ANTEPARTUM HAEMORRHAGE

&
POSTPARTUM HAEMORRHAGE
Full Notes | Based on DC Dutta's Textbook of Obstetrics

PART 1 — ANTEPARTUM HAEMORRHAGE (APH)

1. Definition
📖 Definition: APH = Bleeding from the genital tract after 28 weeks of pregnancy (period of
viability) and before delivery of the baby.

• Incidence: 2–5% of all pregnancies

• A leading cause of maternal and perinatal morbidity and mortality
• Always treated as an EMERGENCY until proven otherwise

⚠️Why 28 weeks? Before 28 weeks → called abortion/miscarriage. After 28 weeks → called

APH (period of fetal viability).

2. Causes of APH
Cause Frequency Key Feature
Placenta Praevia 31% Painless bleeding — placenta covers os
Placental Abruption 22% Painful bleeding — placenta separates
(Abruptio Placentae) prematurely
Indeterminate / Marginal 47% No clear cause found — most common!
Local causes (cervical, Rare Cervical erosion, polyp, carcinoma
vaginal)
Vasa Praevia Very rare Fetal vessels over os — fetal blood loss

📌 Exam Tip: Most common cause of APH overall = Indeterminate (47%). Most dangerous =
Placental Abruption. Most common placental cause = Placenta Praevia.

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 PLACENTA PRAEVIA

3. Placenta Praevia
Definition
📖 Definition: Placenta Praevia = Placenta is implanted wholly or partially in the lower uterine
segment (LUS). It lies in front of the presenting part — hence 'Praevia' (Latin: going before).

Grades of Placenta Praevia (DC Dutta — 4 Grades)

Grade Position of Placenta Vaginal Delivery Possible?
Grade I Placenta in LUS but does not reach internal Yes — possible
(Low-lying) os
Grade II Placenta reaches margin of internal os but Possible (just)
(Marginal) does not cover it
Grade III Placenta partially covers internal os No — C-section
(Incomplete
/Partial
central)
Grade IV Placenta completely covers internal os No — C-section
(Complete/
Total
central)

🪝 Memory: Grade I & II → may deliver vaginally. Grade III & IV → always C-section.

Risk Factors
Category Risk Factors
Uterine Previous C-section (scar), Previous uterine surgery, Uterine
anomalies
Placental Large placenta (twins, diabetes), Bipartite/succenturiate
placenta
Maternal Advanced age, Multiparity, Smoking
Previous history Previous placenta praevia

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Clinical Features
🔑 Classic Presentation: PAINLESS, CAUSELESS, RECURRENT bright red vaginal
bleeding — in the 3rd trimester.

Feature Detail
Bleeding Painless, bright red, causeless, recurrent
Onset Typically at 28–32 weeks (first episode)
Amount Variable — can be minor to severe
Uterus Soft, non-tender, not contracted
Presenting part High up, not engaged, malpresentation common
FHS Usually present and normal
Shock Proportionate to blood loss

⚠️NEVER do PV examination in suspected Placenta Praevia — can cause torrential

haemorrhage! FCE8E8

Diagnosis
Investigation Finding
USG (Gold Standard) Placenta visualised over or near internal os
Transvaginal USG (TVS) More accurate than transabdominal — safe to do
MRI Used when USG inconclusive — especially for accreta
Haemoglobin Low if significant blood loss
Blood group & crossmatch Essential — prepare for emergency transfusion

Complications
Maternal:
• PPH — most common complication (LUS contracts poorly)
• Malpresentation → operative delivery
• Placenta accreta/increta/percreta (especially with previous C-section)
• Air embolism
• Maternal death

Fetal:

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 • Preterm birth
• IUGR
• Fetal hypoxia
• Perinatal death

Management
Expectant Management (if remote from term, bleeding stopped, baby not
distressed)
• Admit to hospital — DO NOT send home
• Bed rest
• IV access — blood ready
• Haemoglobin correction — iron, transfusion if needed
• Steroids (Betamethasone) if < 34 weeks — lung maturity
• Serial USG — monitor placental position and fetal growth
• NO PV examination ever

Active Management (deliver if):

• ≥ 37 weeks gestation
• Severe uncontrolled bleeding at any gestation
• Fetal distress
• Labour onset

Mode of Delivery:
Grade Mode
Grade I & II (anterior) Vaginal delivery — if bleeding mild and head engaged
Grade II (posterior), III, IV C-section — always
Any grade with severe bleeding Emergency C-section

PLACENTAL ABRUPTION

4. Placental Abruption (Abruptio Placentae)

Definition
📖 Definition: Premature separation of a normally situated placenta from its uterine
attachment — occurring after 28 weeks and before delivery of the baby.

