Case Study 29-APH

Case study 29
ANTEPARTUME
HAEMORRHAGE
Zarul naim Mohd Tamizi

APH
• Definition: vaginal bleeding from 24 weeks to delivery of baby.

• Common causes:
 Placenta praevia
 Placenta abruptio
 Local causes (cervicitis, cervical ca, cervical ectropian, vagina
trauma,vagina infection)
 Unexplained APH
Placenta
Praevia
• Placenta which has implanted partially or wholly in the lower

uterine segment
Grade 1 – Just enters lower segment(3-5cm from OS)
Grade 2 – Enters LUS but does not reach os (<3cm from OS)
Grade 3 – Partially covers os but not completely
Grade 4 – Completely covers os
• Risk factors:
 Uterine scar (Caesarian, myomectomy, curretage)
 Multiparity
 Multiple gestations
 Uterine structure anomaly
 Assisted conception
Placenta Abruptio
• The premature separation of the placenta-before delivery of

the fetus.
• Occur in 1% of pregnancy
• Types:
 Revealed - Pain + Vaginal bleeding-80%
 Concealed - pain/shock + no vaginal bleeding-20%
Risk factors:
Polyhydramnios
Trauma to abdomen
Previous abruptio Smoking
Hypertension Crack cocaine usage
Pre-eclampsia Thrombophilia
IUGR Anticoagulant
Multiple gestation therapy
Placenta Praevia Placenta Abruptio
Features of bleeding Painless, recurrent, always Painful, revealed, concealed or

revealed mixed
General condition Proportional to blood loss Out of proportion in

concealed type
Abdomen Soft, relaxed, malpresentation Tense, tender & woody, head

is common, maybe enganged
Fetal heart sound Usually present Usually absent particularly in

concealed type
U/S Low lying placenta Normal lying placenta,

retroplacenta clot
Diagnosis U/S Clinically

CASE
• 30 year old woman, Para 1+0

• Previous spontaneous vaginal delivery and appropriately
grown fetus
• Admitted at term with fresh vaginal bleeding and abd pain
• On examination: in pain, pale, pulse is 100bpm, BP is
110/80mmHg and tender uterus which is contracting 3
minutely
• Blood stains on her feet between her toes
Q1: what is the most likely diagnosis
and why is this the case?
 Placenta abruptio(revealed) because of antepartum bleeding associated with abdominal

pain and tenderness of the uterus.
 Symptoms:
 Vaginal Bleeding ( Revealed) 80%
 Abdominal /Back Pain (Severe) 70%
 Fetal Distress 60%
 Contractions (Hypertonic) 35%
 Preterm Labour 25%
 Fetal Death in utero 15%
Q2: what are the risk
to the mother and
fetus?
Fetus:
• Mother:  Hypoxia - Fetal distress
 Anaemia
 Hypovolaemic shock  Growth Retardation - if
 Acute renal failure treated conservatively and
 DIC survives
 CNS Abnormalities
 PPH – uterine  Intra Uterine Death
atony(Couvelaire
uterus)
 Maternal mortality
 Operative delivery
 Recurrence
Q3: how should you assess and manage this
situation?
• Call for help

• Resuscitation
– Admit labour room
– Estimated amount of blood loss
• Mild : 2 pads soaked / < 200ml
• Severe : > 2 pads soaked / > 200 ml
– Mild : 1 IV line & GXM 2 units blood
– Severe : 3 IV lines & GXM 4 units blood
– Use branula size 16 and below and transfuse immediately
• Blood Investigations
FBC (low Hb, low platelet), BUSE + Creat (Acute renal failure),
Coagulation profile (PT,APTT,INR), GXM
• U/S scan (Retroplacental clot, exclude placenta
praevia, check fetal viability etc)
Hx and P/E
• Hx: vaginal bleeding, painful or not, abdominal pain, risk factors

(previous abruptio,trauma)
• P/E:
 vital sign (BP,pulse,temperature), colour (pale),sign of
anemia
 Abdomen(tense,tender and woody, uterus larger than date
 VE – avoid before exluded placenta praevia
Investigations
• For fetal:
 CTG
• For maternal:
 FBC
 Coagulation screen
 GXM 4 units
 Catheterization (monitor urine output)
 Urea and creatinine (renal failure)
• In this patient because she is already at term, delivery is
indicated
1. Vaginal delivery – cervix favourable or foetal death
- ARM + oxytocin augmentation
2. LSCS – usually indicated for foetal distress
- use prophylactic oxytocin infusion routinely in
these cases
• Before LSCS or Vaginal delivery, always correct
 Hypovolaemia
 DIVC
 Ensure urine output >30ml/hr
 Other causes
Q4:
One hour later :
 Maternal condition unchanged from admission.
 borderline tachycardia, BP satisfactory, uterus contract
3:10 min and remains tender.
CTG: appropriate beat to beat variability, no
decelerations.
Coagulation screens:
Hb - 8.4 g/dl,
platelets - 105x109 /l,
fibrinogen - 2.2 g/l,
APTT - 48 s,
PT - 14 s,
Fibrin degradation
product - 2.1 mg/ml
Comment on these result
and discuss further
management
Results Interpretation Impression
Hb 8.4g/dl Low Anaemia
(11-16g/dl)
Platelets 105x109 /l Low
(150-400x109/l)
Fibrinogen 2.2 g/l Borderline low
Disseminated
(2-4 g/dl)
Intravascular
aPTT 48s Prolonged Coagulation(DIVC)
(35-45s)
pT 14s normal
(12-15s)
Fibrin degradation 2.1mg/ml Raised
products (<1mg/ml)
DIC
Secondary phenomenon following trigger of
generalised coagulation activity
Why?
• Retroplacenta blood clot
– Consumptive coagulopathy
– Hypofibrinogenemia
• Increase pressure within uterus (bp)
• Release of thromboplastin from circulation
/retroplacenta clot
management
1. Involve support services (anaesthethist, blood bank, etc)

early
2. Replace blood constituents and coagulation factors in
addition to blood transfusion, start giving Cryoprecipitate (6
units) followed by FFP (2 units) and platelet concentrate (4
units)
3. Repeat tx if necessary and check coagulation profile 2
hourly.
4. Plan for delivery (treat the cause)
Q5: cervix is found to be 5 cm
dilated and fully effaced with
no placental palpable. The fetal
head is at the level of ischial
spines and is in left occipito-
anterior position, should you
perform amniotomy?
What is amniotomy?
 Artificial rupture of membrane (ARM)

 Enhanced labor
 Using Hollister amniohook
 Stimulates release of endogenous prostaglandin
 Assessment based on Bishop’s score to determine
favourable cervix
After ARM
Assess liquor : for blood stained or
meconium stained
Monitor progress of labour, maternal and
YES fetal condition
• Term
• Favourable cervix If prolonged labour, fetal distress, and
uncontrolled haemorrhage -Emergency
• No fetal distress Caesarian section
Indication for LSCS
• Bishop score <7
• Fetal distress
• Severe abruption with alive fetus
• Other obstetric complication
• No uterine contraction with oxytocin &
prostaglandin
• Uncontrolled bleeding
• Q6: amniotomy is performed and she delivers a
live male infant less than 1 hour later. The infant is
healthy with Apgar score of 9 at 5 min. Placenta is
rapidly delivered and has approximately 500ml of
clot adherent to about 25% of its surface area. She
recovers uneventfully.
• What is the risk of having a similar event in

subsequent pregnancy?
Risk of recurrence :
5-15%% after one abruption

25% after two abruption
Advice patient :
• Get early and continuous prenatal care.
• Early recognition and proper management of conditions in the

mother such as diabetes and high blood pressure
• If pregnant, don't engage in activity more vigorous than what

you were accustomed to before pregnancy.
• Avoid risk factors when possible. Maintain a positive lifestyle

free of smoking, alcohol and recreational drug use (e.g.,
cocaine use).
• Proper and adequate nutrition prior to becoming pregnant

and during pregnancy
THANK YOU

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Case study 29

Zarul naim Mohd Tamizi

• Definition: vaginal bleeding from 24 weeks to delivery of baby.

• Placenta which has implanted partially or wholly in the lower

• The premature separation of the placenta-before delivery of

Features of bleeding Painless, recurrent, always Painful, revealed, concealed or

General condition Proportional to blood loss Out of proportion in

Abdomen Soft, relaxed, malpresentation Tense, tender & woody, head

Fetal heart sound Usually present Usually absent particularly in

U/S Low lying placenta Normal lying placenta,

Diagnosis U/S Clinically

• 30 year old woman, Para 1+0

 Placenta abruptio(revealed) because of antepartum bleeding associated with abdominal

• Call for help

• Hx: vaginal bleeding, painful or not, abdominal pain, risk factors

1. Involve support services (anaesthethist, blood bank, etc)

 Artificial rupture of membrane (ARM)

• What is the risk of having a similar event in

5-15%% after one abruption

• Early recognition and proper management of conditions in the

• If pregnant, don't engage in activity more vigorous than what

• Avoid risk factors when possible. Maintain a positive lifestyle

• Proper and adequate nutrition prior to becoming pregnant

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