Antepartum Haemorrhage

Dr. Achmad Zani

A,SpOG

Definition
Hemorrhage

from the vagina

after the 24th week of gestation
till end of pregnancy

Blood

loss of greater than 300mls

Incidence

: 3-5% of all
pregnancies

Antepartum Haemorrhage: Types

Simple:

Local
Vagina Trauma
Cervical Infection or tumor

- Blood dyscrasias
Thrombocytopenia
Anticoagulants

Complicated:

Abruptio Placentae
Placental praevia
Vasa Praevia

Abruptio Placentae
Premature

separation of the placenta.

Pathophysiology

of placental

abruption:
Bleeding into the decidua basalis layer
Hematoma forms causing further
placental separation
Fetal blood supply is further compromised
Complication - Couvelaire Uterus
(Retroplacental blood goes into the peritoneal cavity)

Classification
Clinical

classification
Class 0 - Asymptomatic
Class 1 - Mild (represents
approximately 48% of all cases)
Class 2 - Moderate (represents
approximately 27% of all cases)
Class 3 - Severe (represents
approximately 24% of all cases)

Placental abruption: types

Placental

abruption can be broadly

classified into two types:
Revealed
Concealed
Mixed

Presentation
Symptoms

Vaginal bleeding - 80%

Abdominal or back pain and uterine
tenderness - 70%
Fetal distress - 60%
Abnormal uterine contractions (eg,
hypertonic, high frequency) - 35%
Idiopathic premature labor - 25%
Fetal death 15%

Presentation
Physical

Examination

Should be done after stabilizing the patient

Ultrasound should be done first to assess
the location of placenta. Only then should a
digital pelvic exam be conducted
Profuse bleeding in waves
Uterine contraction / Uterine hypertonus
Shock
Absence of fetal heart sounds
Increased fundal height (due to hematoma)

Risk factors of Abruptio

Placentae

Maternal hypertension
Maternal trauma
Cigarette smoking
Alcohol consumption
Cocaine use
Short umbilical cord
Maternal age <20 or >35 years
Low socioeconomic status
Elevated second trimester maternal serum
alpha-fetoprotein (associated with up to a
10-fold increased risk of abruption)
Previous placental abruption

Investigations
Laboratory

studies

CBC
PT & APTT
Fibrinogen levels
BUN / creatinine

Imaging

studies

Transvaginal ultrasonography
Transabdominal ultrasonography

Complications of Abruptio placentae Maternal

Can
lead
to DIC

Complications of Abruptio
placentae Fetal
Fetal

complications include
Hypoxia or hypoxic-ischemic encephalopathy
(HIE)
growth retardation
CNS abnormalities
Intra uterine death.

Placenta praevia
Implantation

of placenta over the internal

cervical os and therefore in front of the
presenting part

Pathophysiology

Delay in implantation of blastocyst so that it

occurs in the lower part of uterus
In third trimester isthmus of uterus thins to form
lower uterine segment
Placental attachment is disrupted as the area
gradually thins in preparation of the onset of labor
This leads to bleeding from the venus sinuses

Placenta previa: types

Complete

placenta previa
Partial placenta previa
Marginal placenta previa (placenta
approaching the border of os)

Grading of placenta previa:

Grade

I The placenta is in the lower segment,

but the lower edge does not reach the internal
os.

Grade

II The lower edge of the low-lying

placenta reaches, but does not cover the
internal os.

Grade
Grade

III The placenta covers the internal os.

