ANTEPARTUM HAEMORRHAGE

TOPICS TO BE COVERED
Definition

Etiology

Types of ante partum hemorrhage

Placenta previa

Abruptio placenta

Vasa previa

Management
Definition
Antepartum haemorrhage (APH) is defined as bleeding
from or in to the genital tract, occurring from 22 weeks
(>500g) of pregnancy and prior to the birth of the baby.

complicates 3–5% of pregnancies

leading cause of perinatal and maternal mortality
worldwide.
Up to one-fifth of very preterm babies are born in
association with APH
Most of the time unpredictable.

RCOG
Severity
NO consistent definitions of the severity of APH.
It is recognised that the amount of blood lost is often
underestimated .

The amount of blood coming from the introitus may not

represent the total blood lost (for example in a
concealed placental abruption).

It is important to assess for signs of clinical shock. The

presence of fetal compromise or fetal demise is an
important indicator of volume depletion.
RCOG Guidelines
Different terminologies used:
Spotting – staining, streaking or blood spotting noted on
underwear or sanitary protection

Minor haemorrhage – blood loss less than 50 ml that has

settled

Major haemorrhage – blood loss of 50–1000 ml, with no

signs of clinical shock

Massive haemorrhage – blood loss greater than 1000 ml

and/or signs of clinical shock.

Recurrent APH - > one episode

RCOG Guidelines
Etiology
Placenta praevia
Abruptio placenta
Vasa praevia
Excessive show
Local causes ( bleeding from cervix, vagina and
vulva )
Placenta Praevia (PP)
Implantation of placenta over or near the internal
os of cervix.
Confirm diagnosis of PP can be done at 28 weeks
when LUS forming.

Leading cause of vaginal bleeding in the 2nd and 3rd

trimester.
Classification
Risk Factors of Placenta Praevia
Previous placenta praevia (4-8%) with numbers of c-section)
Previous caesarean sections ( risk
Previous termination of pregnancy
Multiparity
Advanced maternal age (>40 years)
Multiple pregnancy
Smoking
Deficient endometrium due to presence or history of:
- uterine scar
-endometritis
-manual removal of placenta
- curettage
-submucous fibroid RCOG
Assisted conception
Clinical classification
Minor : Deliver vaginally
Type 1 Posterior >
Type 1 (anterior/posterior) likelihood of fetal distress
Type 2 anterior

Major: Caesarean
Type 2 posterior (dangerous type) section Type 2
Type 3 posterior >
chance of fetal
Type 4 distress
Type 3 & 4 anterior
–cut through
placenta to deliver.
Hence need to be
fast and efficient.
Abruptio Placenta (AP)
Separation of normally located placenta after 22
weeks of gestation ( > 500g) and prior to delivery
of fetus.
Risk factors:
- Previous history of AP
- Maternal hypertension
- Advanced maternal age
- Trauma ( domestic violence, accident, fall)
- Smoking/alcohol/cocaine
- Short umbilical cord
- Sudden decompression of uterus (
PROM/delivery of 1st twins)
- Retroplacental fibroids
- Idiopathic
Obstetrics Emergency!!
Diagnosed CLINICALLY :
Painful vaginal bleeding -80%
Tense and tender abdomen/back pain (70%)
Fetal distress( 60%)
Abnormal uterine contractions (hypertonic and high
frequency)
Preterm labour ( 25%)
Fetal death ( 15%)

Ultrasound is NOT USEFUL to diagnose AP.

Retroplacental clots (hyperechoic) easily missed.
Obstetrics today
Vasa Praevia (VP)

Rupture of fetal vessels that run in membrane

below fetal presenting part which is unsupported
by placenta/ umbilical cord.

Predisposing Factors:
-Velamentous insertion of the umbilical cord
-Accesory placental lobes
-Multiple gestations Obstetrics today
The term
velamentous
insertion is used to
describe the
condition in which
the umbilical cord
inserts on the
chorioamniotic
membranes rather
than on the placental
mass.
Diagnosis of VP
Antenatal diagnosis –reduced perinatal mortality and
morbidity.
Painless vaginal bleeding at the time of spontaneous
rupture of membrane or post amniotomy
Fetal bradycardia
Fetal shock or death can occur rapidly at the time of
diagnosis due to blood loss constitutes a major bulk of
blood volume is fetus ( 3kg fetus-300ml)
Hence, ALWAYS check the fetal heart after rupture of
membrane or amniotomy.
Definitive diagnosis by inspecting the placenta and
fetal membrane after delivery.
Obstetrics today
Complications of APH
Maternal complications Fetal complications
Anaemia Fetal hypoxia
Infection Small for gestational age and fetal
growth restriction
Maternal shock Prematurity (iatrogenic and
spontaneous)
Renal tubular necrosis Fetal death
Consumptive coagulopathy
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Complications of blood transfusion

RCOG
Guidelines
Clinical assessment in APH
First and foremost Mother and fetal well
being (mother is the priority)

establish whether urgent intervention is required

to manage maternal or fetal compromise.

Assess the extent of vaginal bleeding,

cardiovascular condition of the mother

Assess fetal wellbeing.

