Antepartum

Haemorrhage

Dr MJP Bilongo
Plan

• Definitions
• Types
• Characteristics
• Managements
Key facts

• Every day, approximately 830 women die from preventable causes

related to pregnancy and childbirth.
• 99% of all maternal deaths occur in developing countries.
• Maternal mortality is higher in women living in rural areas and
among poorer communities.
• Young adolescents face a higher risk of complications and death as a
result of pregnancy than other women.
• Skilled care before, during and after childbirth can save the lives of
women and newborn babies.
• Between 1990 and 2015, maternal mortality worldwide dropped by
about 44%.
• Between 2016 and 2030, as part of the Sustainable Development
Goals, the target is to reduce the global maternal mortality ratio to
less than 70 per 100 000 live births. (WHO, 16 February 2018)
South Africa Maternal mortality rate

• Maternal mortality rate: 138 deaths/100,000 live births (2015 est.)

• Definition: The maternal mortality ratio (MMRatio) is the annual

number of female deaths per 100,000 live births from any cause
related to or aggravated by pregnancy or its management (excluding
accidental or incidental causes). The MMRatio includes deaths during
pregnancy, childbirth, or within 42 days of termination of pregnancy,
irrespective of the duration and site of the pregnancy, for a specified
year.
• Source: CIA World Factbook - last updated on January 20, 2018
Antepartum haemorrhage
• Antepartum haemorrhage (APH) is defined as
bleeding from the genital tract from 20 weeks of
pregnancy up to delivery of the baby.
Causes

 Placental - abruptio placentae, placenta praevia, vasa

praevia.
 Non-placental - vaginal and cervical lesions including
cancer, cervical infections, trauma and decidual bleeding.
 Unknown - APH of unknown origin.
Types of APH
 1. Bleeding in Labor

 Bleeding during labor is common

 Effacement and dilation of the cervix causes tearing
of small vessels
 Often called “bloody show”
 2. Cervical bleeding

 Cervix my be friable due pregnancy or infection

 Cervical polyps
 Ask about recent intercourse
 3.Placental abruption

 Separation from it’s site of implantation before

delivery
 Occurs 1 in 200 deliveries
 Cause of fetal death 1 in 1600
 10% of all 3rd trimester stillbirth due to
abruption
 Pathology of abruption

 Initiated by hemorrhage in to the decidua basalis

 The decidual hematoma leads to separation,
• compression, and destruction of the adjacent placenta
 In the early stages there may be no clinical symptoms
 The blood may dissect the membranes from the uterine
• wall and escape through the cervix
 Placental abruption

 The blood can be retained between the placenta and

uterus resulting in a concealed abruption
 Concealed abruption likely go undiagnosed till
delivery and are associated with a higher rate of
DIC
 Risk factors for abruption

Prior abruption 10 - 25
Preterm ruptured membranes 2.4 – 4.9
Preeclampsia 2.1 – 4.0
Chronic hypertension 1.8 – 3.0
Multifetal gestation 2.1
Polyhydramnios 2.0
Cigarette smoking 1.4 – 1.9
Increased age and parity 1.3 – 1.5
Cocaine use
Uterine fibroids (esp. if behind
placental implantation site)
 Hypertension and abruption

 Most common associated condition

 Can be chronic, gestational, or preeclampsia
 Seen in half of women with abruption severe enough
to kill the fetus
 Abruption occurs in 1.5% of women with chronic
hypertension
 External trauma

 Rare cause of abruption

 Implicated in only 3 of 207 cases in one study
 Usually associated with severe trauma
 After minor trauma (low speed MVA, fall) monitor the
fetus for 2 – 6 hours in the absence of bleeding,
contraction, or tenderness
 Bleeding with abruption is almost always maternal
except in cases of severe trauma that result in a tear
within the placenta
 Diagnosis of abruption

 Signs/symptoms extremely variable

 From profuse vaginal bleeding to no external bleeding
 One women presented with a nose bleed and was
diagnosed with an IUFD and DIC due to abruption
 Bleeding and abdominal pain are the most common
findings
 In 22% PTL(PRETERM LABOR) was the diagnosis till
fetal distress or death occurred
Signs and symptoms of abruption

Vaginal bleeding 78%

Uterine tenderness or back pain 66%
Fetal distress 60%
Preterm labor 22%
High frequency contractions 17%
Hypertonus 17%
Dead fetus 15%
 Ultrasound and abruption

 Ultrasound infrequently confirms the diagnosis of

abruption
 Negative findings do not rule out abruption
 Useful to rule out previa
 Consumptive coagulopathy = DIC

 Occurs in 30% of women with abruption severe

enough to cause IUFD
 Characterized by low fibrinogen (<150 mg/dL)
 Decreases in other clotting factors
 Preterm abruption

 Expectant management possible

 Tocolytics contraindicated
 Rupture of membranes and oligohydramnios are
frequently seen
 The placenta may further separate instantaneously
 Maternal blood transfusion can be used for maternal
anemia
 Management of abruption

