Antepartum Bleeding

ANTEPARTUM
BLEEDING
DEFINITION
Bleeding from or witihin the genital tract

in pregnancy between 20 to 24 week’s
gestation and the onset of labour
Affects 4-5% of all pregnancies
Associated with increased risks of fetal

and maternal morbidity and mortality
CAUSES
Placental Non - Placental

Vasa previa
O N
M M
Abruptio placenta Bloody show
T C O Trauma
S
MO Uterine rupture
Cervicitis
Placenta previa Carcinoma
Idiopathic
ABRUPTIO PLACENTA
DEFINITION
Is premature separation of a
normally implanted placenta,
may be precipitated by a
sudden increase in blood
pressure or trauma
INCIDENCE :
1 in 200 deliveries.
RISK FACTORS
Increased age & Hypertensive Preterm ruptured

Multiple gestation
parity disorders membranes
Polyhydramnios Smoking Cocaine use Prior abruption
Uterine fibroid Trauma

TYPES
PATOPHYSIOLOGY
 Hemorrhage
into the decidua
basalis → decidua
splits → decidural
hematoma →
separation,
compression,
destruction of the
placenta adjacent
to it
PRESENTATION
Vaginal bleeding
Uterine tenderness or back pain
Fetal distress
High frequency contractions
Uterine hyper tonus
IUFD
CLASSIFICATION
GRADE 0 GRADE 1
• Asymptomatic • External vaginal bleeding

• Small retroplacental clot • No signs of maternal
after delivery shock
• No evidence of fetal
distress
• Uterine tetany and
tenderness may be present
CLASSIFICATION
GRADE 3 GRADE 4
• External vaginal bleeding • External bleeding may or

may or may not be present may not be present
• Uterine tender and tentany • Marked uterine tetany
• No signs of maternal • Maternal shock
shock • Fetal death or distress
• Signs of fetal distress • Coagulopathy in 30% of
present the cases
DIFFERENTIAL DIAGNOSIS
Revealed Concealed
may present like placenta
Intraperitonial hemorrhage
previa or local causes
Ruptured uterus
Abdominal pregnancy
Acute polyhydramnious
Degenerated fibroid or
complicated ovarian cyst
Volvolus & Peritonitis

DIAGNOSIS
SIGNS AND SYMPTOMS
Manifestation Abdominal examination Vaginal

examination
• Bleeding • the uterus is hard, tender, tetanically
contracted;
• Pain • the uterus will gradually enlarge
(concealed bleeding);
• it is impossible to outline fetal parts
because of tenderness and the
contracted uterus;
• frequent uterine contractions of
lower amplitude;
• the fetal heart tones → normal /
absent
PLACENTAL ABRUPTION
SHOCK
CONSUMPTIVE
COAGULOPATHY
RENAL FAILURE
FETAL DEATH
DIAGNOSIS
LAB SONOGRAPHY
• hemoglobin - reduced; • Confirm fetal viability, assess fetal

• white blood cell count = 20,000 or growth & normality, measure
30,000; liquor, do umbilical artery Doppler
• the clotting defect → in about 10% velocities.
(in severe abruption associated • Exclude placenta praevia
with fetal death or brisk
hemorrhage);
• coagulation studies (platelet count,
prothrombin time, partial
thromboplastin time, fibrinogen,
test for fibrin split products);
ULTRASONOGRAPHY
MANAGEMENT
Principle of management:
1.Early delivery (50% of abruption present in labour).
2.Adequate blood transfusion.
3.Adequate analgesia.
4.Detailed maternal and fetal monitoring.
Coagulation profile (30% develop DIC).
C/S: distressed baby, severe bleeding, alive baby & not in
advanced labour. Perinatal mortality rate is 15-20%.
Vaginal delivery: very low gestation, dead baby, cervix is fully
dilated (Ventouse delivery).
Conservative: small abruption, well mother and fetus, if the
gestational age < 34, give steroids.
MANAGEMENT
• Conservative: Time taken to achieve delivery depends on:

• •rate of the bleeding.
• •The rate of change in the clotting studies.
• •The clinical condition of the mother and fetus.
• CTG: twice/day.
• Serial U/S and umbilical artery Doppler waveform.
• No conservative after 38 week’s gestation.
• Anti-D if the mother is rhesus positive.
• Anticipate PPH.
• In cases of previous CS, discuss hysterectomy
COMPLICATION
Maternal Fetal
Hypovolemia Hypoxia
DIC IUGR
Renal failure IUFD
Death Anemia
Uterine rupture
PROGNOSIS
• of 17% + neonatal mortality of

