Antepartum Haemorrhage This essay is designed to explore antepartum haemorrhage (APH), but as it is a wide topic area for discussion, the management will focus on haemorrhage due to placental abruption or abruptio placentae. The condition will briefly be defined, followed by a discussion of the predisposing factors. As there are many factors which contribute to APH, domestic violence as a pre-disposing factor will be elaborated upon. The term antepartum haemorrhage is applied to bleeding from the vagina occurring at any time from the 24th week of pregnancy and before the birth of the baby (Baskett, 1999) The largest identifiable cause of stillbirth (13.9%) between 2000-2002 were ante-partum haemorrhage (Cemach,2004) There are 3 main factors which cause APH: Haemorrhage from a normally situated placenta (placental abruption), haemorrhage from partial separation of a placenta abnormally situated in the lower uterine segment (placenta praevia) and haemorrhage from a lesion of the cervix or vagina such as an erosion, polyp or carcinoma (cancer). Other rare causes include uterine rupture (Basket, 1999) When part of the placenta detaches from the uterine wall, maternal blood escapes from the intervillous space. Sometimes the blood escapes past the membranes and through the cervix in what is called placental abruption with revealed haemorrhage as it is obvious to the eye. There may also be some abdominal discomfort if the placenta is in an anterior position. In severe cases it may cause fetal distress or death but in slight cases, the fetus is not affected (Ten Teachers, 1997).When there is placental abruption with no obvious bleeding, this is called a concealed haemorrhage. Symptoms can vary with the severity of the case. In extreme cases the woman may suffer from shock due to the amount of blood diffused into the uterus and painful uterine distension. The abdomen is hard and tender to touch, fetal parts cannot be felt and fetal heart cannot be heard (Ten Teachers, 1997). Gaufberg, 2006 suggests the causes of placental abruption to be: Maternal hypertension - Most common cause of abruption, occurring in approximately 44% of all cases, Maternal trauma (e.g., road traffic accidents and assaults) - Cigarette smoking, Alcohol consumption, Cocaine use, Short umbilical cord, Sudden decompression of the uterus (e.g., premature rupture of membranes, delivery of first twin), Retro placental bleeding from needle puncture (i.e., post amniocentesis), and advanced maternal age. Domestic violence is a predisposing factor widely recognised to possibly cause placental abruption. Domestic violence is reported by up to one in four women in Britain and represents a serious public health issue (refuge, 2006). The psychological and social consequences of domestic violence include alcohol and drug dependence, suicide attempts, depression, and post-traumatic stress disorder (Amaro et al 1990) Pregnancy may increase the risk of violence, and the pattern of assault may alter, with pregnant women being more likely to have multiple sites of injury and to be struck on the abdomen. These in turn have also been shown to increase the risk of abruption and placenta praevia (Boyle, 2002). Chan et a,1999 conducted a study which revealed that mothers over the age of 40 are more likely to suffer from antepartum haemorrhage but they did not elaborate on whether it was more likely to be due to placenta praevia or abruption. It was noted however that the incidence was higher in the primiparous older women than the multiparous. As well as the factors mentioned above, History of spontaneous miscarriage or induced abortion and previous caesarean section are factors which can contribute to placenta praevia All cases of APH should be admitted to hospital. In revealed haemorrhage with slight bleeding, when praevia has been excluded by ultrasound, Ten Teachers, 1999 suggests that the woman should be admitted to the antenatal ward for nothing more than rest and observation. In many cases no further bleeding occurs and the pregnancy continues to term. Ogueh et al 1998 analysed the need for hospitalisation in cases of antepartum haemorrhage with unknown origin and concluded that there was no need as is had no benefit in terms of gestation at birth, recurrent haemorrhage or fetal weight. The management of placental abruption is different from placenta praevia and treatment will depend on the extent of the abruption. When presented with a woman who is suffering from an antepartum haemorrhage, all health professionals involved with the mothers care should be prepared for a post partum haemorrhage. Blood should be taken for grouping, cross matching, full blood count and clotting studies. Kleiheur is usually performed in rhesus negative mothers to see if any fetal blood has crossed the placenta into the maternal circulation (Lindsay, 2004). If the bleeding is light to moderate, and the mother is not in immediate danger, then the course of action depends on the fetal heart rate (WHO, 2003). If it is normal or absent then membranes should be artificially ruptured but if the cervix is unfavourable, caesarean section should be performed. If the fetal heart is abnormal then either rapid vaginal delivery or caesarean section should be performed. When the abruption is severe, more than half the placenta will have separated and it becomes and obstetric emergency. Blood loss will usually exceed 1 litre and the mother will be very shocked (Linsay, 2004). There is also an increased risk of coagulation disorders. WHO, 2003 suggests that delivery of the baby should be made as soon as possible. They suggest delivery by vacuum extraction if the cervix is fully dilated or caesarean section if vaginal delivery is not imminent. Ergometrine 500mcg is given intravenously at delivery to control haemorrhage in the third stage of labour. It is usual to continue syntocinon infusion for some hours after delivery to maintain uterine contraction (Lindsay, 2004). If there are signs of shock then steps should be taken to conduct a blood transfusion if necessary. Throughout all diagnosis and treatment of APH, women and their families should be informed and all choices explained thoroughly. In conclusion, it can be seen that bleeding in pregnancy remains a major cause of maternal mortality. Midwives must therefore be familiar with the management of APH for whatever cause. The multidisciplinary team should be able to work together, responding to haemorrhage quickly and appropriately. Hospital guidelines should be kept up to date and in and area easily accessible to all relevant health care providers. Midwives should also be able to identify those women most at risk, referring them appropriately, also ensuring that the woman and her family are supported throughout. References Amaro H, Fried LE, Cabral H, Zucherman B. Violence during pregnancy and substance use. Am J Public Health 1990;80,575-9 Baskett T. (1999) Essential management of obstetric emergencies Clinical Press [Bristol] p 64-76 Boyle M, (2002) Emergencies Around Childbirth A Handbook for Midwives Radcliffe Publishing Ltd Cemach (2004) Stillbirth, neonatal and post neonatal mortality 2000-2002 England, Wales and Northern Ireland. Confidential Enquiry into Maternal and Child Health. [online] available from: www.cemach.org.uk/publications/2000-2002%20perinatal%20report.pdf. Accessed 10/12/2006 Chan B, Lao T (1999) Influence of parity on the obstetric performance of mothers aged 40 and above Human Reproduction [journal], Vol 14, No. 3, March 1999, pp. 833-837(5) Oxford University press Lindsay P (2004) bleeding in pregnancy in: Macdonald S, Henderson C, Mayes Midwifery, Balliere Tindall. London P772-73 Ogueh O, Johnson M.R. What is the value of hospitalisation in antepartum haemorrhage of uncertain origin? Journal of Obstetrics & Gynaecology, Volume 18, Number 2, 1 March 1998, pp. 120-122(3) Refuge (2006) Pregnancy and domestic violence [online] available from http://www.refuge.org.uk. Accessed 09/12/2006 Ten Teachers. (1997) Abnormal pregnancy in: Chamberlain G (ed) obstetrics Oxford University press WHO. (2003) Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors World Health Organisation [Geneva]