 Depends on the gestational age of the fetus and

status of the mother
 Vaginal delivery is not contraindicated
 Consider coagulopathy before cesarean
 Close observation of the mother and fetus with
facilities for immediate intervention necessary
Management of abruption

• If the fetus is alive and viable

 If the fetal heart rate >100/minute, perform emergency
caesarean section, unless delivery is imminent (cervix ≥9
cm dilated).
 For a non-viable baby, rupture the membranes and
augment labour with oxytocin. Monitor blood loss
carefully.
Management of abruption

• If the fetus is dead

 A dead fetus with abruptio placentae signifies massive
blood loss.
 Resuscitate and transfer urgently to a specialist hospital.
 Rupture membranes as soon as possible, even if the
cervix is unfavourable; before the ambulance arrives.
 4. Placenta previa
 Placenta previa is abnormal implantation of the
placenta over or near the internal cervical os.
 In the Word, the prevalence of placenta praevia is at
around 5 per 1000 pregnancies. There is some
evidence suggestive of regional variation in its
prevalence, but it is not possible to determine from
existing data whether this is due to true ethnic
differences or other unknown factor(s).
 It results from various risk factors.
 Perinatal morbidity and mortality from
preterm delivery
 Maternal morbidity and mortality from
hemorrhage and need for cesarean delivery
Prevalence of Placenta praevia per region

• The overall prevalence of placenta praevia was 5.2 per 1000

pregnancies
• Asian studies (12.2 per 1000 pregnancies)
• Europe (3.6 per 1000 pregnancies)
• North America (2.9 per 1000 pregnancies)
• Sub-Saharan Africa (2.7 per 1000 pregnancies).
 Placenta previa

 Bleeding may be spontaneous or triggered

by digital examination or by onset of labor.
 Placenta previa accounts for about 20% of
bleeding during late pregnancy and is most
common during the 3rd trimester
Classification
• Total placenta previa occurs when the internal cervical os
is completely covered by the placenta.
• Partial placenta previa occurs when the internal os is
partially covered by the placenta.
• Marginal placenta previa occurs when the placenta is at
the margin of the internal os.
• Low-lying placenta previa occurs when the placenta is
implanted in the lower uterine segment. In this variation,
the edge of the placenta is near the internal os but does
not reach it
Pathophysiology

• The exact etiology of placenta previa is unknown.

The condition may be multifactorial and is
postulated to be related to multiparity, multiple
gestations, advanced maternal age, previous
cesarean delivery, previous abortion, and possibly,
smoking.
 Risk factors for previa

 Advancing maternal age (1 in 100 for women > 35yo)

 Multiparity
 Multifetal gestations
 Prior cesarean delivery (4% with 3 or more)
 Cigarette smoking
 Diagnosis of previa

 Should always be on differential in a women with

• bleeding in the later half of pregnancy
 Before ultrasound this diagnosis was made by digital
• exam – THIS CAN CAUSE SEVERE HEMORRHAGE
 Most precise and safest method is ultrasound
 Transvaginal technique is superior to transabdominal
Diagnosis of previa
 Placental migration

 12% of placentas will be low lying at 18-20 weeks

 Of those not covering the os previa does not
persist in the third trimester
 Of those covering the os only40% persisted
 Restriction of activity not necessary
 Placenta previa

 Placental separation is inevitable with formation of the

lower uterine segment and cervical dilation
 This can result in bleeding in the late 2nd and early 3rd
trimester
 “Painless hemorrhage” is characteristic
 Sudden onset with no warning
 Initial bleed rarely profuse and stops spontaneously
 Management of previa

 Admitted for observation after bleeding

 May be discharged with close follow up or remain in
the hospital till delivery
 Being near a hospital with transportation is important
 If bleeding heavy or in labor delivery by cesarean
 Scheduled delivery by cesarean done at 36 – 37 weeks
 Management of placenta praevia

 Resuscitation.
 Check Hb level and cross match.
 less than 10 g/dL, commence blood transfusion and transfer
urgently to a specialist hospital.
At the Specialist hospital
 Obtain consent for caesarean section and hysterectomy
(should hysterectomy becomes necessary during the
caesarean section).
 If the bleeding is significant, perform a caesarean section
(supervised or done by an experienced doctor or specialist).
 if less than 36 weeks, and bleeding subsides, manage
conservatively – keep in hospital, observe vital signs and give
steroids and antibiotics. Deliver electively at 36 weeks.
 Summary

Cause Suggestive Findings Diagnostic Approach

Labor Passage of blood-tinged mucus plug, not active bleeding Diagnosis of exclusion
Painful, regular uterine contractions with cervical dilation
and effacement
Normal fetal and maternal signs

