ANTEPARTUM

HEMORRHAGE
• This is the bleeding from the genital tract at
any time from the 28th week of gestation
before the birth of the baby.
• It is a serious complication which places the
mother and fetus at high risk.
 Causes

• Placenta praevia: The bleeding occurs from the

separation of a placenta situated partially or
wholly in the lower uterine segment
• Abruptio placenta: This is bleeding from the
separation of a normally situated placenta.
• Incidental or extra placental hemorrhage: This
is the bleeding from the local lesions of the birth
canal e.g. polyps, ruptured varicose veins or from
vasa preavia seen when membranes rupture.
 Placenta previa (types and degrees)

• Type 1 placenta praevia (low lying)

• - The majority of the placenta is in the upper uterine
segment
• - Vaginal delivery is possible
• - Blood loss is usually mild
• - The mother and the fetus remain in good condition
• Type 2 placenta praevia (marginal)
• - The placenta is partially located in the lower uterine
segment near the internal cervical os
 Types…….
• Vaginal delivery is possible
• - Blood loss is usually moderate
• - Fetal hypoxia is more likely to be present
Type 3 placenta pracvia (Partial)
• - The placenta partially covers the internal cervical os
• Bleeding is likely to be severe particularly when the
lower segment stretches and the cervix begins to
efface and dilate in late pregnancy
• vaginal delivery is inappropriate.
Type 4 placenta praevia(Total/major)
• The placenta is located centrally over the internal
cervical os and severe hemorrhage is very likely
• Vaginal delivery should not be considered
• Caesarean section is essential in order to save the
life of the mother and fetus.
• vaginal delivery is inappropriate.
• Associated factors
• High parity and Grand-multiparty
• Multiple gestations
• Prior caesarian section or uterine operations
 Clinical presentation

• Recurrent painless bleeding, bright red in color may

occur at rest
• H/o repeated blood loss at intervals and increasing in
amount
• May have history of recurrent threatened abortion
• The uterus is not tense or tender and there is no
abdominal pain
• Malpresentations (especially breech), presenting part
may be high
• Abnormal lie , (Transverse or oblique lie)
 Investigations

• Ultrasound scan for placental location,

• blood for Hb, Rh factor and cross matching in case
of need
• Note: Vaginal examination is absolutely
contraindicated
 Management
Management depends on:
• amount of blood lost,
• the condition of the mother and the fetus
• gestation age,
• Grade of placenta previa
• At any gestation age, with severe hemorrhage:
• resuscitate the patient, I.V access with large bore
cannula
• Check BP, Pulse; correct anemia; transfuse
• Terminate the pregnancy by caesarean
section(Active management)
• Minor hemorrhage before term:
• Aim at Conservative management of patient
• ADMIT Patient with 24-hr available facilities
for transfusion and surgery
• Confirm diagnosis
• Resuscitate if necessary,
• Correct anemia and Book blood,
• Do speculum exam to rule out local lesions
once bleeding has stopped
• Be on the lookout for any hemorrhage
• If minor previa confirmed, no further
bleeding: Do Examination under anesthesia
(EUA) at 37 weeks. If minor previa diagnosed,
rupture membranes, (ARM), Augment labor
• aim at vaginal delivery for type 1 and 2
• Do active Management of the 3rd stage of
labor.
• If major previa is confirmed, no further
bleeding,
• If severe hemorrhage occurs at any
time,
Stop conservative mgt, Do
emergency C/S
• Complications
• Maternal
• Post-partum hemorrhage
• Maternal shock resulting from blood loss and
hypovolemia
• Renal failure if blood replacement is
inadequate
• Anemia
• Puerperal sepsis as mother’s resistance is
lowered
• Maternal death
• Fetal complications:
• Hypoxia
• Asphyxia at birth
• Prematurity
• Neonatal death
 PLACENTA ABRUPTION

• Abruption placenta or accidental ante partum

hemorrhage is bleeding from separation of a
normally situated placenta after 28weeks of
pregnancy.
• Causes
• The cause is not always known there are
associating factors:
• Essential hypertension
• Pre-eclampsia and eclampsia
• Direct trauma to the abdomen as a fall or
blow or following external cephalic version
• Sudden decompression of the uterus after
fetal membrane rupture
• In case of polyhydraminos following
spontaneous rupture of membranes where
the marked reduction in uterine size causes
the placenta to separate
 Types

• Revealed hemorrhage: Blood escapes from

the placental site and drains through the
vagina
• Concealed Hemorrhage: The blood is retained
behind the placenta and may be forced into
the myometrium. There is no vaginal loss.
• The mixed or combined hemorrhage: This is a
combination of these two where some of the
blood drains through the vagina and some is
retained behind the placenta
• In placenta abruption blood may be retained
behind the placenta and may be forced into
the myometrium and it infiltrates between the
muscle fibres of the uterus.
• This extravasation can cause marked damage
and if seen at operation the uterus appears
bruised and oedematous, this is termed as
couvelaire uterus or uterine apoplexy
 Clinical features

• Sudden onset
• Severe abdominal pain, may be associated with
labor
• If revealed dark red bleeding, may be with clots
• Fetal distress,
• Inaudible fetal heart due to uterine muscle spasm
• fetal death
• Fainting, collapse; patient may be very sick or even
toxic in appearance
• Signs of pre-eclampsia or hypertension
• Hemodynamic status may be inconsistent with blood
loss
• Usually normal presentation
• Hemorrhage may be concealed, revealed or mixed in
type
• Diagnosis
• History: A high index of suspicion from history of
sudden onset of abdominal pain (severe, diffuse,
constant) with variable amount of hemorrhage
• Clinical signs: pt may be in shock in severe
cases, or may be apparently normal.
• Signs: Look for pallor, hypotension (severe
cases), hypertension, uterus tense and tender,
abdominal tenderness; fetal demise.
• Confirm diagnosis by:
• Ultrasound scan: to rule out placenta
praevia, or retro placental clot
• Management
• Depends on fetal viability and whether
bleeding continues
• If bleeding continues fetus viable, any
gestation age: emergency caesarean
• Fetal death confirmed on ultrasonography, no
continuing bleeding: do EUA to rule out
placenta previa. If no previa, do ARM,
augment labor, AIM for vaginal delivery
• Any gestation age, fetus dead, continuing
severe bleeding:
• Resuscitate pt, correct volume deficit
• Correct anemia, preferably with fresh blood
products
• check for and correct coagulopathy
• (Do full blood count, assay fibrinogen levels,)
• deliver by c/s if coagulopathy is corrected or
absent
• Vaginal delivery is a much safer and
preferred option for delivery in case fetus is
not viable and maternal condition stable
• Confirm fetal death by ultrasonography, not
fetoscope (due to uterine spasm which may
make fetal heart inaudible)
• Complications
• Hypovolaemic shock. This may lead to acute
renal failure and renal shut down
• Pituitary necrosis ( Sheehan’s syndrome) may
result from severe prolonged shock
• Postpartum hemorrhage
• Anemia
• Sepsis due to lowered immunity
• Disseminated intravascular coagulation (DIC)
• To the fetus
• Severe asphyxia at birth
• Prematurity
• fetal death
• Vasa Previa
• Blood vessels cross internal cervical os
• Occurs with velamentous insertion or
succenturiate lobe
• QN
• Differentiate placenta previa from placenta
abruption