ANTEPARTUM
HEMORRHAGE
DRICI HENRY
MBCHB 4.2
KIU-Mubende Site
Definition
• APH is defined as bleeding from or into the genital tract after the
28th week of pregnancy but before the birth of the baby (the first
and second stage of labor are thus included).
CAUSES
The causes of antepartum hemorrhage fall into the following categories;
• Placental;
- Placenta previa
- Abruptio placenta
• Extra placental; Local cervico-vaginal lesions
- Cervical polyps
- Carcinoma cervix
- Varicose vein
- Local trauma
• Unexplained
- Vasa previa
Causes cont’d…
PLACENTA PREVIA
• This is when the placenta is implanted partially or completely over
the lower uterine segment (over and adjacent to the internal os)
• About one-third cases of antepartum hemorrhage belong to placenta
previa.
• The incidence of placenta previa ranges from 0.5% to 1% amongst
hospital deliveries. In 80% cases, it is found in multiparous women.
• The incidence is increased beyond the age of 35 years, with high birth
order pregnancies and in multiple pregnancy.
ETIOLOGY
The exact cause of implantation of the placenta in the lower segment is
not known. The following theories are postulated;
• Dropping down theory
• Persistence of chorionic activity
• Defective decidua
• Big surface area of the placenta
RISK FACTORS
• Multiparity
• Increased maternal age (> 35 years)
• History of previous cesarean section or any other scar in the uterus
(myomectomy or hysterecotomy)
• Placental size and abnormality (succenturiate lobes)
• Smoking — causes placental hypertrophy to compensate carbon
monoxide induced hypoxemia
• Prior curettage.
TYPES OR DEGREES
TYPES Cont’d…
• Type—I (Low-lying): The major part of the placenta is attached to the
upper segment and only the lower margin encroaches onto the lower
segment but not up to the os.
• Type—II (Marginal): The placenta reaches the margin of the internal
os but does not cover it.
• Type—III (Incomplete or partial central): The placenta covers the
internal os partially (covers the internal os when closed but does not
entirely do so when fully dilated).
• Type—IV (Central or total): The placenta completely covers the
internal os even after it is fully dilated.
Cause of bleeding
• As the placental growth slows down in later months and 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 an
episode of bleeding.
• As it is a physiological phenomenon which leads to the separation of
the placenta, the bleeding is said to be inevitable.
CLINICAL FEATURES
SYPTOMS
• The only symptom of placenta previa is vaginal bleeding. The classical
features of bleeding in placenta previa are;
Sudden onset
Painless,
Apparently causeless and
Recurrent
CLINICAL FEATURES…
SIGNS
• General condition and anemia are proportionate to the visible blood
loss.
• GNS
• The size of the uterus is proportionate to the period of gestation
• The head is floating
• Persistence of malpresentation
• Fetal heart sound is usually present
DIAGNOSIS
• Painless and recurrent vaginal bleeding in the second half of
pregnancy should be taken as placenta previa unless proved
otherwise
• Ultrasonography is the initial procedure either to confirm or to rule
out the diagnosis.
• Sonography; - Transabdominal (TAS)
- Transvaginal (TVS)
- Transperineal (TPS)
• MRI
COMPLICATIONS
• Shock
• Malpresentation
• Premature labor
• Cord prolapse
• Early rupture of the membranes
• Intrapartum hemorrhage
• Slow dilatation
MANAGEMENT
The aim is to continue pregnancy for fetal maturity without
compromising the maternal health.
• Bed rest
• Supplementary hematinics
• Blood for transfusion whenever required
• Facilities for cesarean section should be available throughout 24
hours, should it prove necessary.
• Steroid therapy is indicated when the duration of pregnancy is less
than 34 weeks
ABRUPTIO PLACENTAE
It is one form of antepartum hemorrhage where the bleeding occurs
due to premature separation of normally situated placenta
• The overall incidence is about 1 in 200 deliveries. Depending on the
extent(partial or complete) and intensity of placental separation, it is
a significant cause of perinatal mortality(15–20%) and maternal
mortality (2–5%).
TYPES
• Revealed : Following separation of the placenta, the blood insinuates
downwards between the membranes and the decidua. Ultimately, the
blood comes out of the cervical canal to be visible externally.
• Concealed : The blood collects behind the separated placenta or
collected in between the membranes and decidua. The collected blood
is prevented from coming out of the cervix by the presenting part
which presses on the lower segment. At times, the blood may percolate
into the amniotic sac after rupturing the membranes. In any of the
circumstances blood is not visible outside
• Mixed : In this type, some part of the blood collects inside (concealed)
and a part is expelled out (revealed). Usually one variety predominates
over the other
Concealead Revealed Marginal Preplacental
RISK FACTORS
• High birth order pregnancies with gravida 5 and above
• Advancing age of the mother
• Poor socio-economic condition
• Malnutrition
• Smoking (vasospasm).
• Hypertension in pregnancy
CLINICAL CLASSIFICATION
• Grade 0: Clinical features may be absent. The diagnosis is made after inspection
of placenta following delivery.
• Grade 1 (40%): (i) vaginal bleeding is slight (ii) uterus: irritable, tenderness may
be minimal or absent (iii) maternal BP and fibrinogen levels unaffected (iv) FHS
is good.
• Grade 2 (45%): (i) vaginal bleeding mild to moderate (ii) uterine tenderness is
always present (iii) maternal pulse ↑, BP is maintained (iv) fibrinogen level may
be decreased (v) shock is absent (vi) fetal distress or even fetal death occurs.
• Grade 3 (15%): (i) bleeding is moderate to severe or may be concealed (ii)
uterine tenderness is marked (iii) shock is pronounced (iv) fetal death is the
rule (v) associated coagulation defector anuria may complicate.
DIAGNOSIS
• Mainly clinical
• Ultrasonography
• MRI
COMPLICATIONS
• In revealed type—maternal risk is proportionate to the visible blood loss
and maternal death is rare.
• In concealed variety—The following complications may occur either singly
or in combination.
- Hemorrhage
- Shock
- Blood coagulation disorders
- Oliguria and anuria
- Postpartum hemorrhage
- Puerperal sepsis.
INDETERMINATE BLEEDING
• VASA PREVIA: The unsupported umbilical vessels in velamentous
placenta, lie below the presenting part and run across the cervical os.
• These vessels are torn either spontaneously or during rupture of
membranes.
• Color-flow Doppler (TVS) is helpful for antenatal diagnosis.
• Fetal mortality is high (50%) due to fetal exsanguination.
• Detection of nucleated red blood cells (Singer’s alkali denaturation test)
or fetal hemoglobin (Apt test) is diagnostic.
• Vaginal bleeding is often associated with fetal distress (tachycardia,
sinusoidal FHR tracing).
MANAGEMENT
• Management depends on fetal gestational age, severity of bleeding, persistence
or recurrence of bleeding. Center must be equipped with appropriate neonatal
care facilities in view of preterm delivery.
• Considering the risks of bleeding, patient with confirmed vasa previa, needs
antenatal admission at 28–32 weeks of gestation.
• Expectant management can be done in selected cases for fetal lung maturity
similar to placenta previa. Antenatal corticosteroids should be given
• Any case with bleeding vasa previa, delivery should be done by emergency
cesarean section. Intrapartum diagnosis of vasa previa, needs expeditious
delivery.
• A case of confirmed vasa previa at term (≥37 weeks) should be delivered by
elective cesarean section prior to onset of labor.
• Neonatal blood transfusion may be needed.
THE END!
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