ANTEPARTUM

HAEMORRHAGE
Presenter: Dr. sr .agatha
Facilitator: Dr /Kumpuni

Antepartum Haemorrhage
Defn:Pv Bleeding from a pregnant woman

from 24 wks of gestation and just before

the end of 2nd stage of labour.
Incidence: 3% among hospital deliveries

Classification of APH
Source of haemorrhage:

1. Placental site 70%

a. Placenta previae 32%
b. Abruptio placenta 34%
c. Vasa previae, circumvallate pl. 4%
2. Unexplained 25%
3. Extraplacental site 5%
a. Cervical polyp
b. Cervical lesion eg cacx, erosion, cervicitis
c. Varicose vein
d. Local trauma
e. Infection
f. Ruptured uterus

Class. cont
Cause : 1 Most common cause

2. Others
Cause: 1. Obstretic cause
2. Non obstretic cause

Placenta previae
Implantation at lower uterine segment of

the placenta (partially or completely over

the internal cervical os)
Incidence: about 1/3rd of APH, increases
with age, prev op, multiple pregn
Etiology: unknown

Predisposing factors
Multi parity
Increased maternal age (> 35 yrs)
Prev op (lscs, myomectomy, hysterotomy)
Placental size, abnormalities
Fundal fibroids
Multiple pregn
Smoking placenta hypertrophy to

compensate CO induced hypoxemia

Pathological anatomy
Placenta: may be large and thin, with extensive

areas of degeneration, infarction and

calcification. Adherent placenta due to poor
decidua formation in the lower segment
Umbilical cord: may be attached to the margin
(battledore), or into the membranes
(velamentous). The insertion may be close to
the internal os, or run across it, giving rise to
vasa previa which may rupture during rupture
of membranes
Lower uterine segment: due to increased
vascularity, the lower segment and cervix
becomes soft and more friable.

Types/Degrees/Grades
Type 1: low lying pl extends to the lower

segment, but not reach the internal os, major part

is attached to upper segment
Type 2: marginal pl situated in the lower
segment and extends to the internal os, but does
not cover it.
2A its situated anteriorly
2B its situated posteriorly
Type 3:incomplete or partial pl situated in the
lower segment and partially lies over the internal
os. When cervical dilation occurs, the os is not
completely covered
Type 4:central or total pl situated centrally in the
lower segment, covering the internal os
completely, even after full dilation of the cervix

Clinical presentation
The classic presentation of placenta
previa is painless vaginal bleeding, sudden
onset, causeless, unprovoked and
recurrent.
Nearly two thirds of symptomatic patients
present before 36 weeks' gestation, with
half of these patients presenting before 30
weeks' gestation.
This hemorrhage often stops spontaneously
and then recurs sometimes with labor

Diagnosis
History of present PV bleeding
Hx of previous warning of PV bleeding eg

spots
The amount of bleeding trickles down the
legs, stain under pants or sheets

Signs
Gen cond depends on severity of blood

loss
P/A: cardinal features
Presenting part is high
No engagement
Persistence of malpresentation
Uterus not tender, normal in consistency
Uterus size(FH) corresponds to GA
Fetal parts palpable
FHR audible

Do gentle sterile speculum

PV Digital examination not indicated. Could

be done in the theathre, under

anaesthesia, with double set up
examination, done prior to termination of
pregn

Investigations
USG done to confirm, or to rule out
Blood gr & x-match
Hb levels, FBP
Urine for proteins
Placentography (localization of the placenta),

serial done
- trans abdominal USG
- trans vaginal USG
- trans perineal USG
- colour doppler flow study
- MRI
- Radioactive isotopes

Mngt
Mainly depends on GA, and severity
Bed rest
Sedation
Mode of delivery

- grade 1 to 2A deliver vaginally

- grade 2B to 4 c/s

Indication for C/S

Severe bleeding, irrespective of grades
Transverse lie
Placenta previae Grade 2B to 4
Elderly primegravida
Gross adhesions

Vasa Praevia
Rare event
Umbilical cord vessels are covered only by

chorion and amnion (membranes)

Vessels are exposed and can rupture under
pressure or ARM
Baby at risk of severe bleeding and death
May feel like a cord pulsating on VE
May be diagnosed on colour Doppler U/S

Risk factors vasa praevia

Painless vaginal bleeding after 20 weeks

gestation
Low lying placnta of praevia
Succenturiate lobe or velementous cord
insertion
IVF or multiple pregnancy

