Obs-Gyn Antepartum Haemorrhage:

History:
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Duration? Volume? Nature of bleed? Number of events? Inciting cause?

Last known status of pregnancy? Foetal movements? Contractions? Amnion rupture?
General medical history?
o Cervical screening, UTI screening?
o Coagulopathies? Medications? Medical conditions?
o Prior pregnancies? Complications?
Syndromes of poor placenta:
o IUGR, pre-eclampsia, smoking, obesity, pre-existing HTN, extremes of age
Connective tissue disorders (SLE and lupus anticoagulant), antiphospholipid syndrome
(with previous miscarriages etc as warning flag)
Drug use or withdrawal (particularly such as cocaine and stimulants which increase BP)
Screening for domestic abuse

Examine
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ABCs
Vitals: Temp, HR, RR, CRT, colour, hydration / volume load.
o Haemodynamic stability
o Very good compensating capability until rapid decompensation
PV examination:
o Sterile speculum exam
Ruling out open cervix, products of conception within the os
Identify site of haemorrhage,
o Vaginal exam: only after USS has ruled out placenta / vasa praevia
Foetal monitoring if gestational age appropriate:
o Foetal heart rate via Doppler
o Assess for contractions

Testing:
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FBE, EUC, LFT, beta-HCG

Ultrasound:
o Foetal pole length (cut-off of 7mm)
o Gestational sac: location (intrauterine or ectopic), size (mean diameter >25mm)
o Foetal heart rate (presence or absence)
o Placenta: location, haemorrhage, vasa praevia
Foetal fibronectin assay: quantitative preferred over qualitative

Differentials:
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Cervical shock: excessive vagal tone, bradycardia with hypotension.

Threatened, incomplete or actual miscarriage, threatened pre-term labour, actual preterm labour
Placenta praevia, placenta accreta, vasa praevia, placental abruption, marginal bleed
Ectopic pregnancy, molar pregnancy (gestational trophoblastic disease)
Vaginal trauma, cervical Ca,

Definitions and Questions:

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Miscarriage:
o Passing products of conception before 20w. Were never viable, occurs in up to
1:6 pregnancies, typically represents underlying lethal foetal anomalies
Recurrent miscarriage:
o 3+ miscarriages (<20/40w) without a viable pregnancy within that sequence.
Need investigation
Stillbirth:
o Passing products of conception after 20w. Often still reflects underlying lethal
abnormalities, but may also be from maternal or foetal health insults, placental
problems etc. Birth must be registered.

bHCG levels:
o Double every 48hrs, and once above 3000mIU/ml, should be able to see on TV
USS. If not, ?ectopic?
o If higher than expected, or not settling after confirmed miscarriage, consider
gest. Trophoblastic Dz.
Findings of confirmed or inevitable miscarriage:
o Foetal pole >7mm without foetal heart movement = foetus present but dead.
o Mean Sac Diameter >25mm without foetal pole = foetus has been resorbed.
o Absence of visible embryo >2w after presence of empty sac = no development
of foetus within sac
o Open cervix with POC in
Management of miscarriage:
o Conservative: watch and wait, analgesia. Need follow-up, this process can take
weeks. May require operative Mx
o Medical: 600-800mcg Misoprostol x2, 24hrs apart. Hospitalise or very close
followup. May require operative Mx
o Operative: PV Misoprostol if required, D&C. Variable risks, more involved.
Management of early losses:
o Anti-D
o Analgesia
o Medical Mx probably most appropriate
o Psychosocial support
o Diagnosis of cause: Chromosomal, congenital, maternal health, trauma,
infection, uterine, antiphospholipid syndrome
Management of mid-trimester losses:
o Anti-D
o Analgesia
o Medical Mx probably most appropriate
o Psychosocial support
o Diagnosis of cause: Antiphospholipid syndrome. Chromosomal, congenital,
maternal health, trauma, infection, uterine, cervical incompetence