Antepartum Haemorrhage
(APH)
1
Definition
• It is defined as bleeding from or into the genital
tract after the 28th wks of pregnancy but before the
birth of the baby.
Placenta
previa
Placental Abruptio
Causes placenta
Vasa previa
Cervical Polyp
Causes
Non Placental Cervical
Causes erosion
Ca Cervix
Uterine
Idiopathic
Rupture
Trauma
Placenta Praevia
Placenta that has implanted in part or all of the lower
uterine segment encroaching upon or covering the
internal cervical os.
The following theories are stipulated as the etiology
of placenta previa
• Dropping down theory – When the morula reaches the uterine cavity,
it hangs free for 3-4 days before implantation, during this period if it is
dropped down in the lower part of the uterus, it is implanted in it.
• Defective decidua – the defective decidua in the upper part of the
uterus causes the implantation of the placenta in the lower part of the
uterus.
• Big surface area of the placenta – in case of placenta membranecae
the placenta is big and thin which causes the encroachment of placenta
into the lower uterine segment.
Multiparity
Increased
Smoking
maternal age
Predisposing factors
History of
previous surgery
of upper uterine
Multiple
segment such as
pregnancy
CS,
Myomectomy,
hysterotomy
Placental
abnormalities
Types or Grading
• Grade 1 ( I degree) or low
lying:
Part of placenta lies in
the lower segment but
does not reach os.
• Grade 2 ( II degree)
marginal:
The lower margin of
the placenta reaches
the internal os but
does not cover it.
• Grade 3 ( III degree)
incomplete partial
The placenta covers
the os when it is not
dilated.
• Grade 4 ( IV degree)
central complete:
The placenta lies
centrally over the os.
Types of Placenta praevia
Marginal Central complete
The lower margin of The placenta lies
the placenta reaches Incomplete partial centrally over the os
Low lying the internal os but
Part of placenta lies The placenta covers
does not cover it. the internal os when
in the lower segment
but does not reach os it is not dilated.
Type I
Mild
Type II
Anterior
Clinical
Types Type II
Posterior
Severe Type III
Type IV
Clinical Features
• Bleeding without abdominal pain or uterine tenderness,
usually bright red & causeless
• May be associated with contractions
• Bleeding usually recurs often increasing in severity with
increasing gestational age
• Not usually precipitated by any one factor such as coitus
etc.
• Often occurs during sleep
➢ Abdominal examination – uterus size proportionate, feels
relaxed, soft, elastic without tenderness.
➢ Mal presentation
➢ Head is floating
➢ Stall worthy's sign – when the head of the fetus is pushed
downward causes bradycardia and when it is lifted up the
heart rate becomes normal.
➢ Vulval inspection – blood color is in bright red
Confirmation of diagnosis
▪ Sonagraphy
Transabdominal
Transvaginal
Transperineal
▪ Color doppler flow study – prominent venous flow in
the hypo echoic areas near the cervix
▪ MRI
▪ Double set up examination
Maternal Complications
❖During pregnancy
Shock
Mal presentation
Premature labour
❖During labour
Early rupture of membranes
Cord prolapse
Slow dilatation
IPH
Increased incidence of operative interference
PPH
❖During puerperium
Sepsis
Sub involution
Embolism
Low Birth
Weight
Congenital
Asphyxia
Malformations
Fetal Complications
Birth Injuries IUD
Management
• Bed rest
• Assessment of the blood loss
• Gentle & quick abdominal examination
• Vaginal examination
• Transfer to the hospital
Immediate management
• Check the amount of blood loss
• Blood sample
• Infusion of NS
• Gentle abdominal examination
• Inspection of the vulva
• Formulation of line of treatment
Expectant management
• Blood transfusion
• Termination of pregnancy if > 37 wks
• Steroid therapy < 34 wks
Active interference
➢If bleeding occurs at or after 37 wks of pregnancy
➢If bleeding continues
➢Patient is in labour
➢Non-reassuring FHR pattern
➢Maternal compromise ( if she is in exsanguinated
state)
Definitive treatment
• Vaginal examination if vaginal delivery is possible
• Low rupture of membranes for vaginal delivery
• If vaginal delivery is not possible elective classical
caesarean
• Lower segment may need to be packed
Vasa Praevia
• Rare event
• Umbilical cord vessels are covered only by chorion
and amnion (membranes)
• Vessels are exposed and can rupture under pressure
or ARM
• Baby at risk of severe bleeding and death
• Cord pulsates on vaginal examination
• May be diagnosed on colour Doppler U/S
Risk factors – vasa praevia
• Low lying placenta
• Succenturiate lobe or velementous cord insertion
• IVF or multiple pregnancy
Vasa Praevia
Exposed vessels
Placenta abruption
Premature separation of the placenta after the 28th
weeks of pregnancy and before birth of the baby
Hypertensive
External Disorders
Cephalic
Version, Idiopathic
Induction of
Labour
Smoking,
Cocaine use,
Poor Nutrition, Previous H/o
Causes
Advanced APH
maternal age,
Multiparity
Polyhydramnios Trauma
Multiple
pregnancy
Types
Revealed Concealed Mixed
Clinical Features
• Vaginal bleeding of varying amount
• Uterine tenderness
• Abnormal FHR pattern
• Uterine hyper tonicity
• Clinical features depend upon degree of abruption
and blood loss.
Prevention of abruption
• Treat maternal hypertension
• Advice mother to stop smoking and substance abuse
• Advice the mother to wear seat belt while driving
Haemorrhagic
shock
Uterine
Renal failure
rupture
Maternal
Complications
Maternal
DIC
Death
Fetal
Hypoxia
Fetal
Fetal Death IUGR
Complications
CNS
Damage
Management
• Monitor mother vital signs, blood loss, urine output.
• Insert two large bore cannulas – 14 or 16g
• Fluid replacement
• Cross match 4 units of packed cells
• Resuscitation and/or delivery
• In the presence of significant blood loss – oxygen
• Electronic FHR monitoring
• Anti D if Rh –ve