Antepartum Haemorrhage Presentation- Dr. Jauyo.pdf

CME presentation slides on Antepartum Haemorrhage

Bleeding from or in to the genital tract, occurring from 24
weeks (>500g) of pregnancy and prior to the birth of the
baby

1. ANTEPARTUM
HAEMORRHAGE
Austin Jauyo –MBChB
NYSCH CME
APH

2. Definition
Definedas:
■Bleedingfromorintothegenitaltract,occurringfrom24
weeks(>500g)ofpregnancyandpriortothebirthofthe
baby.
■Complicates3–5%ofpregnancies.
■Leadingcauseofperinatalandmaternalmortality
worldwide.
■Uptoone-fifthofverypretermbabiesarebornin
associationwithAPH
■Mostofthetimeunpredictable.
APH

3. Severity
Assessing severity:
■No consistent definitions of the severity of APH.
■Amount of blood lost is often underestimated.
■Amount of blood coming from the introitusmay not
represent the total blood lost ( e.gin a concealed placental
abruption).
■It is important to assess for signs of clinical shock.
■The presence of fetal compromise or fetal demise is an
important indicator of volume depletion.
APH

4. Severitycont’d
But maybe:
■Spotting–staining, streaking or blood spotting noted on
underwear or sanitary protection.
■Minor haemorrhage–blood loss less than 50mlthat
has settled.
■Major haemorrhage–blood loss of 50–1000ml, with
no signs of clinical shock.
■Massive haemorrhage–blood loss greater than 1000
mland/or signs of clinical shock.
■Recurrent APH-> one episode.
PMTCT

5. Etiology
Placental causes
■Placental abruption
■Placenta previa
■Vasa previa
Bleeding disorders
■Congenital (von willebrand’s
disease)
■Acquired ( DIC)
Causes in Genital Tract
■Labour-Excessive show
■Rupture of uterus
■Trauma
■Infection (cervicitis &
vulvovaginitis)
■Tumours
■Cervical ectropion, polyps
Unexplained APH
APH

6. A 34-year-old multigravida at 31 weeks’
gestation comes to the labor unit stating she
woke up in the middle of the night in a pool
of blood. She denies pain or uterine
contractions. Examination of the uterus
shows the fetus to be in transverse lie. Fetal
heart sounds are regular at 145 beats/min.
On inspection her perineum is grossly
bloody

7. Placenta Praevia(PP)
■Implantation of placenta over or near the internal
osof cervix.
APH

9. Placenta Praevia(PP)
Placenta PraeviaTriad
■Late trimester bleeding (2
nd
& 3
rd
)
■Lower segment placental implantation
■No pain

10. What are the risk factors for placenta praevia?
Abruption is more likely to be related to
conditions occurring during pregnancy
and placenta praeviais more
likely to be related to conditions
existing prior to pregnancy.

11. Risk factors for placenta praevia?
■Previous placenta praevia(4-8%)
■Previous caesarean sections ( risk with numbers of c-section)
■Previous termination of pregnancy
■Multiparity
■Advanced maternal age (>40 years)
■Multiple pregnancy
■Smoking
■Deficient endometrium due to presence or history of:
●uterine scar
●endometritis
●manual removal of placenta
●curettage
●submucousfibroid APH

12. A 32-year-old multigravida at 31 weeks’
gestation is admitted to the labor
unit after a motor-vehicle accident. She
complains of sudden onset of moderate
vaginal bleeding for the past hour. She has
intense, constant uterine pain
and frequent contractions. Fetal heart
sounds are regular at 145 beats/min. On
inspection her perineum is grossly bloody.

13. AbruptioPlacenta (AP)
■Separation of normally located placenta after 22 weeks of
gestation ( > 500g) and prior to delivery of fetus.
PMTCT

14. ■Revealed
■Concealed
■Mixed

15. What are the risk factors for AbruptioPlacenta?
Abruption is more likely to be
related to conditions occurring
during pregnancy and placenta
praeviais more likely to be related to
conditions existing prior to pregnancy.

