Antepartum haemorrhage

Presentation for medical personnel on management of APH

1. ANTEPARTUM
HAEMORRHAGE
Presented by HamzatZaheed

2. Introduction
•Death from hemorrhage still remains a leading cause of maternal mortality.
•APH is defined as bleeding from the genital tract in pregnancy from the age of
viability(24 week’s gestation –WHO but 28wks in Nigeria) and the onset of labour.
•It affects 4% of all pregnancies. It is a medical emergency.
•It is associated with increased risks of fetal and maternal morbidity and mortality.

3. Causes

4. PLACENTA PREVIA
•Is defined as the implantation of placenta partially or wholly in the lower uterine
segment.
•About one-third cases of antepartum hemorrhage belong to placenta previa. The
incidence of placenta previa ranges from 0.5–1% amongst hospital deliveries. In
80% cases, it is found in multiparous women.

5. ETIOLOGY
•The exact cause of implantation of the placenta in the lower segment is not
known.
•The following risk factors are identified:
Advancing maternal age
Multiparity
Multifetal /multiple gestations
Prior caesarean delivery
Smoking
Prior placenta previa
Uterine structural anomaly
Assisted conception

6. TYPES OR DEGREES
•Type—I (Low-lying): the placental edge is in the lower uterine segment but does
not reach the internal os
•Type—II (Marginal): The placenta reaches the margin of the internal osbut does
not cover it. Divided into anterior and posterior.
•Type—III (Incomplete or partial central): The placenta covers the internal os
partially (covers the internal oswhen closed but does not entirely do so when
fully dilated).
•Type—IV (Central or total): The placenta completely covers the internal oseven
after it is fully dilated.

7. Degrees of placenta previa with findings on ultrasound examination

8. CAUSE OF BLEEDING
•Bleedingresultsfromsmalldisruptionsintheplacentalattachmentduring
normaldevelopmentandthinningoftheloweruterinesegment
•Astheplacentalgrowthslowsdowninlatermonthsandthelowersegment
progressivelydilates,theinelasticplacentaisshearedoffthewallofthe
lowersegment.Thisleadstoopeningupofuteroplacentalvesselsand
leadstoanepisodeofbleeding.

9. CLINICAL FEATURES
•Bleeding: usually mild but it could be severe; recurrent, painless and
causeless.
•Soft and non-tender uterus
•Normal fetal heart rate (unless there is severe bleeding or associated
abruption).
•High presenting part.
•Fetal malpresentation(breech/transverse/oblique).
•General condition and anemia are proportionate to the visible blood
loss

10. Abdominal examination
•Thesizeoftheuterusisproportionatetotheperiodofgestation
•Theuterusfeelsrelaxed,softandelasticwithoutanylocalizedareaoftenderness.
•Persistenceofmalpresentation.Thereisalsoincreasedfrequencyoftwin
pregnancy.
•Theheadisfloatingincontrasttotheperiodofgestation.Theheadcannotbe
pusheddownintothepelvis.
•Fetalheartsoundisusuallypresent.
•Vulvalinspection:thebloodisbrightredasthebleedingoccursfromthe
separatedutero-placentalsinusesclosetothecervicalopeningandescapesout
immediately
•Vaginalexaminationiscontraindicated

11. DIAGNOSIS: Painless and recurrent vaginal bleeding in the second half of pregnancy
should be taken as placenta previa unless proved otherwise. Ultrasonography is the
initial procedure either to confirm or to rule out the diagnosis
I. Localization of placenta
• Sonography
––Transabdominal ultrasound
(TAS)
––Transvaginal ultrasound (TVS)
––Transperinealultrasound
––ColorDoppler flow study
•Magnetic resonance imaging
(MRI)
II. Clinical
––By internal examination (double
set up examination)
––Direct visualization during
caesarean section
––Examination of the placenta
following vaginal delivery

12. MANAGEMENT
•PREVENTION:
—Adequate antenatal care
—Antenatal diagnosis at 20th week
—Significance of “warning hemorrhage” should not be ignored
TREATMENT ON ADMISSION
•IMMEDIATE ATTENTION: Overall assessment of the case is quickly
made as regards :
(1) Amount of the blood loss —by noting the general condition, pallor,
pulse rate and blood pressure;
(2) Blood samples are taken for group, cross matching and estimation
of hemoglobin;

13. (3) A large-bore IV cannula is sited and an infusion of normal saline is
started and compatible cross matched blood transfusion should be
arranged;
(4) Gentle abdominal palpation to ascertain any uterine tenderness and
auscultation to note the fetal heart rate
(5) Inspection of the vulva to note the presence of any active bleeding.
•FORMULATION OF THE LINE OF TREATMENT:
•The definitive treatment depends upon the duration of pregnancy,
fetal and maternal status and extent of the hemorrhage.

14. Expectant management
•Theaimistocontinuepregnancyforfetalmaturitywithoutcompromisingthematernal
health.
Conduct of expectant treatment:
•StrictBedrest;
•Investigations—likehemoglobinestimation,bloodgroupingandurineforproteinare
done;
•PeriodicinspectionofthevulvalpadsandfetalsurveillancewithUSGatintervalof2–3
weeks;

15. •Supplementary hematinicsshould be given and the blood loss is
replaced by adequate cross matched blood transfusion, if the patient
is anemic;
•Steroid for lung maturation if gestational age is less than 34 weeks
•Use of tocolysis(magnesium sulfate) can be done if vaginal bleeding is
associated with uterine contractions;
•Rh immunoglobin should be given to all Rh negative (unsensitized)
women.

