Antepartum

Haemorrhage (APH)
DR MOHD DAUD CHE YUSOF
PAKAR PERUBATAN KELUARGA
KLINIK KESIHATAN BANDAR KUANTAN

Contents

Definition
Importance
Causes
Management of APH
Prognosis

Bleeding in
early
Pregnancy

Antepartum
haemorrhage
(APH)

Bleeding
In
Pregnancy

Post partum
Haemorrhage
(PPH)

Antepartum Haemorrhage
Antepartum haemorrhage (APH,prepartum
hemorrhage) is bleeding from the vagina during
pregnancy from twenty four 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
about 40% of APH

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 praevia

Multiparity
Advanced maternal age
Prior LSCS or other uterine surgery
Prior placenta praevia
Uterine structural anomaly
Assisted conception

Degrees of Placenta praevia

Classification of degrees of
Placenta praevia
Four grades:
Grade I: Placenta encroaches lower segment
but does not reach the cervical os (< 2cm)
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 praeviaComplications cont.

Foetal
IUD
Hypoxic ischemic encephalopathy
Cerebral paulsy
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
haemorrhage

Retro placental blood clot

Etiology

Risk factors
1.Increased age and parity
2.Vascular diseases: preeclampsia, maternal
hypertension, renal disease,SLE and APS
3.Mechanical 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

2.Severe 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
Sheehans 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

1.Moderate vaginal bleeding + feotal distress
2.Vessels may be palpable through dilated
cervix
3.Vessels may be visible on ultrasound
(Transvaginal colour Doppler ultrasound)
Difficult to distinguish from abruption
Can look for feotal Hb (Kleihauer-Betke test) or
nucleated RBCs in shed blood
Tachycardia or bradycardia in CTG

Rupture of Uterus

Uterine scar dehiscence:

Foetal membranes remain intact, foetus is not

extruded intraperitoneally, separation limited to
old scar, peritoneum overlying is intact
Usually no foetal distress / maternal Hemorrhage

Uterine rupture:

Separation of scar extension, rupture of foetal

membranes with extrusion
Results in foetal distress / maternal hemorrhage
Maternal mortality
Foetal mortality = 35%

Rupture of Uterus

Rupture of Uterus
High Index of clinical suspicion
In all cases of antepartum and intra
partum haemorrhage uterine rupture must
be excluded

Risk factors
Scarred uteri Previous caesarian section &
other uterine surgeries
Grand multiparous
Inadvertent use of oxytocin &
prostaglandins
Shoulder dystocia
Forceps deliveries
Trauma
Uterine abnormalities

Rupture of Uterus-Clinical
features
Maternal
Pain in between contractions
Scar tenderness
Vaginal bleeding
Profound maternal tachycardia and Hypotension
Loss of uterine contractions
Haematurea
Postpartum haemorrhage may be a sign

Rupture of Uterus-Clinical
features cont..
Foetal
Foetal distress-CTG changers
Loss of station
Absence of FHS
Palpable foetal parts through maternal
abdomen

 Maternal

Complications

Hemorrhage
Bladder rupture
Maternal death
PPH
DIC

Foetal

Respiratory distress
Hypoxia and cerebral paulsy
Acidemia
Death

Comparison of Presentation of
Abruption v. Previa v. Rupture

Abd. pain
Vag. blood
DIC
Acute foetal
distress

Abruption

Praevia

Rupture

present
old or fresh
common
common

absent
fresh
rare
rare

variable
fresh
rare
common

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 patients 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
Ascertain 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 Kleihauer
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

1.Near term / Term

Delivery is considered
Grades I and II - May be able to deliver
vaginally
Grades III and IV - Will require caesarean
section by senior obstetrician
Should anticipate PPH

Placenta praevia Management

cont

2.Early in pregnancy
Continuation of 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
1.Caesarean section
2.Vaginal
If coagulopathy present
If feotus is not compromised
If feotus is dead

Rupture of Uterus Management

Emergency laparotomy
Deliver the baby
Uterine repair if possible specially in
primi gravida
PPH haemostasis sequence
Caesarian hysterectomy (may be
preferred)

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