Full History
Should be taken after the mother is stable.
associated pain with the haemorrhage?
Continuous pain : Placental abruption.
Intermittent pain : Labour.
Risk factors for abruption and placenta praevia
should be identified.
reduced fetal movements?
If the APH is associated with spontaneous or
iatrogenic rupture of the fetal membranes : ruptured
vasa praevia
Previous cervical smear history possibility of Ca
cervix. Symptomatic pregnant women usually present
with APH (mostly postcoital) or vaginal discharge.
Examination
General: PULSE & BP ( a MUST!)
Abdomen:
- The tense, tender or ‘woody’ feel to the uterus
indicates a significant abruption.
- Painless bleeding, high fetal presenting part –
Placenta praevia
- soft, non-tender uterus may suggest a lower
genital tract cause or bleeding from placenta or
vasa praevia.
Examination
Speculum :
-identify cervical dilatation or visualise a lower
genital tract cause.

Digital vaginal examination

- Should NOT be done until Placenta Praevia has
been excluded by USG.

RCOG Guidelines
Investigations
FBC
Coagulation profile
Blood Grouping
Ultrasound
D-dimer : AP
colour doppler TVS

Fetal monitoring:
CTG monitoring
RCOG Guidelines
Management
WHEN to admit?
Based on individual assessment
-Discharge after reassurance and counselling
Women presenting with spotting who are no longer
bleeding and where placenta praevia has been
Excluded.
However, a woman with spotting + previous IUD due to
placenta abruption, an admission would be
appropriate.

- All women with APH heavier than spotting and women

with ongoing bleeding should remain in hospital at
least until the bleeding has stopped.
Management
If preterm delivery is anticipated, a single course of
antenatal corticosteroids ( dexamethasone 12mg 12 hourly
,2 doses) to women between 24 and 34 weeks 6 days of
gestation.
Tocolytics should NOT be given unless for VERY preterm
women who need time to transfer to hospital with NICU.

For very preterm ( 24-26 weeks) ,

-conservative management if mother is stable .
-Delivery of fetus – life threatening
At these gestations, experienced neonatologists should be
involved in the counselling of the woman and her partner
RCOG
Management
For Placenta Praevia
Conservative – MaCafee’s regime
( premature < 37 weeks;mother haemodynamically
stable,no active bleeding, fetus stable)
-advise bed rest, keep pad chart, vital signs
monitoring , Ultrasound, steroids, GSH, Daily
CTG and biophysical profile, fetal movement
count.

Plan for delivery ( >37 weeks)

Crossmatch 4 units of blood.
 Definitive treatment

Type Type II( post),

I,II(ant) III,IV

ARM +/-
oxytocin Caesarean section

Satisfactory
progress without Bleeding continues
bleeding

Caesarean section
Vaginal delivery
For Abruptio placenta,(obs emergency)

ICU admission : Close monitoring and

resuscitation!
- ABC ( high flow O2, aggressive fluid
resuscitation)
- Continuous Vital signs monitoring and urine
output
- Monitor vaginal bleeding – strict pad chart
- Continuous CTG for fetal heart rate
- Crossmatch 4 units of blood
- FFP – Fresh frozen plasma ,coagulopathy
- Dexamethasone – preterm
Abruptio Placenta
Decide Mode of delivery
Vaginal delivery – when fetal death
Caesarean section –if maternal/ fetal health
compromised
- Consent should be taken for hysterectomy in
case bleeding could not be controlled.

Obstetrics today
 QUIZ

1. Common causes of antepartum haemorrhage (APH, bleeding

from the genital tract from 24 weeks' gestation) include which of
the following?
A Vasa praevia
B Undetermined origin
C Placenta praevia
D Uterine rupture
E Placental abruption
F None of the above
2. Regarding placenta praevia, which of the following are true?
A Placenta praevia complicates about 0.4% of pregnancies at term.
B Placenta praevia cannot be diagnosed with ultrasound.
C The majority of ‘low-lying’ placentas diagnosed at 20 weeks will
remain so at term.
D The patient should be routinely managed under inpatient care with
delay of delivery until the patient labours, at which time caesarean
section will be performed.
E Complications of placenta praevia include need for caesarean
section, haemorrhage, placenta accreta, placenta percreta and
hysterectomy.
F Placenta praevia is typically more painful than an abruption.
3. Placental abruption: which of the following are true?
A Many antepartum haemorrhages of ‘undetermined origin’ are
probably small placental abruptions.
B Most of the blood loss is fetal.
C Visible haemorrhage is absent in 20%.
D Risk factors for abruption include pre-eclampsia, autoimmune
disease, maternal smoking, cocaine use and a previous history.
E Abruption is best diagnosed by ultrasound.
F Abruption is usually painless.
 BIBLIOGRAPHY
[Link] Sharma” midwifery and gynaecological nursing” 1st
edition,2015, published by Avichal publishing house, page
n0-265-286

2. Dc Dutta “ textbook of obstetrics” 8th edition ,2006,

published by Jaypee brothers, page no -253-.278.