MATERNAL AND EARLY CHILD HEALTH

Health Evidence Bulletins - Wales

Date of Completion: 23.6.97

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available


9. Haemorrhage in late pregnancy (and labour)

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

The Statements The Evidence
9a. Placental abruption and placenta praevia are important causes of maternal and perinatal mortality and morbidity and must be managed by experienced staff in well equipped obstetric units(i,ii).

(Health gain notation - 1 "beneficial")

i. Department of Health and Others. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1991-1993. London: HMSO,1996. pp.42-43
(Type V evidence - expert opinion);
ii. Department of Health. Confidential Enquiry into Stillbirths and Deaths in Infancy. Annual Report for 1 January - 31 December 1993. Part 1. London: HMSO,1996 p.36
(Type V evidence - expert opinion)
9b. Early ultrasound scan showing a low lying placenta (placenta praevia) should be repeated at 32 weeks when 90% will be found to be normally situated(i).

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 603
(Type IV evidence - observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 137)
9c. When placenta praevia is suspected on clinical grounds, diagnosis should be confirmed by ultrasound and elective Caesarean section planned. Expectant management to 37 weeks is generally accepted but has not been subjected to controlled trial (i).
(Health gain notation - 2 "likely to be beneficial")
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 605-607
(Type IV evidence - observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 138-139)
9d. Pelvic examination should be avoided other than in an operating theatre(i)

(Health gain notation - 6 "likely to be harmful")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 604
(Type IV evidence - observational studies Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 138-139)

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9e. A high index of suspicion should exist in regard to placental abruption allowing early diagnosis and optimum management(i)i.
(Health gain notation - 1"beneficial")
i. Department of Health. Confidential Enquiry into Stillbirths and Deaths in Infancy. Annual Report for 1 January - 31 December 1993. Part 1. London: HMSO,1996 p.39
(Type V evidence - expert opinion)
9f. When placental abruption is diagnosed, meticulous blood accountancy and replacement, with early tests for blood clotting are essential (i,ii).

(Health gain notation - 1"beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 598-599
(Type IV evidence - observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 136);
ii. Department of Health and Others. Confidential Enquiries into Maternal Deaths 1988-1990. London: HMSO, 1994. pp. 43-44
(Type V evidence - expert opinion)
9g. In a case of placental abruption with a live fetus and no evidence of fetal distress, vaginal delivery may be the management of choice providing facilities exist for efficient monitoring and immediate Caesarean section, if required(i).
(Health gain notation - 2 "likely to be beneficial")
i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 599-600
(Type IV evidence - observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 136)
9h. Vaginal delivery is the treatment of choice in the presence of a dead fetus(i)i.

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 600
(Type IV evidence - observational studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 136)
9i. With every episode of bleeding , a Rhesus negative woman should have a Kleihauer test and be given prophylactic anti-D immunoglobulin(i,ii).

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 605
(Type II evidence - one small trial. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 138);
ii. Whittle, MJ. Antenatal serology testing. PACE review No. 97/02. London: Royal College of Obstetricians and Gynaecologists, 1997
(Type IV evidence - observational studies)
9j. In the management of massive haemorrhage in women who do not wish to receive a blood transfusion expert advice is available (i). i. Department of Health and Others. Confidential Enquiries into Maternal Deaths 1988-1990. London: HMSO, 1994. p. 44
(Type V evidence - expert opinion)
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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk