Antepartum Haemorrhage - Final

Antepartum
Haemorrhage
DAMAR NAGHEER
Definition
 ANTEPARTUM HAEMORRHAGE (APH) IS DEFINED AS BLEEDING FROM OR

INTO THE GENITAL TRACT, OCCURRING FROM 24 WEEKS OF PREGNANCY
AND PRIOR TO THE BIRTH OF THE BABY.
One of the
APH
leading cause
complicates 3-
of perinatal
5% of
and maternal
pregnancies
mortality
worldwide
worldwide
Epidemiology
Estimate to
cause About 1/5 of
approximately preterm babies
50% of are as a result
maternal of APH
mortality
 Non obstetric - Cervical polyps ,
cervicitis, vaginal trauma (5%) , blood
disorders(<1%)
 Obstetric – Maternal :
Causes of Placental abruption (35%)

Placenta Praevia (30%)
Antepartum
Indeterminate (30%)
Haemorrhage
Fetal:
Vasa praevia (<1%)
Placental abruption
Placental abruption is the separation of a normal situated
placenta from the inner uterine wall prior to delivery
causing hemorrhage from both the mother and fetal
vessels.
It is associated with the highest rate of fetal morbidity and

mortality of all APH causes.
Placental
abruption
Occurs most often in the 3rd trimester
It has a recurrent rate of 3-15%

Types of placental abruption
Factors associated with
placental abruption
• Hypertension
• Multiparity
Aetiology • Advanced maternal age
• Polyhydramnious
• Trauma
• Smoking and substance misuse
(cocaine &Amphetamine)
• Previous placental abruption
Initiated by bleeding into the deciduous basalis
The source of the bleeding in most cases is the small

arterial vessels in the basal layer of the decidua that
are pathologically altered and prone to rupture.
The resultant haemorrhage splits the decidua, leaving

Pathophysiology a thin layer attached to the placenta.
As the decidua hematoma expands there is further

separation and compression.
Ultimately, There is destruction of the placenta tissue in

the area resulting in loss of surface area for gaseous
exchange and nutrients.
 In a few cases, it may be self-limited.
 However, if the initial separation was towards the center of the placenta
there may be continued dissection and separation In the decidua as well
as extravasation into the myometrium and through to the peritoneal
surface.
 This is results in couvelaire uterus.

 Once the blood reaches the edge of the placenta it may continue to
dissect between the the decidua and the fetal membranes and gain
access to the vagina through the cervix.
 It may pass through the membranes into the amniotic sac causing the
port wine discoloration.
 The amount of blood that eventually reaches the cervix is often only a
small portion of the lost from the circulation and is not a reliable indication
of the severity.
However , 50% of cases
Mild abrupt is not of severe abruption
usually associated with with a dead foetus are
maternal hypertension. associated with
maternal hypertension.
Clinical Features
 Dependent on the degree of separation of the placenta.

 Vaginal bleeding ( revealed or mixed)
 Suddenly onset of abdominal pain, which progressively worsens in intensity
and spreads.
 Pain is constant
 Symptoms of shock – palpitations, dizziness, weakness , syncope
Physical examination
 Signs of anemia – pallor , pale MM, tachycardia

 Shock
 Tender, tense uterus ,‘woody hard’
 Fetus difficult to palpate
 Diminished or absence of fetal movements
 Increase or Absence of fetal heart rate
 Diagnosis is usually made clinically

Investigation
 CBC & U&E’s

 Coagulation studies
 Ultrasound maybe done and may show the presence of retroplacental
clot , but is not a reliable tool
 If ultrasound is normal , it doesn’t rule out a placental abruption.
 Fetal heart monitoring
Management
 Immediate hospitalization
 ABC’s
 Large bore IV line , U-cath
 CBC , U&E, coagulation studies
 Group and cross match – 2 packed RBC
 RhoGAM if Rh-ve and not sensitized
 Abdominal examination and vital signs
 Vital signs are repeated every 15 mins
 It foetus is alive , CTG monitoring for fetal distress
Management
Mild cases :
If mother <38 weeks , conservative management- bed rest ,

blood studies , vitals and fetal monitoring
If mother >38 weeks - vaginal delivery post induction of labour (
Amniotomy followed by synthocinon , fetal monitoring
If there is fetal distress -C-section.
Management
Moderate to severe cases :
Maintain blood volume , transfuse as necessary
Strict urine output monitoring via catheter
Immediate amniotomy and syntocinon infusion followed by vaginal

delivery
Complications
Maternal Fetal
 Perinatal mortality (up to 50%) Fetal hypoxia
 DIC Prematurity
 Postpartum haemorrhage Fetal growth restriction
 Hypovolemic shock
 Acute renal failure
 Amniotic fluid embolism
Placenta
Praevia
Placenta praevia
 Abnormal placement of the placenta ( in the lower uterine segment)

where the placenta is low lying and may partially or completely obstruct
the internal OS.
 Occurs in 0.5% of all pregnancies
Associated factors of placenta praevia
includes:
 Previous c section
 Previous placenta praevia
Aetiology  Prior uterine trauma

 Multiparty
 Multiple pregnancy
 Smoking
 Advance maternal age (40 years)
 Previous induce abortion
Type 1: The placenta reaches the lower
segment but not the internal os
Types of Type 2: The placenta reaches the internal os

but does not cover it
placenta
Type 3: The placenta covers the internal os
praevia before dilatation but not when dilated
Type 4: The placenta completely covers the

internal os of the cervix even when dilated
Mean gestational age 30-32
weeks
Recurrent painless , bright red