16. Active Management-Delivery
1.Bleeding occurs at or after 37 weeks of pregnancy
2.Patient is in labor
3.Fetal distress
4.Torrential Bleeding
5.Congenital anomaly not compatible with life
6.Intrauterine fetal death
Cesareandeliveryisdoneforallwomenwithsonographicevidenceof
placentapreviawhereplacentaledgeiswithin2cmfromtheinternal
os.Itisespeciallyindicatedifitisposteriororthick

18. Complications
•MATERNAL
•During pregnancy: Antepartum haemorrhage, Malpresentation,
Preterm labour.
•During labour: PROM, Cord prolapse, Intrapartum hemorrhage,
Increased incidence of operative interference, Postpartum
hemorrhage, Retained placenta, Shock.
•Puerperium: Sepsis, Subinvolution, Embolism
•FETAL: Low birth weight, Asphyxia, Intrauterine death, Birth injuries.

19. ABRUPTIO PLACENTAE
•It is one form of antepartum hemorrhage where the bleeding occurs
due to premature separation of normally situated placenta after the
age of viability.
•Occurs in 1-2% of all pregnancies
•Perinatal mortality rate associated with placental abruption was 119
per 1000 births compared with 8.2 per 1000 for all others.

20. Types
(1)Revealed : Following separation of the placenta, the blood comes
out of the cervical canal to be visible externally.
(2)Concealed : The blood collects behind the separated placenta or
collected in between the membranes and decidua.
(3)Mixed : In this type, some part of the blood collects inside
(concealed) and a part is expelled out (revealed).
(A) Concealed; (B) Revealed; (C) Marginal (subchorionic) and; (D) Preplacental (subamniotic)

21. CLINICAL CLASSIFICATION
Grade—0: Clinical features may be absent. The diagnosis is made after
inspection of placenta following delivery.
Grade—1 (40%): (i) Vaginal bleeding is slight (ii) Uterus: irritable, tenderness
may be minimal or absent (iii) Maternal BP and fibrinogen levels unaffected
(iv) FHS is good.
Grade—2 (45%): (i) Vaginal bleeding mild to moderate (ii) Uterine tenderness
is always present (iii) Maternal pulse ↑, BP is maintained (iv) Fibrinogen level
may be decreased (v) Shock is absent (vi) Fetal distress or even fetal death
occurs.
Grade—3 (15%): (i) Bleeding is moderate to severe or may be concealed (ii)
Uterine tenderness is marked (iii) Shock is pronounced (iv) Fetal death is the
rule (v) Associated coagulation defect or anuria may complicate

22. Risk factors
•The primary cause of placental
abruption is unknown, but there
are several associated conditions.
•Increased age and parity
•Preeclampsia
•Chronic hypertension
•Preterm ruptured membranes
•Multifetal gestation
•Hydramnios
•Cigarette smoking
•Folic acid deficiency
•Thrombophilias
•Cocaine use
•Prior abruption
•Uterine leiomyoma
•External trauma

23. Clinical Presentation
•Bleeding: revealed/concealed, so clinical picture is important.
•Pain on the uterus and this increases in severity.
•Signs of shock (hypovolaemia): fainting and collapse.
•Woody hard tender uterus ( uterine tetany).
•Couvelaireuterus (Bluish uterus)
•Difficult to palpate the fetal parts and to hear the fetal heart.
•Normal fetal lie and presentation
•Ultrasonography: is done to confirm fetal viability, assess fetal
growth & normality, measure liquor.

24. MANAGEMENT
•Treatment for placental abruption varies depending on gestational
age and the status of the mother and fetus.
•Admit
•History & examination
•Assess blood loss
•Nearly always more than revealed
•IV access, X match, DIC screen
•Assess fetal well-being
•Placental localization

25. Principle of management
Early delivery (50% of abruption present in labour).
Adequate blood transfusion.
Adequate analgesia.
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
(Ventousedelivery).
Conservative: small abruption, well mother and fetus, if the
gestational age < 34, give steroids

27. COMPLICATIONS
•MATERNAL: Shock, Blood coagulation disorders, Oliguria and anuria,
Postpartum haemorrhage, Puerperal sepsis, Acute renal failure: acute
tubular or cortical necrosis.
•FETAL: IUGR, Anaemia, Premature delivery, Fetaldistress and death

29. VASA PRAEVIA
•Rarelyreportedconditioninwhichthefetalvesselsfromtheplacenta
crosstheentrancetothebirthcanal.
•Incidencevariesoccurrencein1:3000pregnancies.
•Associatedwithahighfetalmortalityrate(50-95%)whichcanbe
attributedtorapidfetalexsanguinationresultingfromthevessels
tearingduringlabor

30. Causes
•There are three causes typically noted for vasa praevia:
•Bi-lobed placenta
•Velamentousinsertion of the umbilical cord
•Succenturiate (Accessory) lobe

31. Risk factors
•Bilobed and succenturiate placentas
•Velamentousinsertion of the cord
•Low-lying placenta
•Multiple gestation
•Pregnancies resulting from in vitro fertilization
•Palpable vessel on vaginal exam

32. Symptoms
•Usually asymptomatic
•Sudden onset of painless bleeding in second or third trimester or at
rupture of membranes
•No sign or symptom of placenta praeviaor abruption
•IUGR
•Congenital malformation
•Abnormal fetal heart rate.

33. MANAGEMENT
•Detection of nucleated red blood cells (Singer’s alkali denaturation
test) or fetal hemoglobin is diagnostic.
•Management depends on fetal gestational age, severity, persistence
or recurrence of bleeding, and the presumed cause of bleeding
•Pregnancy > 37 weeks 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
done. Intrapartum diagnosis of vasa previa, needs expeditious
delivery. Neonatal blood transfusion may be needed.

34. THANKS