Fetal 14% (anoxia, complications of
mortality prematurity and maternal
hypertension).
Maternal • about 1% (hemorrhage, cardiac

failure, acute renal failure, acute
mortality hepatic failure).
PLACENTA PREVIA
DEFINITION
The presence of placental tissue overlying or proximate to the

internal cervical os after viability
4/1000 pregnancy
over 20 weeks
INCIDENCE
RISK FACTOR
Previous placenta
Increased
Multiparty previa, recurrence
maternal age
rate 4-8%
Previous cesarean
Multiple gestation Uterine anomalies
section
Maternal smoking
PATHOGENESIS
Endometrial scarring in the upper segment
Initial tropnoblastic nidation or unidirectional growth into

LS .
Increased placental surface to compensate for a reduction in

uteroplacental oxygen
CLASSIFICATION
Total placenta previa
The internal cervical os is covered

completely by placenta
Partial placenta previa
The internal os is partially covered by

placenta
Marginal placenta previa
The edge of the placenta is at the margin of

the intenal os.
DIAGNOSIS
CLINICAL PRESENTATIONS
• Painless vaginal bleeding – 70-80%
• 1/3 prior to 30 weeks
• Mostly during third trimester – shearing force from lower uterine
segment growth and cervical dilation
• Sexual intercourse
• Uterine contraction – 10-20%
• Soft uterus.
• Normal fetal heart rate (unless there is severe bleeding or associated abruption)
• High presenting part
• Fetal malpresentation (breech/transverse/oblique)
DIAGNOSIS
EXAMINATION
INSPEKUL ULTRASONOGRAPHY
Vaginal O
examination • Transvaginal is better than
transabdominal; the woman does not
is Contraindicated need full bladder and can determine the
placental edge in posterior PP.
• 5% of low lying placenta can be
diagnosed at 16-18 weeks but only 0.5%
have PP at delivery.
• in the second trimester, if the placenta
covers the internal os with an overlap >
2.5 cm and the placental edge is thick;
placenta praevia will persist
ULTRASONOGRAPHY
COMPLICATIONS
• •Preterm delivery.
• •Preterm premature rupture of membranes.
• •IUGR (repeated bleeding).
• •Malpresentation; breech, oblique, transverse.
• •Fetal abnormalities (double in PP).
• •↑ number of C/S.
• •Morbid placenta: placenta acreta(80%), increta and
percreta.
• •Postpartum haemorrhage: lower segment not contract
and retract.
DIFFERENTIAL DIAGNOSIS
Placental abruption  vagina bleeding

with pain, tenderness of uterus.
Vascular previa
Abnormality of cervix  Cervical erosion

or polyp or cancer
MANAGEMENT
NO VAGINAL
Admit to hospital
EXAMINATION
Placental
IV access
localization
MODE OF DELIVERY
Vaginal • placenta 4.5 cm from the internal os,

low head, no bleeding. Consider
delivery examination in theatre if in doubt
C/S (of • grade 4, 3, placenta within 2cm of the

internal os, high head, bleeding,
choice) presence of the added factors
THANK YOU

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ANTEPARTUM

Bleeding from or witihin the genital tract

Affects 4-5% of all pregnancies

Associated with increased risks of fetal

Placental Non - Placental

Increased age & Hypertensive Preterm ruptured

Polyhydramnios Smoking Cocaine use Prior abruption

Uterine fibroid Trauma

Uterine tenderness or back pain

High frequency contractions

Uterine hyper tonus

• Asymptomatic • External vaginal bleeding

• External vaginal bleeding • External bleeding may or

Volvolus & Peritonitis

Manifestation Abdominal examination Vaginal

• hemoglobin - reduced; • Confirm fetal viability, assess fetal

• Conservative: Time taken to achieve delivery depends on:

Renal failure IUFD

• of 17% + neonatal mortality of

Maternal • about 1% (hemorrhage, cardiac

The presence of placental tissue overlying or proximate to the

Endometrial scarring in the upper segment

Initial tropnoblastic nidation or unidirectional growth into

Increased placental surface to compensate for a reduction in

The internal cervical os is covered

Partial placenta previa

The internal os is partially covered by

Marginal placenta previa

The edge of the placenta is at the margin of

Placental abruption  vagina bleeding

Abnormality of cervix  Cervical erosion

Vaginal • placenta 4.5 cm from the internal os,

C/S (of • grade 4, 3, placenta within 2cm of the

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