Clinical vaginal bleeding which occurs
Features spontaneously or after coitus.
Warning haemorrhages – small

painless bleeds that occurs a few
weeks prior to a heavy bleed.
Maternal pulse and BP- Signs of anemia/shock
Uterus – soft & non tender
Abnormal Lie of the foetus
Physical High presenting part

examination
Fetal heart monitoring
Speculum vaginal examination
Digital vaginal examination may precipitate heavy

bleeding and is contraindicated
 CBC , U&E , PT , PTT
 Group and cross match
 Transabdominal ultrasound (95% accuracy)

Maybe affected by : maternal obesity , over-
distended bladder
Investigations
➢ Transvaginal ultrasound
➢ NB: 90-95% of praevias diagnosed in T2

resolve by T3. This is due to differential growth
upper and lower segments of the uterus. In
this case, if patient still asymptomatic at 32
weeks, repeat ultrasound
Management
 Admission
 ABC’s
 Set up large bore IV
 Full hx and exam
 If Rh-ve give RhoGAM
 Monitor vitals
 Monitor blood loss by the number of sanitary pads used
 Aim- to prolong pregnancy to 38 weeks
depends on the extent of bleeding
 Optimal delivery is at 38 weeks by
elective lower segment C-section under
spinal anesthesia
Management  Grade I , where the presenting part is
below the lower edge of the placenta –
safe to wait until labour , vaginal
delivery
 Grade iii and IV- C section
Complications
Fetal
 1.Perinatal mortality low but still higher than with a normal pregnancy
 2. Prematurity
 3. Intrauterine hypoxia
 4. Fetal malpresentation
 Maternal
 1. < 1% maternal mortality
 2. Hemorrhage and hypovolemic shock , Anaemia or Acute renal failure.
 3.Placenta accreta - especially if previous uterine surgery, anterior placenta
praevia
 4. PPROM
 5. Hysterectomy
Vasa praevia
Definition
 Refers to fetal vessels running through the membranes over the cervix and
under the presenting part , unprotected by the placenta or umbilical
cord.
A velamentous insertion of
the umbilical cord
Aetiology
Joining an accessory
(succenturiate) placental
lobe to the main disk of
placenta
Once baby is
Associated with
alive and
high perinatal
diagnosis is
mortality from
suspected –
fetal
emergency c
exsanguination.
section
Risk Factors
2nd trimester Pregnancies Placenta with

Multiple
low lying from in vitro accessory
pregnancies
placenta fertilization lobes
Kleihauer test- fetal haem
resistance to alkalinization
Apt test – NaOH with blood,

Investigations supernatant – pink ( fetal ) ,
yellow- maternal
Wright stain- nucleated red

cells on blood smear - fetal
Scanty bleeding at time of membrane rupture
CTG- bradycardia, alterations in fetal heart rate
Diagnosis
U/S- succenturiate lobe on the opposite side of the internal
os to the placenta
Diagnosis is suspected when there is either spontaneous or

artificial rupture of the membranes is accompanied by
painless fresh vaginal bleeding from rupture fetal vessels
Management
 Deliver the foetus as soon as possible and prepare to transfuse as needed.

Reference
 Hamilton-Fairley, D. (2004) Lecture notes on obstetrics and gynaecology. (2nd

Edition) Blackwell Publishing Ltd.
 Kenny LC., Baker PN. (2011) Obstetrics by Ten Teachers. (19th Edition)
Hodder Arnold, an Hachette UK Company
 Thomson AJ.,Ramsay JE, et al. (2011) Antepartum Haemorrhage. The Royal
College of Obstetricians and Gynaecologists. Green–top Guideline No.
63. reteived:https://www.rcog.org.uk/globalassets/
documents/guidelines/gtg_63.pdf
 ps://next.amboss.com/us/article/UO0b7T?q=antepartum%20hemorrhage#Z10
d2395a0456b5fa18cc3bbcbd3335bb
 https://emedicine.medscape.com/article/262063-overview#a3
 Textbook of obstetrics by roopnarinesingh

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Antepartum

 ANTEPARTUM HAEMORRHAGE (APH) IS DEFINED AS BLEEDING FROM OR

Causes of Placental abruption (35%)

It is associated with the highest rate of fetal morbidity and

It has a recurrent rate of 3-15%

The source of the bleeding in most cases is the small

The resultant haemorrhage splits the decidua, leaving

As the decidua hematoma expands there is further

Ultimately, There is destruction of the placenta tissue in

 This is results in couvelaire uterus.

 Dependent on the degree of separation of the placenta.

 Signs of anemia – pallor , pale MM, tachycardia

 Diagnosis is usually made clinically

 CBC & U&E’s

If mother <38 weeks , conservative management- bed rest ,

Moderate to severe cases :

Maintain blood volume , transfuse as necessary

Strict urine output monitoring via catheter

Immediate amniotomy and syntocinon infusion followed by vaginal

 Abnormal placement of the placenta ( in the lower uterine segment)

Aetiology  Prior uterine trauma

Types of Type 2: The placenta reaches the internal os

Type 4: The placenta completely covers the

Recurrent painless , bright red

Warning haemorrhages – small

Uterus – soft & non tender

Abnormal Lie of the foetus

Physical High presenting part

Speculum vaginal examination

Digital vaginal examination may precipitate heavy

 Transabdominal ultrasound (95% accuracy)

➢ NB: 90-95% of praevias diagnosed in T2

2nd trimester Pregnancies Placenta with

Apt test – NaOH with blood,

Wright stain- nucleated red

CTG- bradycardia, alterations in fetal heart rate

Diagnosis is suspected when there is either spontaneous or

 Deliver the foetus as soon as possible and prepare to transfuse as needed.

 Hamilton-Fairley, D. (2004) Lecture notes on obstetrics and gynaecology. (2nd

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