Antepartum haemorrhage

Obstetrics

2. CAUSES
Placenta praevia
Abruptioplacenta
Local causes like polyp,cancercervix,varicose
veins and local trauma
Circumvallateplacenta
Vasapraevia
Unclassified or indeterminate haemorrhage

3. ABRUPTIO PLACENTA
DEFINITION
•It is defined as hemorrhage
occuringduring pregnancy due to
separation of normally situated
placenta.
•Also called accidental hemorrhage
or premature separation of
placenta.

4. GRADING
Sherand statland’sgrading
It is of prognostic significance and
differentiates between a live and
dead fetus.
GRADE 1:Unrecognised clinically
before delivery,butevidence of
retroplacentalclots on examining
the placenta

5. GRADE 2:Intermediate with
classical signs of abruption,butno
maternal distress and live fetus
GRADE 3:severe abruption with the
fetus dead
A.withcoagulpathy
B.withoutcoagulopathy

6. INCIDENCE
1% and is leading cause for perinatal
mortality

7. AETIOLOGY
The following are some of the risk
factors that are implicated
1.Medical factors
Preeclampsia and hypertension are
associated in 50% cases
Another strong correlation is with
chorioamnionitissecondary to
preterm premature rupture of
membranes

8. 2.Thrombophilias
Congenital and acquired thrombophilias
are associated with abruption.
Aquiredtype is antiphospholipid
syndrome-thrombosis,recurrent
miscarriage,earlyonset of preeclampsia
and fetal growth restriction in addition to
abruption
Congenital ,includes prothrombingene
mutation factor v mutation protein C and S
deficiency are also associated with
abruption

9. 3.Hyperhomocystinaemia
Elevated levels of homocysteine-damage
vascular endothlium-causes abruption
This is the basis for association noticed
in women with folatedeficiency
4.trauma
Blunt trauma to the abdomen
Amniocentesis
External cephalic version
Sudden uterine
decompression(hydramniosand
following delivery of 1
st
twin)

10. 5.Other associations
Previous abruption
Smoking and cocainabuse
Raised serum αfetoprotein level
Myomasesp. submucusmyomas

11. CLASSIFICATION
Vasospasm→myometrial
contraction→venousengorementand
arteriolar rupture into deciduabasalis
→dev. of decidualhematoma→
seperationof placenta
Abruption is divided into 3 based on
the type of hemorrhage:
Revealed(60%):
effused blood dissects the membranes
away from the uterine wall and make
its way through cervix into vagina.

12. Concealed(35%):
blood is retained in the uterus
Due to loss of tone of uterine muscle and
absence of uterine contractions
Uterus distends to accommodate the
blood
Sometimes amnion may rupture and
there is bleeding into amniotic sac
Concealed type is more likely to lead to
couvelaireuterus and cause fetal demise
and maternal complications

13. Mixed(5%):
In this partly revealed and partly concealed

14. COUVELAIRE UTERUS
There can be extensive extravasationof blood into uterine
musculature beneath serosaesp. in concealed type.
uterus show ecchymosesand tubes and ovaries drain blood.
Peritoneal cavity is also filled with blood.
This is called couvalaireuterus or uteroplacentalapoplexy.
Already there is fetal hypoxia due to placental seperation
Tetaniccontraction brought about by the seepage of blood
into myometriumin abruption cause ↑sedintrauterine
pressure.
this cuts off placental blood flow adding to fetal
hypoxia.thussudden fetal death is common.
Concealed abruption is more likely to lead to couvelaire
uterus and cause fetal demise and maternal complications

16. DIAGNOSIS
SYMPTOMS
Severe and constant abdominal
pain(more in concealed and less in
revealed)
Bleeding is present in revealed and
mixed types but may be absent in
concealed type.

17. SIGNS
Pallor which is out of proportion to the
extent of bleeding
Hypertension(if there is associated
preeclampsia)
Uterus larger than the expected for the
period of amenorrhoea
Uterus may be tense and tender and
even rigid(woody hard)
Difficulty in palpating underlying fetal
parts easily
Fetal distress or absent FHS.

