Antepartum haemorrhage
O&G
Introduction
Author: Idayat Olawale
Antepartum haemorrhage is bleeding that occurs during pregnancy after the 24th week until delivery. It is a potentially life-threatening condition if left untreated/ unmanaged.
WIPER
Wash hands:
Introduction: Introduce yourself by your full name and your role
Patient details: Gather the patient’s full name and DOB
Explain/Establish: Explain what you are going to do and Establish consent
ExPose: Expose & Position the patient if necessary.
Presenting Complaint
Main symptom: Bleeding during pregnancy
History of Presenting complaint:
Use the acronym SOCRATES where applicable
Site-
Onset- When did you first notice the bleeding, has it happened before? How many weeks pregnant are you?
Character- Light or heavy bleeding, Amount of blood, Are there any clots, Colour
Radiation
Associated features – Fatigue, Pain eg (pelvic pain/dyspareunia), Nausea, Vomiting
Timing – Continuous bleeding or at specific times eg: post-coital bleeding
Exacerbating & relieving factors: Intensifies or becomes present after any activity
Severity – Amount of blood eg: bleeding through clothes
Don’t neglect asking in-depth questions about associated features, eg: regarding the fatigue, how long have you been feeling that way? You can again use SOCRATES if applicable. This may help separate acute issues from non-acute ones
Systems review:
A systems review may help identify risk factors which will help to narrow down differentials
For antepartum histories ask about current and past pregnancies as well as foetal well-being
Menstruation: Date of LMP, Regular/irregular
Obstetrics: Gravida and Parida, Methods of delivery, Any previous/current complications, Current foetal movements
Sexual activity: Is the patient sexually active, One or more sexual partners, Using any contraception, Previous STI screening
Cervical smear: If of age then has the patient had smear tests?, Any previous abnormal results?
Always do a constitutional systems review asking about: Unintentional weight loss, SOB, fevers, fatigue, loss of appetite, pain
Elicit ideas, concerns and expectations using the acronym ICE
Ideas- Do you have any ideas what might be causing this?
Concerns- Is there anything you’re worried about?
Expectations- What are you most hoping for from me today?
Summarise everything the patient has told you to ensure you have correct information or incase anything was missed
Past Medical History
Wash hands:
Introduction: Introduce yourself by your full name and your role
Patient details: Gather the patient’s full name and DOB
Explain/Establish: Explain what you are going to do and Establish consent
ExPose: Expose & Position the patient if necessary.
Medications
Ask about allergies and OTC, herbal or prescribed medications
For antepartum haemorrhage specify blood thinners even if the patient says they aren’t on any current regular medications
Family History
Are there any medical conditions that run in the family
Specify family history of bleeding, clots, breast or ovarian cancer or any familial history of complications during pregnancies
Social History
Social history refers to a patient’s sexual activity, smoking, alcohol and drug use, as well as housing, dietary, and occupational status
Tailor these towards whichever history you are undertaking. For antepartum haemorrhage important factors include: smoking (how many a day and for how long), sexual activity (may have been asked during systems review)
Differential Diagnosis
Separate differentials into most likely, less likely and can’t miss. Each section will differ based on results from the history and examination
Examples of differentials for antepartum haemorrhage include: Ectopic pregnancy, Placenta praevia, Placental abruption, etc
Management
Remember: Bedside --> Laboratory --> Imaging
Bedside examination includes:
Bimanual +/- speculum examination
Laboratory investigations include bloods such as:
Group and save/crossmatch depending on amount of bleeding
FBC to check for anaemia
Pregnancy test/ beta HcG
Imaging includes:
Ultrasound eg: TVUS, Abdominal
Hysteroscopy +/- biopsy
Summarise and present findings from history, exam and lab results
Management plan
Tailor the management based on diagnoses
Discuss with all relevant persons ie: the patient and colleagues