Initial assessment of patients with antepartum haemorrhage
The initial assessment of pregnant women presenting with APH should follow a streamlined and structured approach aimed at establishing the cause of the bleeding, maternal resuscitation, fetal assessment, and appropriate triaging based on the working or confirmed diagnosis.
This assessment should include a focused clinical history and examination, relevant point-of-care testing, and the involvement of a senior obstetrician in the decision-making for a definitive or ongoing management plan.Clinical history
Clinical history should establish the basic obstetric parameters including the gestational age and any previously known risk factors during the pregnancy (Box 22.2). Focused history should elicit a description of the circumstances of the bleeding, including the time of onset, precipitating factors, the amount of bleeding, previous bleeding episodes, and any associated symptoms of cardiovascular compromise including dizziness and fainting episodes. Importantly, the presence or absence of pain and its characterization should be elicited as well as any changes in fetal movement.
Clinical examination
General examination of the pregnant woman with APH should focus on assessment of pallor (conjunctiva, palm of the hands, oral mucosa, capillary refill), vital signs including blood pressure, pulse rate, oxygen saturation, and respiratory rate. The presence of maternal tachycardia in association with pallor reflects the degree of blood loss and even when the blood pressure remains within the normal range this is indicative of significant blood loss. The presence of hypertension should prompt routine testing for proteinuria in the context of diagnosing pre-eclampsia. Clinical examination of the abdomen should include the fundal height, assessment of tenderness, bruises, contraction, presentation and lie of the fetus, and fetal assessment with cardiotocography. An assessment of ongoing bleeding should be performed by inspecting the vulva and gently
Box 22.1 Causes of antepartum haemorrhage
• Placenta praevia
• Placenta abruption
• Vasa praevia
• Local genital causes:
— Cervical ectropion
— Inflammation/infection-cervicitis, vaginitis
— Cervical neoplasia
— Polyps
— Trauma
• Bleeding of unknown origin
parting the labia minora.
Digital examination of the cervix should be avoided until placenta praevia has been objectively excluded. A gentle speculum examination allows direct visualization of the cervix, to assess ongoing blood loss and exclude local genital causes.Initial resuscitation, investigations, and triaging
The assessment and resuscitation of patients presenting with APH should ideally occur simultaneously. A large-bore intravenous access (French gauge 14/16) should be inserted and blood drawn for a full blood count including platelets, blood crossmatch, and coagulation profile. Fluid resuscitation should be commenced promptly to restore circulating blood volume particularly in those patients who are bleeding heavily or who are haemodynamically unstable. Up to 2 L of crystalloids can be administered quickly over 1 hour to restore circulating volume and stabilize the patient. A shock index (pulse rate/systolic blood pressure) of greater than 1.2 is a pointer to the severity of the blood loss. The normal shock index range is 0.7-0.9 in pregnant women (10). An ultrasound scan to assess the placenta site forms part of the assessment. Once a working diagnosis has been made, the patient can be triaged into expectant management or a decision to expedite delivery. This decision is usually based on the likely diagnosis, maternal and fetal conditions, and the gestational age. This decision should involve a senior obstetrician.