ANTIPARTUM HEAMORRHAGE

PRESENTER
NSUBUGA IVAN MBCHB STUD 3.2 KIU
LIRA CENTER
DATE
23th / 2 /2022

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 OUTLINE

• Introduction
• Definition.
• Causes.
• Placenta previa
• Abruptio placentae
• Indeterminate causes

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Introduction
•20% of cardiac output is shunted to pregnant uterus - risk of catastrophy
following significant vaginal bleeding.
•Bleeding ranges from spotting to severe haemorrhage (life- threatening)
•Severe haemorrhage is much less common but leading cause of maternal and
foetal mortality & morbidity
• 4 - 5 % of pregnancies are complicated by vaginal bleeding in third tremester of
pregnancy
•commonest causes are placental (70%) i.e P.revia (35%) & abruptio placentae
(35%)
•Focussed, comprehensive history and physical exam crucial in assesing obstetric
bleeding

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Definition.
• Antepartum hemorrhage is pelvic bleeding which occurs between 24 wks of
pregnancy and the period just prior to delivery of the baby.
• Dc Duuta: is the bleeding from or into the genital tract after 28wks of pregnancy
but before the birth of the baby (1st and 2nd stage of labor included)

• Graded according to ammount of blood loss as ;

- Mild
- Moderate
- Severe , associated with shock.

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CAUSES
Vulva
• Varicose veins
• Tears or lacerations
Vagina
• Tears or lacerations
Cervix
• Polyp
• Cervicitis
• Carcinoma
Intrauterine
• Uterine rupture
• Placenta previa
• Placental abruption
Vasa previa

BLOODY SHOW: small amount of blood with mucus d/c may precede onset of labour by as much as
72 hrs
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 PLACENTA PREVIA
• Refers to placental implantion in the lower uterine segment.
Classified as ;
1. Low lying (type 1)- placental edge is in lower uterine segment but not reaching
internal os.
2. Marginal (type 2) - placenta reaches margin of internal os but doesn't cover it,
anaterior or posterior marginal
3. Incomplete (type 3) -placenta covers internal os partially when closed but not
when fully dilated
4. Complete (type 4) - placenta covers internal os fully even when fully dilated.
Also classified into
• Placenta previa major; type 2 posterior, 3 & 4.
• Placenta previa minor; type 1 and type 2 anterior.
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Epidemiology
• World wide 4 per 1000 births
• It is responsible for 35% of APH cases.
• In 80% of cases is found in multiparous women.
Risk factors.
• Increasing parity
• Advanced maternal age (>35 yrs)
• Multiple gestation
• H/o uterine surgery/ c/s, prior curettage
• H/o P. previa
• Prior uterine artery embolization
• maternal smoking , cocaine use
• assisted conception/ infertility treatment
• Male fetus @DE ORACLE HIGH PRIEST
CAUSES OF BLEEDING
In early pregnancy,
placental tissue growth rate synchronous with uterine distension but in second half
of pregnancy placental tissue growth stops amidst progressive uterine dilatation.
• The inelastic placenta is sheared off the walls of the lower segment.
• This leads to the opening up of the utero placental vessels hence bleeding .
• The blood is always maternal but fetal blood can also be lost(torn villi).
• Placental separation can also occur secondary to trauma caused by coitus actus,
obstetric procedures; V.E, external cephalic version.

•PATHOGENESIS: UNKNOWN: Hypothesis-DROPPING DOWN THEORY(fertilized

ovum drops down and implants in the lower segment probably due to poor
decidua reaction), in multiple pregnancy, large placental surface area increases
the probability that placenta will cover os, defective decidua.
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 CLINICAL PRESENTATION

• History of
✓Painless recurrent vaginal bleeding (bright red) with no cause. May be mild or
severe.
✓Often occurs during sleep, in most cases before 28wks of gestation.

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Physical examination
• General condition varies according to amount of blood loss.
• P/A.
✓Fundal heightproportionate to gestation period or bigger (? multiple gestation).
✓Uterus soft, relaxed, elastic, non-tender.
✓Floating presenting part in contrast to gestation age
✓fetal mal presentation (persistent following obs maneuvres )
✓Fetal heart sound normal, unless severe hemorrhage with(out) abruptio
placentae. Stallworthy’s sign read about it

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Continua….
• Vulvular inspection ; active bleed /bright red blood.
✓Digital V.E only done after uss ruling out grade 2 posterior, 3 &4 . Otherwise do
speculum VE for above types preffered to be done in a theatre setting ready for
intervention.
Complications.
• Maternal .
Antepartum
 anemia
✓ preterm labor.
✓APH.
Intrapartum
✓PROM
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Continua……

✓Slow dilatation of the cervix.