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Types of Abruption
Type Blood Description Frequency
Revealed Escapes through cervix — Blood tracks down and comes Most common
(External) visible out vaginally — ~80%
Concealed Trapped behind placenta Blood collects between ~20% — most
(Internal) — hidden placenta and uterine wall dangerous
Mixed Both concealed and Combination of both Rare
revealed

⚠️Important: Concealed abruption is MORE dangerous — actual blood loss is

underestimated. Shock is out of proportion to visible bleeding!

Risk Factors
Category Risk Factors
Hypertensive Pre-eclampsia, Chronic hypertension (most common association)
Trauma Road accident, External cephalic version, Domestic violence
Uterine Sudden decompression (after ROM in polyhydramnios, after Twin 1
delivery)
Lifestyle Smoking, cocaine use
Previous history Previous abruption (10x higher risk)
Others Short umbilical cord, Thrombophilia, Folic acid deficiency

Clinical Features
🔑 Classic Presentation: PAINFUL, REVEALED or CONCEALED dark red bleeding with a
HARD, WOODY, TENDER uterus.

Feature Detail
Bleeding Dark red, painful — may be concealed
Pain Sudden onset, severe abdominal pain — constant (not colicky)
Uterus Hard, woody, board-like, extremely tender
FHS May be absent — fetal distress or death
Shock Out of proportion to visible blood loss (concealed type)
Presenting part Difficult to feel — uterus rigid

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 Feature Detail
Coagulation DIC may develop

Grades of Abruption (Page's Classification)

Grade Features
Grade 0 Asymptomatic — retroplacental clot found after delivery
Grade 1 (Mild) Slight vaginal bleeding, uterine tenderness, no fetal/maternal distress
Grade 2 Moderate bleeding, fetal distress present, maternal not compromised
(Moderate)
Grade 3 Severe bleeding (may be concealed), maternal shock, fetal death, DIC
(Severe)

Diagnosis
Investigation Finding
USG Retroplacental clot, placental thickness — but can be
NORMAL in abruption!
CTG (Cardiotocography) Fetal distress — late decelerations, reduced variability
Haemoglobin Low
Coagulation profile (PT, aPTT, Abnormal if DIC develops
fibrinogen)
Serum fibrinogen < 150 mg/dL → DIC
Urine output Reduced — renal involvement

⚠️USG Warning: Normal USG does NOT rule out abruption! Clinical diagnosis is
paramount.

Complications
Maternal:
• DIC — most feared complication (fibrinogen released from retroplacental clot)
• Acute Renal Failure — renal cortical/tubular necrosis
• PPH — uterine atony + DIC
• Sheehan's syndrome — pituitary necrosis from shock
• Maternal death

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Fetal:
• Fetal distress
• IUFD — intrauterine fetal death
• Preterm birth
• IUGR

Management
Mild Abruption (Grade 1) — Expectant if preterm:
• Admit, bed rest, monitor
• Steroids if < 34 weeks
• Correct anaemia
• Serial USG and CTG

Moderate to Severe Abruption (Grade 2 & 3) — Immediate delivery:

• IV access — two large bore cannulas
• Blood transfusion — correct hypovolaemia
• Coagulation factors — FFP, cryoprecipitate if DIC
• Foley catheter — monitor urine output
• Deliver immediately — vaginal or C-section

Mode of Delivery in Abruption:

Situation Mode
Fetus alive, favourable cervix Amniotomy + oxytocin → vaginal delivery
Fetus alive, unfavourable cervix, distress Emergency C-section
Fetus dead (IUFD) Vaginal delivery preferred — avoid C-section if
possible

5. Placenta Praevia vs Abruption — KEY Comparison ⭐

Feature Placenta Praevia Placental Abruption
Bleeding type Painless, bright red Painful, dark red
Cause Placenta covers os Premature separation of
placenta
Placenta position Abnormally low (LUS) Normally situated
Uterus Soft, non-tender Hard, woody, board-like, tender
FHS Usually present May be absent