Abruptio Painful, tender uterus, often tense with contractions Clinical suspicion
placentae Dark or clotted blood Often, ultrasonography, although it is not very
Sometimes maternal hypotension sensitive
Signs of fetal distress (eg, bradycardia or prolonged
deceleration, repetitive late decelerations, sinusoidal
pattern)
Placenta Sudden onset of painless vaginal bleeding with bright red Sometimes suspected based on findings
previa blood and minimal or no uterine tenderness during routine screening ultrasonography
Transvaginal ultrasonography
Vasa previa Painless vaginal bleeding with fetal instability but normal Sometimes suspected based on findings
maternal signs during routine screening ultrasonography
Often, symptoms of labor Transvaginal ultrasonography with color
Doppler studies
Uterine Severe abdominal pain, tenderness, cessation of Clinical suspicion, usually history of prior
rupture contractions, often loss of uterine tone uterine surgery
Mild to moderate vaginal bleeding Laparotomy
Fetal bradycardia or loss of heart sounds
 5. Placenta Accreta

 Abnormally adherent placenta

 Trophoblastic invasion beyond the decidua basalis
 Attaches directly to the myometrium and beyond
 Normal boundary established by the Nitabuch
• fibrinoid layer
Three grades of accreta
Placenta Accreta

 Most common cause for peripartum

hysterectomy
 Massive transfusion usually unavoidable
 Urologic or vascular injury not infrequent
 Commonly involves ICU admission, prolonged
• hospitalization, and infectious morbidity
Complications of accreta

Silver RM, et al. Maternal morbidity associated with multiple repeat

cesarean deliveries. Obstet Gynecol 2006
 Risk factors

 Advanced maternal age

 Parity
 Smoking
 Asherman syndrome
 Uterine anomalies and fibroids
 Placenta previa
 Prior uterine surgery
 Diagnosis of accreta

• No method alone affords complete assurance

• Ultrasound
• Clear zone
• Venous lakes (lacunae)
• Interruption of the bladder line
• MRI
• Elevated 2nd trimester MSAFP(maternal serum alpha-fetoprotein )
Diagnosis of accreta
 Placenta accreta

 If there is attempted removal of the

placenta at the time of delivery
massive hemorrhage occurs
 Cesarean hysterectomy is
recommended
 Type and cross (Massive transfusion
protocol)
 Ureteral stents and balloon
occlusion of the internal iliac have
been used
 Placenta accreta

 Several studies have suggested benefit with planned

rather than emergent hysterectomy
 As GA increases women have an increased risk of labor
and bleeding
 Decision analysis showed the best strategy was delivery
at 34wks after antenatal corticosteroids
 There was no benefit to expectant management beyond
37wks
 Most clinicians plan for delivery between 34 – 37 weeks
Diagnosis of percreta
 6. Vasa previa
Definition: bleeding from umbilical vessels.
Diagnosis: Apt test (hemoglobin alkaline denaturation
test.
Complications: bleeding is fetal in origin (mortality is
>75%).
Treatment: Emergent CS if fetus is viable.
Vasa Previa

 Fetal vessels coursing in the membrane cross the cervical os below

the presenting fetal part
 Incidence 1 in 5200 pregnancies
 Rupture of membranes can tear fetal vessels leading to exsanguination
 Fetal blood volume is so small (78mL/kg) that fetal death is almost
instantaneous
 Diagnosis by transvaginal ultrasound
Apt Test

The APT test is a qualitative procedure used to visually detect the pink
color of Fetal hemoglobin present in a stool or gastric specimen
Addition of 2-3 drops of alkaline solution to 1 ml of blood.

Fetal erythrocyte are resistant to rupture and the mixture will remain
red.
If the blood is maternal, erythrocytes will rupture and the mixture will
turn browne.
 Vasa previa

 Risk factors
 Bilobed, succenturiate, or low lying placenta
 Multifetal pregnancy
 IVF
6. Antepartum Haemorrhage Of
Unknown Origin

 Where there is no evidence of abruptio placentae,

placenta praevia, or
 cervical or vaginal (local) causes.
 Admit the mother to hospital to exclude an abruptio
that may not be clinically apparent.
 Do six hourly CTG until the bleeding stops; then daily
CTG.
 Observe for symptoms and signs of abruptio
placentae.
Antepartum Haemorrhage Of
Unknown Origin

 Observe for any evidence of

chorioamnionitis
 Discharge from hospital 24-48 hours
after bleeding has stopped.
 Assess the cervix before discharge to
excluded imminent preterm labour.
 Continue antenatal care at hospital, with
attention to fetal growth and fetal
movements.
Can APH be predicted?

• APH has a heterogeneous pathophysiology and cannot be

predicted.
• In a study investigating risk factors for placental
abruption, the authors concluded that abruption is
usually a sudden and unexpected obstetric emergency,
not predictable by means of known reproductive risk
factors.
• 70% of cases of placental abruption occur in low-risk
pregnancies.
Can APH be prevented?

• Women should be advised, encouraged and helped to change

modifiable risk factors (such as smoking and drug misuse e.g. cocaine
and amphetamine).
• There is limited evidence to support interventions to prevent APH
Bibliography

- Guidelines for Maternity care in SA , 2015

- Merks, medical manuals, www.msdmanuals.com
- London School of Hygiene & Tropical Medicine, London, UK.
jenny.cresswell@lshtm.ac.uk
Thank you