✓Retained placenta.-increased surface area, morbid adhensions
✓PPH ending into shock(30%)

Puerperium
• Sepsis due to ↑operative inteferences, placental site near to vaginal, anemia and
devitalised state of patient.
• Embolism
• subinvolusion

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• 

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Diagnosis
Note- Need for a high index of suspicion of pp following h/o painless pv bleeding in
second half of pregnancy
• Transvaginal ultrasound scan (at 20 wks & above)
• MRI - gold standard.
Ddx- abruption placentae, local cervical lessions, circumvallate placenta

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MANAGEMENT
• Emergency management may or may not be needed depending on
haemodynamic state.
• Definitive management can be expectant or active.
Choice depends on;
• Gestational age
• General fetal and maternal condition
• Extent of hemorrhage.

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Continua....
EXPECTANT MANAGEMENT(by Macafee and Johnson 1945)
• Aim - to continue pregnancy to allow fetal maturity with out compromising the
mother's life.
Indications
• No active bleeding
• Mother haemodynamically stable(hg >10g, haematocrit >30percent)
• Reassuring fetal well being ; FHR etc.
• Gestational age < 37 weeks
Mgt: determine whether previa resolves with increasing gestation age, or
morbidly adherent( placenta accreta spectrum), reduce risk of bleeding,
determine time for c/s if previa persists

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Continua....
Plan
• Bed rest, caution: risk of DVT
• periodic inspection of vulval pads to assess for active bleeding
• If Pv bleeding associated with uterine contractions, use of tocolytics(MgSO4,
indomethacin, nifedipine)
• Foetal surveillance with uss at 2-3 ws intervals
• Supplemental hematemics with(out) blood transsfusion
• Gestation age < 34 wks, -steroid therapy: dexamethasone, Betamethasone
reduces risk of respiratory distress in newborn preterm
• Investigations; CBC, blood group, urinanlysis
• Rh imunoglobulin to Rh D negative(unsensitized)
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mother
Continua.....

CONDITIONS FOR PRETERM DELIVERY.

• Recurrent active hemorrhage.
• IUFD
• congenital anomalies incompatible with life.

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ACTIVE MANAGEMENT
Plan : ABC if in shock
Monitor maternal blood loss and hemodynamic status
Cbc, blood grouping,
Fibrinogen levels, activated partial thromboplastin time, prothrombin time in
patients with suspected coexisting abruption
Monitor FHR
Blood transfusion
Delivery
Indications for emc/s
• significant Pv bleeding at 34 wks or more
• Mother in active labor
• Foetal distress unresponsive to resuscitative measures
• Congenital anomalies incompatible with life
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•Severe and persistent vaginal bleeding such that maternal hemodynamic
Continua....
•P.previa grade 2 posterior, 3 & 4 ; Caesarian delivery
•P.previa grade 1 & 2 anterior ; vaginal or caesarian delivery
Case scenarios
1. minimal pv bleeding , good general condition at <37 WOA.
- conservative mgt
2. Pregancy at <37 WOA, moderate pv bleeding mildly affecting mother's life
- close monitoring , transfuse blood.
aim - prolonging pregnancy until fetal maturity then delivery afterwords
3. Severe pv beeding compromising mother's life ,irrespective of fetal maturity
- terminate the pregnancy
- deliver by c- section and transfer the new born to ICU.
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SVD
-Mother hemodynamically stable with IUFD or fetus without chance of
extrauterine survival
-- previa grade 1 and 2 anterior
C/S PREPARATION
Plan for possibility of PPH
Book blood( 2-4 units of packed cells)
Plan for hysterectomy incase of accreta
Avoid disrupting placenta, if incised, fetal vessels-fetal anaemia, deliver fetus
rapidly and clamp cord proptly
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Anaesthesia
For elective c/s- S/A
Actively bleeding or emc/s- general anaesthesia prefered.

