ANTEPARTUM

HAEMORRHAGE

LEARNING OBJECTIVES:
At the end of this tutorial the student will be
able to:
Define APH
Discuss the etiology and differential diagnosis of
APH
Describe the assessment and management of a
woman with APH

Definition and Classification

Definition bleeding from or in to the
genital tract, occurring from 22 weeks
(>500g) of pregnancy and prior to the
birth of the baby.

Classification Placenta praevia

Abruptio placenta

CAUSES OF 763 PREGNANCY-RELATED

DEATHS
DUE TO HEMORRHAGE
CAUSES OF HEMORRHAGE
Placental abruption
Laceration/uterine rupture
Uterine atony
Coagulopathies
Placenta previa
Uterine bleeding
Placenta accreta/increta/percreta
Retained placenta

NUMBER (%)
141 (19)
125 (16)
115 (15)
108 (14)
50 (7)
47 (6)
44 (6)
32 (4)

ETIOLOGY

Placental:
- Placenta praevia
- Placenta abruption
- Vasa praevia

Local cause:
- Cervical polyps
- Cervicitis, Vaginitis
- Cervical cancer.

FULL HISTORY
(Should be taken after the mother is stable.)

Severity of the bleeding

-associated pain with the haemorrhage?
-Continuous pain : Placental abruption.

-Intermittent pain : Labour.

Time of onset
Triggering factors
A/w pain or uterine contractions?

Fetal movement

-If it reduced and associated with spontaneous or iatrogenic rupture of the fetal membranes : ruptured
vasa praevia

Hx of ruptured membranes
Hx cervical smear (date/normal or abnormal)
-Previous cervical smear history possibility of Ca cervix. Symptomatic pregnant women usually present
with APH (mostly postcoital) or vaginal discharge.

Previous ultrasound report

Risk factors for abruption and placenta praevia should be identified.

EXAMINATION

General: PULSE & BP

Abdomen:
The tense, tender or woody feel to the uterus
indicates a significant abruption.
Painless bleeding, high fetal presenting part
Placenta praevia
- soft, non-tender uterus may suggest a lower
genital tract cause or bleeding from placenta or
vasa praevia.

EXAMINATION
Speculum :
-identify cervical dilatation or visualise a lower
genital tract cause.

Digital vaginal examination

Should NOT be done until Placenta Praevia
has been excluded by USG.

INVESTIGATIONS

Blood test
- FBC
- Coagulation profile
- Cross-match blood
Ultrasound
Colour doppler
Kleihauer test

Fetal monitoring:
CTG monitoring

MANAGEMENT
Conservative Management
Admit ( according to RCOG is 28weeks)
Monitor BP & Pulse rate
Pad chart - to monitor progress of the
leaking liquor
Minimize the abdominal examination

Monitor fetal well being

- Fetal kick chart(daily)
- CTG (weekly)
- U/S (fortnightly)
Steroid injection (> 24w, <36w) IM
dexamethasone 12mg stat and repeat the
second dose after 12 hours.

Any symptoms or signs of labour

COMPLICATIONS OF APH
Maternal complications

Fetal complications

Anaemia

Fetal hypoxia

Infection

Small for gestational age and fetal

growth restriction

Maternal shock

Prematurity (iatrogenic and

spontaneous)

Renal tubular necrosis

Fetal death

Consumptive coagulopathy
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae

Complications of blood transfusion

Definition

The condition that

the placenta is wholly or partly
attached to the lower uterine
segment

Classification (GRADING/CLINICAL)

TYPE 1

The placenta
enroaches
into lower
segment

TYPE II

The placenta
reaches the
margin of
cervical os

Type III
The placenta
covers the os but
not at full
dilatation.

Type IV

The placenta
completely covers
the cervical os.

Cervix

Placenta

Uterus

A PLACENTA WHICH HAS IMPLANTED OVER THE OS

CLINICAL CLASSIFICATION

Minor :
Type 1 (anterior/posterior)
Type 2 anterior

Major:
Type 2 posterior (dangerous type)
Type 3
Type 4

Deliver vaginally
Type 1 Posterior >
likelihood of fetal distress

Caesarean section
Type 2 posterior >
chance of fetal distress

Type 3 & 4
anterior cut
through placenta to
deliver. Hence need
to be fast and
efficient.

ETIOLOGY
Advancing maternal age
Multiparity
Prior cesarean section ,manual removal
of placenta and dilatation and
curettage(D&C)
Multiple gestation
Smoking
History of PP

ETIOLOGY
The incidence of placenta praevia is 0.5%, bleeding from a placenta
praevia is about 20% of all cases of antepartum hemorrhage.

Maternal
influence
Haemorrhage
Shock
Anemia

Fetal influence
Distress or death
IUGR
Premature
Neonatal death

During the trimester of pregnancy Slight or

severe bleeding from the vagina without evident
cause and without any pain on the abdomen.

During delivery Severe haemorrhage is

inevitable as the cervix dilates, especially in type I
and type II.

During the third stage of labour

Postpartum

Intermittent painless PV bleeding

Minimal/spotting
Bleeding mainly from mother
Abdomen is soft and non tender
CTG usually normal

a/w with abnormal lies and presentation

History

1) Quantity the amount of bleeding(pads? Spotting/minimal)

2) Nature of the bleeding(fresh blood/clots)
3) a/w symptoms (abd pain,uterine contraction,leaking liquor/show)
4) Symptoms of anaemia
5) Preceded events(sexual intercourse,vaginal discharge,abd trauma,massage,heavy
work)

Signs and symptoms

Repeated bleeding from vagina without pain. There is no tenderness on the
abdomen. The fetal heart sounds are present and normal.
Examination
The vaginal examination must be avoided. Ultrosonograph. (can provoke
massive bleeding)
Inspect after vaginal delivery
(The distance from the ruptured situs of membranes to the edge of the
placenta <7cm)

Maternal:
1) FBC
2) BUSE/RP
3) GSH

Fetal
1)CTG
2)U/S

Low Lying Placenta Praevia

Image shows (Transvaginal Ultrasound, 33
weeks gestation): On transvaginal scan, the
placenta is situated on the posterior uterine wall
(arrow) and extends to 15mm of the internal
cervical os. The cervix is long and closed
through its entire length and measures 38mm.
Normal fetal measurements and activity are
noted which are not illustrated.

Partial Placenta Praevia

Image by (Transvaginal Ultrasound): The
placenta partially overlies the internal
cervical os (arrow).

Complete Placenta Praevia

Image by (Transvaginal
Ultrasound): The placental
completely covers the top of the
internal cervical os (arrow).

MANAGEMENT

MANAGEMENT

DEFINITIVE TREATMENT
Type I,II(ant)

Type II( post), III,IV

ARM +/- oxytocin

Caesarean
section
Satisfactory
progress without
bleeding

Vaginal
delivery

Bleeding continues
Caesarean section