ANTEPARTUM
HAEMORRHAGE
BY:
MS. R. LIANGKIUWILIU
ASSISTANT PROFESSOR, OBG
SSNSR, SU
INTRODUCTION
Antepartum Haemorrhage refers to vaginal bleeding occurring
from the 24th weeks of gestation and prior to the birth of the
baby.
It is commonly seen during the third trimester and is
associated with significantly fetal as well as maternal
morbidity and mortality.
It should be considered a medical emergency(regardless of
whether there is pain) and medical attention should be sought
immediately.
CAUSES OF APH
Placental Bleeding
Placenta Previa
Abruption
Extra Placental Causes
Local cervico-vaginal lesions
Cervical polyp
Carcinoma of cervix
Local trauma / accident
CLASSIFICATION
APH
Placenta Abruption
Previa Placenta
Vasa
Previa
ABRUPTIO PLACENTA
Definition: The term, abruptio placenta refers to a condition
when hemorrhage occurs as a result of premature separation
of a normally situated placenta.
It attaches to the wall of the uterus and supplies the baby with
nutrients and oxygen.
1:150 deliveries, maternal mortality about 2-5%.
ETIOLOGY OF AP
Hypertension in Pregnancy
Trauma
Maternal smoking
Short Cord
Supine hypotensive syndrome
Placental anomaly
Prior abruption
Uterine fibroid
Torsion of the uterus
PATHOGENESIS
Due to etiological factors
Haemorrhage into decidua basalis
Decidua splits
Development of decidual hematoma
Separation, compression, ultimate destruction of placenta
Abruption Placenta
CLINICAL FEATURES
FEATURES REVEALED MIXED / CONCEALED
Symptoms Abdominal pain followed by Acute intense pain in
vaginal bleeding abdomen followed by slight
vaginal bleeding
Character of bleeding Continuous, dark colour slight to Continuous, dark
moderate
General condition Shock usually absent Shock pronounced out of
Proportionate to loss proportion to the blood loss
Pallor R/t visible blood loss Severe
Features of pre- May be present Frequent association
eclampsia
SYMPTOMS REVEALED MIXED / CONCELAED
Uterine feel Normal, tenderness, Tense, tender, rigid
contractions frequent
Uterine height proportionate Disproportionately enlarged
Fetal parts Can be identified easily Difficult to make out
FHS Usually present Usually absent
Urine output Normal Oliguria
GRADES OF ABRUPTIO PLACENTA
INVESTIGATIONS OF AP
History Collection – Personal, Family,
Obstetrical history
Physical examination
Ultrasonography
CT Scan
MRI
MANAGEMENT OF ABRUPTIO
PLACENTA
Confirm Antepartum haenorrhage
Admit patient diagnosed with AP
Perform thorough examination
Blood investigations
Assess the fetal status
If chances of shock, be prepared for resuscitation
Concealed type
• Intensive fetal monitoring
• FBC to be arranged
• Monitor urine output
• Artificial rupture of membrane with Oxytocin, if patient not
responding to treatment
• Fetal distress opted for cesarean section
• If atonic uterus, then hysterectomy to be done
Revealed Type
Assess for active bleeding
Ensure woman is hemodynamically
stable
Good fetal heart sound, with less than 37
weeks, continue pregnancy till 37 weeks
Choose trial vaginal delivery with ARM
and induction of labour, if in labour and
bleeding continues if more than 37
weeks.
PLACENTA PREVIA
Placenta previa is a condition in which
the placenta is implanted very near the
internal os or covering it either
completely or partially.
placenta previa complicates about
0.5% of deliveries.
ETIOLOGY / RISK FACTORS
The exact cause is unknown. The following theories are postulated:
Dropping down theory: (fertilized ovum drops down and implant in the
lower segment due to poor decidual reaction in the upper segment)
Advancing maternal age
Multiple gestation
Defective decidua
History of smoking
Risks factors are:
Advanced maternal age
History of previous CS
Placental size and abnormality
Smoking
Prior curettage
TYPES OR DEGREES OF PP
LOW LYING MARGINAL INCOMPLETE COMPLETE
or TYPE 1 or TYPE II or TYPE III or TYPE IV
PATHOPHYSIOLOGY
As placental growth slows down in later months, the
lower segment progressively dilates.
The inelastic placenta is sheared off the wall of the
lower segment.
This leads to opening up of uteroplacental vessels and
leads to episode of bleeding.
CLINICAL FEATURES
SYMPTOMS SIGNS
Painless bleeding Tachycardia
Causeless bleeding not related to Hypotension
accident Anemia
Recurrent bleeding On abdominal palpation
Relaxed uterus unless pt in labour
Floating fetal head
Fetal heart sound heard
No difficulty in palpating fetal parts.
INVESTIGATIONS
History Collection
Sonography – Placentography
Trans-vaginal sonograophy
Transperineal ultrasound
Colour Doppler flow study
MRI
MANAGEMENT OF
PLACENTA PREVIA
Confirm antepartum haemorrhage:
Admit patient diagnosed with PP
Perform thorough physical examination and locate site of
placenta
Do not perform any vaginal examination
Estimate blood loss and perform blood investigations
Be prepared for resuscitation if expecting a hypovolemic shock
Expectant Treatment: If GA less than 37weeks
Assess for active bleeding
Ensure woman is haemodynamically stable
Good FHR and reactive Cardio Tocography
Choose trial vaginal delivery with ARM and induction if
TYPE I and TYPE II anterior placental attachment
Caesarean section either if bleeding continues or TYPE II
posterior, TYPE III and TYPE IV
Active management: if GA is 37 weeks or more
Persistent bleeding and the patient has hypotension and shock
Labour process already begun
Unsatisfactory Heart Rate and non reactive Cardiotocography
If TYPE 1 and II (anterior), perform ARM and induction,
If TYPE II (posterior), TYPE III, and TYPE IV do caesarean section
VASA PREVIA
Definition :
Vasa previa is an obstetric complication in which the fetal blood vessels
cross or run near the internal os or orifice of the uterus
These vessels are risk of rupture when the supporting membrane
rupture as they are unsupported by the umbilical cord or placental
tissue.
The complication can happen during labour.
TYPES OF VASA PREVIA
Type I, vasa previa with velamentous cord insertion.
Vasa previa sometimes happens with velamentous cord insertion where
the umbilical cord doesn’t insert into the placenta as it should.
Instead, the umbilical cord blood vessels travel outside the placenta,
where they’re unprotected and at risk of breaking.
Type II, vasa previa with a bilobed placenta.
Vasa previa can happen when the placenta splits into two lobes,
with the umbilical cord connecting one lobe to the other.
If the exposed blood vessels traveling between the lobes lie close
to the cervix, they can burst and bleed once labor starts.
CAUSES:
A low lying placenta
An abnormally or unusually form of placenta
Velamentous insertion of umbilical cord
Multiple pregnancies
DIAGNOSIS:
Ultrasonography
Transvaginal sonography in combination
with colour doppler help to detect vasa
previa as early as 16th week of pregnancy
SYMPTOMS
There is no warning sign but these can be
Painless vaginal bleeding in 2nd and 3rd
trimesters
Darker red color blood
Fetal bradycardia
MANAGEMENT
The only treatment plan to be followed is a health care delivery
by cesarean section
Cesarean section should be planned as early enough to avoid
an emergency and should be late enough in order to prevent the
problem related with prematurity.
Unusually CS is recommended at 35-36 weeks provided the
mother is normal without any risk.
Emergency cesarean delivery is usually indicated if any of the
following occurs:
Premature rupture of the membranes occurs.
Vaginal bleeding continues.
Fetal status is nonreasoning