PREVENTION
• Adequate antenatal care to improve the health status and correction of
anemia.
• Antenatal dx of low lying placenta at 20wks need confirmation at 34wks.
• Significance of warning hemorrhage should not be ignored .

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In case of c/section
lower incision vs classical incision.
•Lower incision advs
1. Conversant technique, 2. bleeding sinuses at site can be better
dealt with under direct vision and decision to preserve or remove
the uterus can be made.
3. Placenta accreta if found can be effectively tackled
Disadvs
4. Profuse bleeding incase of cut of the engorged vessels in anterior
lower segment
5. In anteriorly situated placenta, the placenta has to be cut and
seperated to deliver the baby, this cause massive hemorrhage
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Continua….
3. Risk of fetal exsangiution
4. Risk of cesarean hysterectomy
Classical incision
Advs
•Operation can be done more quikly
•Baby delivered without disturbing the placenta
•No risk of fetal exsangiution
•In case of acretta, placenta maybe left in situ if no bleeding
•Uterus maybe preserved Disadv- no visualisation of lower segment
•QN-why is placenta previa typeII posterior refered to as dangerous
type? @DE ORACLE HIGH PRIEST
 ABRUPTIO PLACENTAE
• Abnormal premature separation of otherwise normally implanted placenta
before delivery
CLASSIFICATION.
A).
• Revealed - commonest type.
• Concealed.
• Mixed.
B). clinical classifiction
• Grade 0 - Assymptomatic. clinical features may be absent, dx made after
inspection of the placenta after delivery.
• Grade1 - mild. Slight pv bleeding, uterus irritable, minimal or absent uterine
tenderness, maternal BP and fibrinogen levels are unaffected, FHR is good. 40%
of cases

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continua..

• Grade 2 - moderate. Mild to moderate pv bleeding, uterine tenderness is always

present with possible contractions, maternal tachycardia + orthostatic changes in
BP and HR, Hypofibrinogenemia (<250 mg/dl), shock is absent, fetal distress or
death occurs. 45% of cases
• Grade 3 (15%) bleeding is moderate to severe or may be concealed, marked
uterine tenderness with tetany , pronounced maternal shock , fetal death,
associated coagulopathy & hypofibrinogenemia (<150).
C)
- complete abruption
- Partial abruption
- Marginal abruptio
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Continua….
• EPIDEMIOLOGY.
• Overall incidence is about 0.5%.
• Significant cause of perinatal mortality (15 to 20%) and maternal mortality (2 to
5%).
Risk factors.
• hypertensive disorders-vasospasm(decidual spiral artery)-anoxic endothelial
damage-rupture
• folic acid deficiency
• trauma
• short umbilical cord-mechanical pull during labor
• grand multiparity
• prolonged ROM (> 24 hrs)
• chorioamnionitis
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Continua….
• Drugs; Cocaine (↑ transiet hypetension, vasospasm, and placental abruption)
• maternal age > 35 & <20 yrs.
• sudden decompression of uterus-delivery of 1st baby in twins,sudden escape of
liquor amnii in hydramnios,PROM
• Premature rupture of membranes.
• Malnutrition.
• Smoking (vasospasm)
• Placental abnormalty e.g circumvallate placenta.
• Sick placenta anomaly; poor placentation evidenced by abnormal uterine artery
Doppler wave forms is associated with placenta abruptio.
• Uterine factors; septate placenta, submucosal fibroids.
• Thrombophilias-placenta infarcts and abruption
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PATHOPHYSIOLOGY

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Clinical presentation
clinical features depend on;
✓site of separation
✓severity of haemorrhage
✓Amount of blood concealed in the uterine cavity.
✓Concealed vs revealed
• Pv bleeding
• Abdominal pain
• lower back pain (posteriorly implanted placenta)
Read about: Couvelaire uterus(uteroplacental apoplexy)- only diagnosed on
laparatomy
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Investigations.
• Ultrasonography; at times negative findings in presence of p. abruptio
hence a high index of suspicion important.
Ddx
Revealed type
Planceta previa
Mixed type
-rupture of uterus, rectus sheath hematoma, appendicular or intestinal
perforration, twisted ovarian tumor, acute hydramnios, tonic uterine contractions
Essential pnts for Dx of concealed type:
-shock out of proportion to external bleeding, unexplained extreme pallor,
presence of preeclamptic features, uterus is tense, tender and woody hard, FHS is
absent, diminished urinary output, presence of coaugulopathy
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Management.
✓ Assess the maternal vitals and FHR.
✓Rescucitaion +-
✓blood draws; cbc, Coagulation profile (PT, FDPs), RFTs & electrolytes, blood group
& x-match
✓Brief careful speculum examination to establish uterine bleeding
✓foleys catheterisation - monitor urinary output
✓ quick establishment of gestational age

