answers…
How much blood has been lost
What is the maternal condition
What is the fetal condition
Is the patient in labour
What is the cause of the bleeding
THINK in terms of aetiology...
Bleeding from a normally situated
placenta = Abruption
 Bleeding from a low placenta =
Placenta previa
 Cervical bleeding:
• “Show”
• Ectropion or Cancer
Other sites of bleeding i.e. rectal or
• rare
Fetal bleeding
• rare but serious
ACT in terms of priority...
Assess maternal wellbeing
Assess fetal wellbeing
Resuscitate if required
Anticipate further problems
Is the fetus salvageable
Is the fetus compromised
Then attempt diagnosis
Essential observations
Maternal vital signs
• General appearance
• Pulse and BP
Nature and amount of PV loss
Tone and tenderness
You can’t do this with CTG belts in place
Just blood or blood and liquor
• Fetal heart present or absent
Discretionary observations
Fetal lie, presentation and
• A deeply engaged presenting part excludes
major previa
Speculum examination of the cervix
• For minor APH where a cervical cause is
Digital examination of the cervix
• For the patient in labour with an engaged
presenting part
• Also helpful if a prior scan has shown a non
previa placenta
Essential Investigations
HB, Blood group and save or Xmatch
• Depends on the amount of blood lost
• And the suspected diagnosis
• Remember that abruption is often associated with
a large concealed loss
• Best done “on the ward” if bleeding is substantial
• Requires skill in distinguishing blood clot from
• Vaginal scan the best way of evaluating degrees
of placenta previa
Urinalysis for proteinuria
• May require bladder catheterisation
• Abruption may be associated with “acute” pre
• And the blood pressure may not be raised
Discretionary investigations
Clotting studies
• Platelets, COAG and FDPs
• Only of help in management of severe APHs
Maternal Kleihauer
• Only useful for assessing Anti-D dose in Rh
negative patients
A bedside test for Fetal Haemoglobin
• Useful if fetal bleeding is suspected
• Typically occurs with ARM or SROM in labour
• Apt’s test using 1% NaOH
Immediate management
Large bore IV line
• If estimated loss is >250 ml
• Or if abruption or placenta previa is diagnosed
Resuscitate with IV Fluids
• Commence with saline
• Colloids if shocked
• Blood if estimated loss >2 L
 Corticosteroids for gestation <37wks
 Anti-D if Rh negative
• Dose according to Kleihauer
Monitoring response
Maternal PR and BP
• Watch for pre eclampsia
Indwelling catheter
• Hourly urine output
• Only a few require CVP
Watch for coagulopathy
• A bedside test of clotting
• Prothrombin time (aPTT) and platelets
• HB takes a while to adjust
CTG and umbilical Dopplers for the
Definitive management
Conservative for placenta previa
• Most will settle
• Deliver when paediatric resources permit
• CS if placenta within 2 cm of internal os
 Aggressive
management for
• CS sooner rather than later for fetal reasons
• And the role of CS in averting maternal
coagulopathy even with FDIU requires RCT
Watch for preterm labour for all others
• Observe in hospital

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