Antepartum Haemorrhage
(APH)
by
Dr. Samar Hassan Mohammed
Ali
APH Def inition
• Vaginal bleeding from 24 weeks
until delivery.
APH
• Incidence: 2-5%.
• It should be taken seriously even if the
amount of bleeding is small.
APH: Causes
• Placental:
Placenta praevia.
Abruptio placentae.
Vasa Praevia.
• Local causes.
• Idiopathic.
Placenta Praevia
• Defined as a placenta that has
implanted into the lower segment
of the uterus.
Placenta praevia
Placenta Praevia : Types
• Major degree placenta praevia:
The placenta covering the cervix.
• Minor degree placenta praevia:
The placenta is sited within the lower
segment but does not cover the cervix.
Placenta Praevia : Types
Placenta Praevia: Risk factors
• High parity.
• Uterine surgery.
• Multiple pregnancy.
• Uterine anomaly.
• Uterine fibroid.
• Assisted conception.
• Previous history of placenta praevia.
Placenta Praevia :History
• The patient presents with painless,
causeless, recurrent vaginal bleeding (small
or large amount).
Placenta Praevia: Examination
• The vital signs and the pallor depends on the
amount of bleeding.
• The uterus is soft, not tender, can easily
palpate the fetal parts and the presenting
part is frequently not engaged.
• The condition may be associated with
abnormal lie or malpresentation.
Placenta Praevia
• Digital examination is contraindicated
as this may precipitate vaginal
bleeding.
• Ultrasound should be done to confirm
the abnormal localization of the
placenta.
Placenta praevia
Morbidly adherent placenta
The placenta is abnormally invades an old
scar and implants beyond the endometrium --->
morbidly adherent placenta.
Placenta accreta: adherent to the
myometrium.
Placenta increta: invades into the
myometrium.
Placenta Percreta: invades through the
myometrium and reaching the serosa and
even the bladder in some cases.
Placenta Praevia :
Management
• Major degree placenta praevia:
It depends on the amount of bleeding.
In heavy bleeding and compromised patients:
Call for help.
Airway, breathing , oxygen.
Two wide bore cannulae, iv fluids.
Blood for grouping , cross-matching of 4-6
units of blood.
Placenta Praevia :
Management
Blood transfusion.
Catheterization + monitoring of vitals of
mother and fetus.
Blood for investigations, CBC,RFT,
coagulation profile.
Bed side US to confirm the diagnosis.
Delivery by C/S by senior obstetrician.
Placenta Praevia :
Management
Minor degree placenta praevia :
• If the placenta is a minimum of 2 cm away
from the cervix with no other indication for
C/S vaginal delivery is considered.
Placenta Praevia :
Management
In cases of small amount of bleeding and the
patient is stable:
Conservative management in form of
admission with preparation of blood +
dexamethasone.
Delivery is postponed until 37 weeks if the
patient does not develop severe bleeding.
Indications of delivery in placenta
praevia:
Reaching 37 weeks gestation.
Severe bleeding at any gestational age.
Continuing significant vaginal
bleeding.
Abruptio placentae: Def inition
• Defined as premature separation of a
normally situated placenta from the uterine
wall.
Abruptio placentae
Abruptio placentae: Types
• Revealed : there is apparent vaginal bleeding
due to separation of the edge of the placenta.
• Concealed: the separation of the placenta is
centrally with no obvious vaginal bleeding.
Abruptio placentae: Types
Abruptio placentae
• Incidence : 0.4 – 2 %.
• The fetus is at risk of distress or death
because of hypoxia.
Abruptio placentae: Risk
factors
• Hypertension.
• High parity.
• Polyhydramnios.
• Sudden decompression of uterine over-distension.
• Smoking.
• Trauma.
• Cocaine use.
• Anticoagulant therapy.
• Folate deficiency.
Abruptio placentae
Abruptio placentae: Diagnosis
• Present with abdominal pain and vaginal
bleeding.
• Some cases have small bleeding or no
bleeding (concealed).
• Some cases may present with shock in large
abruptions (vital signs do not correlate with
the amount of bleeding in concealed
haemorrhage).
Abruptio placentae: Diagnosis
• The abdomen is woody hard, fetal parts are
difficult to be palpated.
• The fetus may be distressed or dead.
• US is helpful to exclude the placenta praevia.
Abruptio placentae: Management
If the patient is compromised :
Call for help.
Airway, breathing , oxygen.
Two wide bore cannulae, iv fluids.
Blood for grouping , cross-matching of 4-6
units of blood.
Blood & blood products transfusion.
Abruptio placentae: Management
Catheterization + monitoring of vitals of
mother and fetus.
Blood for investigations, CBC,RFT,
coagulation profile.
Bed side US to exclude placenta praevia.
Analgesia in form of pethidine is given.
Delivery ??
Abruptio placentae: Management
• C/S is indicated if there is :
1. Severe bleeding.
2. If the fetus is alive.
3. If there is other cause for C/S.
Abruptio placentae: Management
• If the fetus is dead and the blood loss can be
replaced ( no massive bleeding) ----> vaginal
delivery is expected.
• So ARM with or without oxytocin should be
done to expedite the delivery.
Abruptio placentae: Complications
Shock.
Organ failure.
PPH.
Coagulation disorder (DIC).
Couvelaire uterus.
Vasa praevia
Vasa praevia
• Rupture of fetal vessels running within the
membranes near the cervical os.
• Its damage occurs with rupture of
membranes.
• Very rare but catastrophic to the fetus ----->
fetal death.
Vasa praevia: Risk factors
• Placenta praevia.
• Velamentous insertion of the cord.
• Multiple pregnancy.
Vasa praevia
• If suspected C/S should be done
before rupture of membranes.
APH: Local Causes
• Cervical ectropian.
• Cervical polyp.
• Cervical carcinoma.
• Cervicitis.
• Vaginal infection.
• Vaginal trauma.
• Excessive show
APH: Local Causes
• Insignificant blood loss.
• Diagnosed by speculum examination if
clinical examination and US excludes
placental causes.
• Treatment depends on the cause.
Message To Take Home
• Call for help + resuscitation if there is
significant APH.
• Digital examination should be done
only after exclusion of placenta praevia
by US.
• Abruptio placentae is diagnosed
clinically.
• Anticipate PPH in cases of APH.
THANK YOU FOR
ATTENTION