16. Risk factors for AbruptioPlacenta ?
■Previous history of AP
■Maternal hypertension
■Advanced maternal age
■Trauma ( domestic violence, accident, fall)
■Polyhydramnios
■Intrauterine infections
■Non-vertex presentations
■Short umbilical cord
■Sudden decompression of uterus (PROM/delivery of 1st twins)
■Retroplacentalfibroids
■Fetal growth restriction
APH

17. Risk factors for AbruptioPlacenta ?
■Smoking/alcohol/cocaine/amphetamines
■Low body mass index (BMI)
■Idiopathic
■First trimester bleeding increases the risk of abruption later in
the pregnancy
■When an intrauterine haematomais identified on ultrasound
scan in the first trimester, the risk of subsequent placental
abruption is increased
APH

18. AbruptioPlacenta
■Diagnosed CLINICALLY
●Painfulvaginal bleeding -80%
●Tense/woody hard, and tender abdomen/back pain
(70%) increase in fundal height
●Fetal distress ( 60%)
●Abnormal uterine contractions (hypertonic and high
frequency)
●Preterm labour( 25%)
●Fetal death ( 15%)
●Ultrasound is NOT USEFUL to diagnose AP;
retroplacentalclots (hyperechoic) easily missed

19. Vasa Praevia(VP)
●Present when fetal
vessels traverse
the fetal
membranes over
the internal
cervical os.
PMTCT

20. Vasa Praevia(VP)
■Antenatal diagnosis –reduced perinatal mortality and morbidity.
■Painless vaginal bleeding at the time of spontaneous rupture of
membrane or post amniotomy
■Fetal bradycardia;
■Fetal shock or death can occur rapidly at the time of diagnosis
due to mainly fetal blood loss; blood volume in fetus ( 3kg
fetus~300ml)
■ALWAYS check the FHR after rupture of membrane or
amniotomy.
■Definitive diagnosis by inspecting the placenta and fetal
membrane after delivery.

21. Reminder!!
A 27-yo G2 P1 woman comes to the maternity unit for
evaluation for regular uterine contractions at 34 weeks’
gestation. Her previous delivery was an emergency CS at
32 weeks because of hemorrhage from placenta previa. A
classical uterine incision was used because of lower uterine
segment varicosities. Pelvic exam shows the cervix to be
closed and long. As she is being evaluated, she experiences
sudden abdominal pain, profuse vaginal bleeding, and fetal
bradycardia. Uterine contractions cannot be detected. The
fetal head, which was at –1 station, now is floating.

23. Complications of APH

24. Clinical assessment in APH
Initial: Primary Survey~~~ ABCD
●First and foremost: Mother and fetal well being (mother is the
priority)
●Establish whether urgent intervention is required to manage
maternal or fetal compromise.
●Assess the extent of vaginal bleeding, cardiovascular condition of
the mother
●Assess fetal wellbeing
APH

25. Full History
Taken after the mother is stable:
■Associated pain with the bleeding?
●Continuous pain: Placental abruption.
●Intermittent pain: Labour.
■Risk factors for abruption and placenta praeviashould be
identified.
■Reduced fetal movements?
■If APH is associated with spontaneous or AROM: ruptured vasa
praevia
■Previous cervical smear history; possibility of Ca cervix.
Symptomatic pregnant women present with APH (mostly
postcoital) or vaginal discharge.

26. Examination
■General: PULSE & BP (a MUST!)
■Abdomen:
●The tense, tender or ‘woody’ feel to the uterus
indicates a significantabruption.
●Uterine contractions–mild, moderate, strong
●Abnormal uterine contractions (hypertonic
and high frequency)
●Progressive increase in fundal height?–
concealed, major abruption?