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Mgt cntd.
Definitive mgt is delivery.
The timing and method of delivery depend on
•maternal & foetal condition
•gestational age
•cervical status
case scenarios
•1. Premature foetus with mild abruption + minimal bleeding- expectant mgt
•2. As in case 1 above + uterine contractions - use a tocolytic (Mgso4). cts
monitoring for s/s of deteroriation
•3. Premature foetus, with persistent heavy vaginal bleeding - expeditious delivery
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Indication for C/section

•Severe abruption with a live fetus

•Amniotomy couldnot be done due to unfavorable cervix
•Prospect of immediate vaginal delivery despite rupture of
membranes is remote
•Amniotomy failed to control bleeding
•Rising fundal height despite amniotomy
•Appearance of adverse features(fetal distress, oliguria…

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Complications.
Maternal
• Haemorrhage
• Hemorrhagic shock
• Blood coagulation disorders
• DIC (consumptive coagulopathy)
• Peurperal sepsis
• Renal failure( read about role of serotonin released due to uterine damage in
renal ischeamia)

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 Foetal
•IUGR
•Preterm birth
•preinanatal death

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Prevention.
• Early detection and effective managemen at antnatal care; routine USS (placental
location etc), folic acid , family planning
• Needle puncture during amniocentesis should be under ultrasound guidance.
• Avoidance of trauma e.g during external cephalic version under anesthesia.
• Advise mother to lie in the left lateral position in the later month of pregnancy to
avoid supine hypotension.-passive engorgement of uterine&placental vessels-
rupture&extravasation of blood
• Routine administration of folic acid.-its value is still doubtful

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Differences between PP and AP
o/e
PP AP
• FH proportionate to gestation age. • Enlarged in concealed type.
• Uterus soft and relaxed • May be tense, tender and rigid and
• Malpresentation is common. woody hard
• FHS usually present. • Unrelated
• USG placenta in the lower segment. • Usually absent.
• V.E placenta felt in the lower segment. • Placenta in the upper segment.
• Placenta not felt.

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Differences between PP and AP

Placenta previa abraptio placenta.

• Painless, causeless, reccurent • Painful, often attributed to
bleeding. preeclampsia or trauma and
continuous.
• Bright red blood • Dark colored blood.
• Gc and anemia are proportionate to • Out of proportion to the visible blood
visible blood loss. loss in concealed or mixed variety.
• Features of pre eclampsia not • Present in 1/3 of cases.
relevant.

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UNDETERMINATE BLEEDING.
• This should be done after exclusion of placenta previa, abruptio placentae and
local causes.
✓Rupture of vasa previa
✓Marginal sinus hemorrhage.
✓Circumvallate placenta.
✓Marked decidua reaction on endocervix.

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 VASA PREVIA.
• The unsupported vessels in velamentous placenta, lie below the presenting part
and across the cervical os.
• These vessels are torn either spontenously or during rupture of membranes.
Color flow Doppler is helpful for antenatal dx.
• Fetal mortality is high 50% due to fetal exsanguination.
• Detection of nucleated red blood cells( singers alkali denaturation test) or fetal
hemoglobin is dx.
• Vaginal bleeding is often associated with fetal distress ( tachycardia, sinusoidal
FHR tracing)

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 MANAGEMENT
• Depends on gestation age, severity, persistence or recurrence of bleeding and the
presumed cause of bleeding.
• A pregnancy >37 wks and bleeding recurrent, delivery is recommended. The
mode of delivery depends on the state of the fetus and other associated
factors(cervix).
• Expectant management can be done in selected cases for fetal maturity. Similar
to placenta previa.
• Fetal monitoring must be carefully be done. Intrapartum dx of vasaprevia, needs
expeditious delivery, neonatal blood transfusion may be needed.

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DOMO ARIGATOGOZAIMASU
“ ANAZITATE PANTA TI GNOSI” By nsubuga ivan

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