IV The placenta covers and entirely

surrounds the internal os

Presentation
Symptoms

Painless vaginal bleeding

Bleeding stops spontaneously and
recurs with labor
Malpresentation (Breech, transverse lie)
Physical

Exam

Digital exam is contraindicated

Uterus is soft and non tender
Concurrent contractions with bleeding
are present

Placenta previa : Risk factors

Previous

placenta previa.
Multiple pregnancies- due to the
placenta occupying a large
surface area.
Cigarette smoking
Increased maternal age
Uterine scar (previous caesarean
section)
Endometritis

Investigations
Laboratory

studies

CBC
PT & APTT
Imaging

studies

Transvaginal ultrasonography
Transabdominal ultrasonography

Abruptio Placentae

Placenta Previa

Pain

Abdominal pain, low back pain

Painless unless in labour

Uterus

Tender, irritable

Nontender, soft (unless

contracting)

Presentation

Not associated with abnormal

presentation

Breech or high presenting part

Fetus

Fetal heart tracing abnormal,

atypical

Fetal tracing not affected since

blood is maternal

Shock

Shock/anemia out of
proportion to amount of
blood seen

Shock/anemia proportionate
to blood seen

Imaging

U/S cannot rule out

U/S sensitive

Differential Diagnosis
Abruptio Placentae

Placenta Previa

Labour with bloody show

Abruptio Placentae

Vasa previa

Cervicitis

Vaginal trauma

Premature rupture of
membranes

Vaginitis

Vaginitis

Preterm labour

Preterm labour

Non Placental causes of

APH

Vasa previa:
Vasa

previa is a condition when fetal vessels

traverse the fetal membranes over the
internal os.
These vessels course within the membranes
(unsupported by the umbilical cord or
placental tissue) and are at risk of rupture
when the supporting membranes rupture.

Management of Antepartum
Hemorrhage

Initial management
Assessing

the airways:
Assessing the breathing:
Assessing the circulation
Cannula

inserted for

Drug adminstration
Blood sampling
IV fluid adminstration

Placenta previa
If

uncomplicated pregnancy no need of

intervention
Vitamins and Iron supplements should be taken
If minimal bleeding expected management
may be continued
If needed tocolytics may be considered to
administer antenatal steroids
Before the delivery the following should be
consulted

Obstetric anesthesiologist
Interventional radiologist
General surgeon
Urologist

Placenta previa
If

placental edge is more than 2cm from

internal cervial os trial of labour can be
offered.
If the distance is less than 2cm cesarian
section is done although an SVD can be
done
Delivery is mostly done at 36-37 weeks of
gestation
Low transverse uterine incision is used
If the patient is at risk of invasive
placentation than informed consent should
be taken for cesarian hysterectomy

Abruptio placentae
Vitamins

and Iron supplements should be taken

Initial management
Transfusion, correction of coagulopathy and Rh
immune globulin if needed
Cesarian section preferable mode of delivery
Vertical incision
Hysterectomy might be needed if severe blood loss
Tocolytics

may be used in case of preterm

delivery only if
Hemodynamically stable
No fetal distress
Preterm fetus may benefit from corticosteroid therapy

In

case of fetal death mode of delivery is SVD

Types of tocolytics
Types of Tocolytics
B2 agonist
Calcium channel blockers
Oxytocin antagonist Atosiban
NSAIDs

Uterine rupturemanagement
It

is an emergency
Laprotomy is urgently done
Uterine rupture can be an
antepartum or postpartum event

Vasa previa
When

vasa previa is diagnosed

antenatally, an elective
Caesarean section should be
offered prior to the onset of
labour.
In cases of vasa previa,
premature delivery is most likely,
therefore, consideration should be
given to administration of
corticosteroids at 28 to 32 weeks

Antepartum hemorrhage
Massive
bleeding
Call for help
Evaluate ABCs
Administer IV
fluids
Consider
transfusion
Consider CS
History and Physical

Examination
Fetal monitoring
Normal Bloody
show

Severely
distressed fetus

Routine
Evaluation

Suspect Vasa
Previa

No pain or pain
only with
contractions. Non
tender fundus
Suspect Placenta
previa
Immediate
ultrasound
examination if
available

Urgent
Cesarean
delivery

Inflamed cervix
or mucopurulent
discharge

Uterine pain ??

Pain between
contractions and
tender fundus

Consider
abruptio
placentae

Probable
cervical
infection
Culture and
treat as
appropriate
Consider uterine
rupture

Monitor fetus.
Supportive
mother care

Cesarean
Cesarean if fetal
delivery if in
distress
labour

SVD if fetal
death

Consider urgent
lapartomy

THANKS