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Feature Placenta Praevia Placental Abruption
Shock Proportionate to loss Out of proportion (concealed
type)
Presenting part High, not engaged Difficult to palpate
PV examination ABSOLUTELY Cautiously done in hospital
CONTRAINDICATED
DIC risk Low HIGH — most feared
complication
USG Diagnostic — shows placenta May be NORMAL — clinical
over os diagnosis
Management Expectant or C-section by grade Immediate delivery in severe
cases

PART 2 — POSTPARTUM HAEMORRHAGE (PPH)

1. Definition
Type Definition
Primary PPH Blood loss ≥ 500 mL within 24 hours of delivery
Secondary PPH Abnormal bleeding from 24 hours to 12 weeks after delivery
Severe PPH Blood loss ≥ 1000 mL within 24 hours

📌 Incidence: PPH occurs in ~5% of all deliveries. Leading cause of maternal mortality
worldwide.

2. Causes of PPH — The 4 T's ⭐

T Cause Frequency Examples
TONE Uterine atony ~80% — MOST Overdistended uterus, prolonged
COMMON labour, multiparity, twins,
polyhydramnios
TRAUMA Genital tract injury ~10% Cervical/vaginal tears, uterine
rupture, episiotomy extension

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T Cause Frequency Examples
TISSUE Retained products ~5% Retained placenta, placental
fragments, succenturiate lobe
THROMB Coagulation failure ~5% DIC, pre-eclampsia, abruption, IUD,
IN anticoagulants

🪝 Memory: 4 T's = Tone (80%) + Trauma + Tissue + Thrombin. TONE is always first to rule
out!

3. Risk Factors for PPH

Category Risk Factors
Antenatal Previous PPH, Anaemia, Placenta praevia, Abruption, Twins,
Polyhydramnios, Fibroids, Grand multipara
Intrapartum Prolonged labour, Precipitate labour, Operative delivery, General
anaesthesia, Oxytocin use
Placental Retained placenta, Placenta accreta/increta/percreta, Manual removal
of placenta
Others Coagulation disorders, Pre-eclampsia, Infection

4. Clinical Features
Feature Detail
Bleeding Excessive — may be sudden or gradual
Uterus (atony) Soft, boggy, large — not contracted (most common finding)
Uterus (rupture) Tender, rigid
Shock Tachycardia, hypotension, pallor, sweating
Coagulation failure Oozing from IV sites, DIC features

5. Management of PPH — Step by Step

🚨 PPH Management = HAEMOSTASIS + RESUSCITATION simultaneously! FCE8E8

Step 1 — Call for Help + Resuscitation

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 • Call senior obstetrician, anaesthetist, blood bank — IMMEDIATELY
• Two large bore IV cannulas
• Rapid IV fluids — crystalloids first
• Blood transfusion — O negative if type unknown
• Oxygen by mask
• Foley catheter — monitor urine output
• Keep patient warm — prevent hypothermia

Step 2 — Find the Cause (4 T's) and Treat

TONE (Atony) — most common:
Step Intervention
1st Uterine massage — rub up the uterus
2nd Oxytocin 10 IU IV bolus or IM (first line drug)
3rd Ergometrine 0.5mg IV/IM (contraindicated in hypertension)
4th Syntometrine (oxytocin + ergometrine combination)
5th Carboprost (PGF2α) — 0.25mg IM every 15 min (max 8 doses)
6th Misoprostol 800–1000 mcg rectal/sublingual
7th Tranexamic acid 1g IV — within 3 hours of PPH

TRAUMA — Genital tract injuries:

• Inspect cervix, vagina, perineum thoroughly
• Suture all lacerations under good light
• Repair uterine rupture or hysterectomy if severe

TISSUE — Retained placenta/products:

• Manual removal of placenta under anaesthesia
• Curettage for retained products
• Check placenta is complete after every delivery

THROMBIN — Coagulation failure:

• FFP (Fresh Frozen Plasma) — replace clotting factors
• Cryoprecipitate — replace fibrinogen
• Platelet transfusion if < 50,000
• Treat underlying cause (DIC, pre-eclampsia)

Step 3 — Surgical Interventions (if medical fails)