18. In revealed uterus fundalheight may
correspond to period of gestation
FHS are present
Initial presentation may be as preterm
labourwith an irritable uterus and there
should be a high index of suspicion
Due to association of preeclampsia BP
may be normal even with severe
abruption.Hencefindngof a normal BP
is not always reassuring

19. VAGINAL EXAMINATION
Performed after ruling out placenta praevia
Usually patient will be in labourwith fixed
presenting part and on artificial rupture of
membranes,liquorwill appear to be uniformly blood
stained
ULTRASOUND
Less significant role
Mainly useful to rule out placenta praevia
Sometimes retroplacentalhematoma may be seen
Negative findings do not exclude abruption
Abruption is essentially a clinical diagnosis and not
an ultrasound diagnosis

20. DIFFERENTIAL DIAGNOSIS
Placenta praevia
Other causes of APH
Preterm labour
Acute polyhydramnios(absence of pallor and
ultrasound is diagnostic)
Rupture uterus(esp. incomplete rupture)
Red degeneation,pyelonephritis,andother causes
of acute abdomen

21. COMPLICATIONS
MATERNAL
1.shock
2.renal failure
3.disseminated intravascular coagulation
(liberation of thromboplastinfrom placenta →intravascular
coagulation→ consumption of all coagulation factors →
fall in fibrinogen level →bleeding).
4.Postpartum hemorrhage(due to atonicityand
coagulation failure)
FETAL
1.Prematurity
2.Hypoxia and fetal death

22. MANAGEMENT
Immediademanagement
Similar in all cases of APH
Resuscitation with blood and crystalloids and prompt
delivery
Blood transfusion
Indwelling catheter introduced and monitered
Central venous pressure line inserted
Blood taken for Hb,PCV,grouping,crossmatching and
coagulation profile
Coagulation profile includes fibrinogen ,fibrin
degradation products , partial thromboplastintime,
prothrombintime and platelet count
(best marker –fibrinogen)
Clotting time,clotretractontest,stabilityof the clot is
also looked for
Ultrasound to confirm normal placenta and live fetus

23. Obstetricmanagement
Immediate delivery is vital in abruption
Mode of delivery depends on gestational
age and condition of mother and fetus
fetus is alive
Ceasarianis the best method
In mild cases of revealed
abruption,imminentvaginal dliveryis
carried out

24. Fetus is dead
Vaginal delivery preferred unless bleeding is so severe or
there are other obstetric complications
Hence artificial rupture of membranes and immediate
infusion of oxytocinto hasten delivery
If delivery is not imminent after reasonable
time,caesareansection may have to be resorted to
Caesarean section
Done by experienced person with the help of an expert
anaesthetist
PPH must be anticipated
Indications for caesarean section:
Fetus is alive and capable of survival
Severe bleeding and vaginal delivery is not imminent
Failure to progress after artificial rupture of membranes
and oxytocin

25. oCoagulation failure
oIt is treated by blood tranfusion
oHuman recombinant activated factor
vii is best agent but very expensive
oCryoprecipitate used if fibrinogen is
very low
oVaginal delivery is preferred ,if
caesarean becomes
neccesary,coagulationdefect is
corrected before proceeding.
oPlenty of cross matched boodshould
be available

28. OTHER TYPES OF APH
CIRCUMVALLATE PLACENTA
In this condition chorionic plate which is on the fetal
side is smaller than than basal plate on maternal side
Fetal surface of placenta presents a central
depression surrounded by thickened greyishwhite ring
These pregnancies may be complicated by IUGR,↑sed
chance of fetal malformations
Bleeding is usually painless
Antenatal diagnosis is unlikely and diagnosis usually
made after examination of placenta post delivery

30. VASA PRAEVIA
When the fetal vessels in the membrane cross the
region of the internal osand are ahead of
presenting part the condition is called vasa
praevia.
Occurs in 2 situations
Type 1-velamentous to cord insertion where cord
insertion is into the membranes
Type 2-presence of fetal vessels running between
lobes of a placenta with one or more accessory
lobes
these can remain undiagnosed and andit can
rupture during artificial rupture of membranes
leading to death of the fetus

32. Aptstest or singer’s alkali denaturationtest can
be used to confirm vasapraevia
Principle-fetal Hbmore resistant to alkali
denaturation
When water and blood are mixed with NaOHit
remains pink for longer if fetal in origin or turns
yellow brown in 2 min if maternal in origin
Risk factors-
Succenturiatelobe
Multiple pregnancy
IVF

33. Sometimes vessels can b palpated on vaginal
examination
Prenatal diagnosis is rarely possible by
ultrasound and doppler
Vaginal bleeding associated with variable
deccelerationson cardiotocographyalerts one to
diagnose vasapraevia

34. Unclassified or intermediate APH
Exact cause of APH is unknown
There is mild bleeding but no features of
abruption or placenta praevia
Speculum examination may not reveal local
cause
Apt test-exclude VP
IUGR and poor perinataloutcome are
associated
If there is recurrent bleeding and GA is 37
weeks or more,riskfactors like fetal growth
restriction delivery is preferred
In majority of cases marginal sinus rupture
is later found to be the cause