Antepartum

Haemorrhage (APH)

Dr Nitin Tiwari
DNB Resident
• Definition
• Importance
• Causes
• Management of APH
• Prognosis
Bleeding in Antepartum
early
Pregnancy haemorrhage
Bleeding
(APH)
In
Pregnancy

Post partum
Haemorrhage
(PPH)
 Antepartum Haemorrhage
• Antepartum haemorrhage (APH,prepartum
hemorrhage) is bleeding from the vagina during
pregnancy from 28 weeks of gestational age to term.

• Epidemiology
Affects 3-5% of all pregnancies
3 times more common in multiparous
than primiparous women
 Importance
• Obstetric emergency
• Attention should be sought immediately
• If left untreated can lead to death of
the mother and/or foetus
• Can leads to DVT
• Management reduce the risk of
premature delivery and
maternal/perinatal morbidity/mortality
 Causes
• Blood stained show (benign) - Most common cause
of APH

• Placental abruption - Most common pathological

cause (1/100)

• Placenta praevia - Second most

common pathological cause (1/200)

• Vasa praevia- Often difficult to diagnose,

frequently leads to foetal demise (1/2000-3000)

• Uterine rupture - (<1% in scarred uterus)

 Causes ctd…
• Bleeding from the lower genital tract
Cervical bleeding – Cervicitis , cervical
neoplasm, cervical polyp,
Cervical ectropion
Vagina bleeding - Trauma, neoplasm,
Vulval varices , infection

• Inherited bleeding problems - Very rare,

1 in 10,000
women
• Unexplained - No definite cause is diagnosed
in
Bleeding that may be confused
with vaginal bleeding
• GI bleed - Hemorrhoids, inflammatory bowel
disease

• Urinary tract bleed - UTI

 Placenta praevia

• Definition
Insertion of the placenta, partially or fully,
in the lower segment of the uterus
 Etiology
• No definitive cause
• Endometrial factors:
– A scarred endometrium
– Curettage for several times
– Abnormal uterus
• Placental factors
– Large plcenta
– Abnormal formation of the placenta
• Development retardation of fertilized egg
 Risk factors for Placenta previa

• Multiparity
• Advanced maternal age
• Prior LSCS or other uterine surgery
• Prior placenta previa
• Uterine structural anomaly
• Assisted conception
Degrees of Placenta previa
 Classification of degrees of
Placenta previa
• Four grades:
– Grade I: Placenta encroaches lower segment
but does not reach the cervical os
– Grade II: Reaches cervical os but does not
cover it
– Grade III: Covers part of the cervical os
– Grade IV: Completely covers the os, even
when the cervix is dilated
 Placenta praevia-
Clinical Features
• Recurrent painless vaginal bleeding (not always)
• Abdominal findings
Uterus is soft, relaxed and non tender
Contraction may be palpated
Presenting part is usually high
Abnormal presentations
• Maternal cardiovascular
• compromise
Foetal condition satisfactory until severe maternal
• compromise
Vaginal examination- should not be done
 Investigation
• Diagnosis by ultrasound scan showing that
the placenta coming in to the lower
segment
• Transvaginal ultrasound is safe and is more
accurate than transabdominal ultrasound in
locating the placenta
• Leading edge within the 2 cm from internal
os or completely covering the internal os
is incompatible with normal vaginal
delivery
 Placenta praevia-Complications
Maternal
• Major hemorrhage, shock, and death
• Renal tubular necrosis and acute renal failure
• Post partum haemorrhage
• Morbid adherence of Placenta : placenta accreta
complicates approximately 10% of placenta praevia
cases
• Anaemia in chronic haemorrhage
• Sensitization of mother for foetal blood in Rh (-)
patients
• Disseminated intravascular coagulopathy (DIC)
 Placenta previa-
Complications cont….
Foetal
• IUD
• Hypoxic ischemic encephalopathy
• Cerebral palsy
• Placental abruption
• Premature labour
 Placental abruption
• Definition
Premature separation of a normally
situated placenta in a viable
foetus

• Placental abruption should be considered

in any pregnant woman with abdominal
pain with or without PV bleeding, as mild
cases may not be clinically obvious
 Placental abruption
Concealed Retro placental blood clot
haemorrhage
 Etiology
Risk factors
[Link] age and parity
[Link] diseases: preeclampsia, maternal
hypertension, renal disease,SLE and APS
[Link] factors: Trauma, intercourse
Sudden decopression
of uterus
Polyhydroamnios
Multiple pregnancy
4. Smoking, cocaine use,
5. Uterine myoma
6. Premature rupture of membranes
7. Supine hypotensive syndrome
 Pathology
• Main changes
Hemorrhage into the decidua basalis →
decidua splits → decidural hematoma →
separation, compression, destruction of the
placenta adjacent to it

• Types of abruption
1. Revealed abruption
2. Concealed abruption
3. Mixed type
Revealed abruption Concealed abruption
 Diagnosis-Clinical Features
• Painful vaginal bleeding
• Pain is usually continuous