27. Examination cont’d
■Abdomen:
●Painless bleeding, high fetal presenting part –
Placenta praevia
●Soft, non-tender uterus may suggest a lower
genital tract cause or bleeding from placenta or
vasa praevia

28. Examination cont’d
■Speculum:
●Identify cervical dilatation or visualize a lower
genital tract cause.
■Digital vaginal examination
●Should NOT be done until Placenta Praevia
has been excluded by USG if suspicious for PP
●Can provide information on cervical dilatation
if APH is associated with pain or uterine
activity

29. Investigations
■FBC (HB, Platelets) UEC, LFT, Coagulation profile,
■GXM 4 units,
■Ultrasound-r/o PP & IFUD ***does not exclude abruption***
■D-dimer : AP
■ColourdopplerTVS –VP
■In all women who are RhD-negative, a Kleihauertest should be
performed to quantify FMH to gauge the dose of anti-D Ig
required.
■Fetal monitoring: FHR, CTG monitoring

30. Management
The four pillars of management:
■communicationbetween all members of the
multidisciplinary team
■resuscitation
■monitoringand investigation
■arrest bleeding by arranging delivery of the
fetus

31. Managementcont’d
WHEN to admit?
■Based on individual assessment
■Dischargeafter reassurance and counselling danger signs
●Presenting with spotting, no longer bleeding and
placenta praeviahas been excluded.
●However, spotting +previous IUFD due to placenta
abruption, an admission would be appropriate.
■All women with APH heavier than spotting and women
with ongoing bleeding should remain in hospital at least
until the bleeding has stopped.

32. Managementcont’d
■If preterm delivery is anticipated, a single course of
antenatal corticosteroids(dexamethasone 12mg 12
hourly, 2 doses) to women between 24 and 34 weeks 6
days of gestation.
■Tocolytics-not to be used to delay delivery in major
APH, or haemodynamicallyunstable, or if there is
evidence of fetal compromise.
■For very preterm (24-26 weeks),
●Conservative management if mother is stable .
●Delivery of fetus –life threatening
●Experienced neonatologists should be involved

33. Managementcont’d
For Placenta Praevia
■Conservative:
●Premature < 37 weeks; mother haemodynamically
stable, no active bleeding, fetus stable
●Advise bed rest, keep pad chart, vital signs
monitoring , Ultrasound, steroids, GSH, Daily
●CTG and biophysical profile, fetal movement count.
■Plan for CS delivery
●>37 weeks. Crossmatch4 units of blood.

34. Managementcont’d
For Abruptioplacenta,(obsemergency!!)
■ABC, high flow O2, aggressive fluid resuscitation
■Continuous vital signs monitoring and urine output
■Monitor vaginal bleeding –strict pad chart
■Continuous CTG for fetal heart rate
■Crossmatch4 units of blood
■FFP –coagulopathy
■Dexamethasone –preterm
■** ICU admission: Close monitoring and resuscitation!

35. Managementcont’d
For Abruptioplacenta,(obsemergency!!)
■Decide Mode of delivery
●Vaginal delivery –when fetal death,
hemodynamically stable
●Caesarean section
●If maternal/ fetal health compromised
●Indicated when early DIC sets in
●Consent should be taken for hysterectomy in
case bleeding could not be controlled.
Err on the side of caution!!!

36. 1.Should the antenatal care of a woman be altered following
APH?
2.Is it blood-stained showor APH?
3.Any concerns for third stage of labourin women with
APH?
4.Who should be included in the management and
resuscitation team?
5.Any concerns with the APH newborn?
6.Any postnatal issues to be addressed with the woman
&family?
7.

37. NI HAYO TU!
ASANTE

38. APPENDIX

39. Appendix 1

40. Appendix 2

41. Appendix 3

42. Appendix 4

43. Appendix 5:
visual
estimation of
blood loss
Measure blood
loss accurately,
and remember it
is safer to
overestimate
than
underestimate