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Procedure Description When Used
Bimanual One hand in vagina, one on abdomen Immediate — while
compression — compress uterus preparing for surgery
Aortic compression Press aorta against spine externally Emergency — buys time
B-Lynch suture Compression suture placed around After C-section, uterus
uterus — squeezes it open
Uterine balloon Bakri balloon inserted → inflated → Minimally invasive —
tamponade tamponades uterus before surgery
Uterine artery ligation Tie off uterine arteries bilaterally Reduces blood supply to
uterus
Internal iliac artery Tie off internal iliac arteries Reduces pelvic blood flow
ligation by 75%
Uterine artery Radiological — catheter blocks uterine Stable patient, wants
embolization arteries future fertility
Hysterectomy Remove uterus — DEFINITIVE last Life-saving when all else
resort fails

🔑 Key Principle: Move from least invasive to most invasive. Hysterectomy = last resort but
do NOT delay when life is at risk!

6. Prevention of PPH — AMTSL ⭐

📖 AMTSL: Active Management of Third Stage of Labour = Gold standard for PPH
prevention.

AMTSL = 3 Steps:
Ste Action Timing
p
1 Oxytocin 10 IU IM/IV — within 1 minute of baby's Immediately after birth
delivery
2 Controlled cord traction (Brandt-Andrews method) After signs of placental
separation
3 Uterine massage after placental delivery Immediately after placenta
out

💡 Remember: Oxytocin is the FIRST line uterotonic for both prevention AND treatment of

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 PPH.

7. Secondary PPH
📖 Definition: Abnormal uterine bleeding occurring between 24 hours and 12 weeks after
delivery.

Causes:
• Retained products of conception (most common)
• Endometritis (uterine infection)
• Subinvolution of placental site
• Breakdown of C-section scar
• Choriocarcinoma (rare but important)

Management:
• USG — detect retained products
• Antibiotics — if infection present
• Evacuation of uterus (ERPC) — if retained products confirmed
• Oxytocin/Ergometrine — promote uterine contraction

8. Uterotonics — Drug Summary ⭐

Drug Dose/Route Mechanism Contraindication
Oxytocin 10 IU IV/IM Oxytocin receptor agonist None significant
Ergometrine 0.5mg IV/IM Alpha-adrenergic — Hypertension, pre-
sustained contraction eclampsia
Syntometrine 1 ampoule IM Oxytocin + Ergometrine Hypertension
combined
Carboprost 0.25mg IM q15min Prostaglandin — powerful Asthma
(PGF2α) (max 8) uterotonic
Misoprostol (PGE1) 800–1000mcg Prostaglandin — Few
rectal uterotonic
Tranexamic acid 1g IV Antifibrinolytic — prevents Thromboembolic
clot breakdown disease

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9. Master Quick Revision Card — APH & PPH
Topic Key Point
APH Definition Bleeding after 28 weeks before delivery
Most common cause APH Indeterminate (47%)
Placenta Praevia bleeding PAINLESS, bright red, causeless, recurrent
Praevia grades I (low) → II (marginal) → III (partial) → IV (complete)
C-section in Praevia Grade III and IV always. Grade II posterior usually
PV exam in Praevia ABSOLUTELY CONTRAINDICATED
Abruption bleeding PAINFUL, dark red — may be concealed
Abruption uterus Hard, woody, board-like, tender
Concealed abruption Shock out of proportion to visible blood loss
Abruption complication DIC — most feared
PPH definition ≥500mL within 24 hours of delivery
Primary PPH Within 24 hours
Secondary PPH 24 hours to 12 weeks
Most common cause PPH Uterine ATONY (Tone — 80%)
4 T's of PPH Tone + Trauma + Tissue + Thrombin
First line uterotonic Oxytocin 10 IU
Carboprost contraindication Asthma
Ergometrine contraindication Hypertension/Pre-eclampsia
Tranexamic acid 1g IV — within 3 hours of PPH
AMTSL Oxytocin + Controlled cord traction + Uterine massage
Last resort for PPH Hysterectomy
B-Lynch suture Compression suture — uterus sparing surgery
Secondary PPH cause Retained products (most common)

📖 Reference: DC Dutta's Textbook of Obstetrics (Latest Edition). These notes cover APH
and PPH chapters for exam and viva preparation.

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