1. Mild type
• Abruption≤ 1/3
• Vaginal bleeding may be present or
absent
Diagnosis-Clinical Features ctd
[Link] type
• Abruption > 1/3
• Large retroplacental haematoma
• Vaginal bleeding associate with
persistent abdominal pain
• Tenderness on the uterus
• “Woody” hard uterus
• Change of foetal heart rate –CTG changers
• Features of hypovolemic shock
 Complication of Placental
abruption
Maternal
• Disseminated intravascular coagulopathy
• Hypovolemic shock
• Amnionic fluid embolism
• Renal tubular necrosis and acute renal failure
• Post partum haemorrhage
• Sensitization of Rh(-) mother for foetal blood
• Sheehan’s syndrome
• Maternal death
 Complication of Placental
abruption
Feotal
• Premature labour
• IUGR in chronic abruption
• Hypoxic ischemic encepalopathy and
cerebral paulsy
• Foetal death
 Investigations
• Ultrasonography
Mainly to exclude placenta praevia
Can detect
Retroplacental hematoma
Feotal viability
Most of the time findings will be negative
Negative findings do not exclude placental abruption
• CTG – Sinosoidal pattern,Feotal tachycardia or
bradycardia
• Laboratory investigations
1. Investigation for Consumptive coagulopathy – Platelet
count/BT/CT/PT/INR & APTT
2. Liver and Renal function tests
 Vasa praevia
• Foetal blood vessels from the placenta or
umbilical cord cross the internal os beneath
the baby
• Rupture of membranes leads to damage of
the foetal vesseles leading to
exsanguination and death
• High foetal mortality (50-75%)
Vasa praevia
 Risk factors
• Eccentric (velamentous) cord insertion
• Bilobed or succenturiate lobe of placenta
• Multiple gestation
• Placenta praevia
• In vitro fertilization (IVF) pregnancies
• History of uterine surgery or D & C
 Eccentric (velamentous) cord insertion

Succenturiate lobe Bilobate placenta

 Diagnosis - Vasa praevia
[Link] vaginal bleeding + feotal distress
[Link] may be palpable through dilated
cervix
[Link] may be visible on ultrasound
(Transvaginal colour Doppler ultrasound)
• Difficult to distinguish from abruption
• Can look for feotal Hb (Kleihauer-Betke test)
or nucleated RBC’s in shed blood
• Tachycardia or bradycardia in CTG
 Comparison of Presentation of
Abruption v. Previa
Abruption Praevia

Abd. pain present absent

Vag. blood old or fresh fresh
DIC common rare
Acute foetal common rare
distress
Management of APH
 Management of APH
• Admit to hospital for assessment and management
• May need resuscitation measures if shocked or severe
bleeding
Airway, breathing and circulation
Senior staff must be involved –Consultant
obstetrician and consultant
anaesthetist, neonatalogist
Two wide bore canula
Take blood for Grouping & DT,FBC , coagulation
profile,Liver & renal function
 Management of APH

• Volume should be replaced by

Crystalloid
/ colloid until blood is available

• Severe bleeding or feotal distress:

Urgent delivery of baby irrespective of
gestational age
 Management of APH cont…
History
• Obtain a history if patient’s condition including:
• Colour and consistency of bleeding
• Quantity and rate of blood loss
• Precipitating factors i.e. Sexual
intercourse,
• Vaginal examination
• Degree of pain, site and type
Placental location-review ultrasound report
• if available
• Ascertain foetal movements
blood group
 Management of APH cont…
Examination
• Assess maternal and foetal well-being
Pallor, record temperature, pulse and BP
• Perform abdominal examination
Note areas of tenderness and hypertonicity
Determine gestational age of foetus, presentation
and position, auscultate foetal heart
• No vaginal examination should be attempted at least until
a placenta praevia is excluded
• Do speculum examination to assess cervix / bleeding and
exclude local lesions
 Management of APH cont…
Investigations
• Arrange urgent ultrasound scan
• Foetal monitoring
Continuos electronic foetal
monitoring is indicated
 Management of APH cont…

• Rhesus negative woman should have a klihaver

test and be given prophylactic anti-D
immunoglobulin (Rhogum)

• For pre-term delivery when immediate delivery is

not necessary, maternal steroids - to promote
feotal lung maturity
Betamethasone

Dexamethasone
 Further management of APH

• Further management will depend on

Cause of the APH
Extent of bleeding
Presence of feotal distress
Gestational age and feotal
maturity
 Placenta praevia - Management
[Link] term / Term
• Delivery is considered
Grades I and II -
May be able to
deliver
vaginally
Grades III and IV -
Will require
• Should anticipate
caesarean PPH
secti
on by
senio
 Placenta praevia –
Management
[Link] in pregnancy
• Continuation of
cont…
pregnancy better if
possible
• Need bed rest
• Educate patient regarding condition and risk
• 3 pint of crossed matched blood should be
available till delivery
• Foetal well being and growth should be
monitored –KCC,CTG,USS
• Medications may be given to prevent
premature
labour- Nifidipine, Atosiban
 Placental abruption –
Management ctd

• Small abruption
Conservative management depending
on gestational age
Careful monitoring of feotal
condition
 Placental abruption -
management
• Moderate or severe placental abruption:
• Restore blood loss
• Ideally measure central venous pressure (CVP) and
adjust transfusion accordingly
• Prevent coagulopathy
• Monitor urinary output
• Delivery
[Link] section
[Link]
If coagulopathy
present
If feotus is not compromised
If feotus is dead
 Vasa Previa management

• Urgent delivery
Most of the time urgent LSCS
• Neonatologist involvement
• Aggressive resuscitation of the baby with
blood transfusion following delivery
 Prognosis of APH
• Feotus may die from hypoxia during
heavy bleeding

• Perinatal mortality more than 50 per

1000 even with tertiary care facilities

• High rates of maternal mortality

 Thank
Egypt