Exposed vessels

Abruptio placentae
Defn: Premature separation of the normally

implanted placenta
Incidence: 1 in 150 del
Perinatal mortality 15-20%, maternal mort 2-5%
Etiology: Unknown
Associated factors;
PIH & Chronic HT
Short cord
High parity
Nutritional def: eg Folic acid, Ascorbic acid
Stress and emotional disturbances
Direct trauma
Torsion of the uterus

Types
Concealed blood clot retroplacentally
Revealed
Mixed type

Clinical classification
Depends upon degree of separation
Grade 0; clinical feature may be absent. Dx after

delivery

following inspection of placenta

Grade 1 .external bleeding is slight

.uterus irritable, may be tender or not

.shock is absent
.FHS is good
Grade 2 .external bleeding, mild to moderate
.uterine tenderness always present
.shock is absent
.fetal distress or even fetal death

Grade 3 .bleeding is mod to sev, or may be

concealed
.uterine tenderness is marked
.shock is pronounced
.fetal death is a rule
.ass coagulation defect or anuria
may complicate

Risk factors

Previous placental abruption

Chorioamnionitis
Prolonged rupture of membranes (24 h or longer)
Preeclampsia
Hypertension
Maternal age of 35 years or older
Male fetal sex
Low socioeconomic status
Elevated second trimester maternal serum alpha-

fetoprotein (associated with up to a 10-fold

increased risk of abruption)

Clinical features

Depends on degree of separation of

placenta, speed of separation, amount of

blood concealed
Symptoms
Character of bleeding; cont dark color
Palor: related with blood loss
Features of preeclampsia
FH
Uterine feel; tenderness,
stony hard
FHR;

Complications of abruption
Maternal

Fetal

Haemorrhagic

Fetal Hypoxia

shock
Coagulopathy/DIC
Uterine rupture
Renal failure
Maternal death

Anaemia
Growth restriction
CNS damage
Fetal death

Management
Open I/V lines, large bore canulla, 3L

NS/RL to run in the 1st hr

4 tubes
Blood gr & X-match
Bedside clotting time
Coagulation profile
RFT

Urine for protein

Mode of delivery, decide

Vaginal delivery
This is the preferred method of delivery for a

fetus that has died secondary to placental

abruption.
The ability of the patient to undergo vaginal
delivery depends on her remaining
hemodynamically stable.
Delivery is usually rapid in these patients
secondary to increased uterine tone and
contractions.

Cesarean section
Cesarean delivery is often necessary for both fetal and

maternal stabilization.
While cesarean delivery facilitates rapid delivery and direct
access to the uterus and its vasculature, it can be
complicated by the patient's coagulation status. Because of
this, a vertical skin incision, which has been associated with
less blood loss, is often used when the patient appears to
have DIC.
The type of uterine incision is dictated by the gestational age
of the fetus, with a vertical or classic uterine incision often
being necessary in the preterm patient.
If hemorrhage cannot be controlled after delivery, a
hysterectomy may be required to save the patient's life.
Before proceeding to hysterectomy, other procedures,
including correction of coagulopathy, ligation of the uterine
artery, administration of uterotonics (if atony is present),
packing of the uterus, and other techniques to control
hemorrhage, may be attempted.
ICU: If the patient is hemodynamically unstable, either before
or after delivery, invasive monitoring in an ICU may be
required.

Placenta previa covering

the entire cervical os

Placenta previa partially

separated from the lower
uterine segment.

Placenta previa invading

the lower uterine segment
and covering the cervical
os.

Uterine rupture
Essential for Dx
Increased suprapubic pains and tenderness
with labour
Sudden cessation of uterine contraction
Vaginal bleeding (or bloody urine)
Recession of the fetal presenting part
Disappearance of fetal heart tones

Characteristic Categories for

Determining Risk of Uterine
Rupture:

Uterine status
Native (unscarred)
Scarred
Previous cesarean delivery
Single

low transverse (further subcategorized by 1-layer or

2-layer hysterotomy closure)

Single low vertical

Classic vertical
Multiple previous cesarean deliveries

Previous myomectomy
Transabdominal

Laparoscopic

Characteristics cont
Uterine configuration
Normal
Congenital uterine anomaly
Pregnancy considerations
Grand multiparity
Maternal age
Placentation (accreta, percreta, increta, previa,

abruption)
Cornual (or angular) pregnancy
Overdistension (multiple gestation,
polyhydramnios)
Dystocia (fetal macrosomia, contracted pelvis)
Trophoblastic invasion of the myometrium
(hydatidiform mole, choriocarcinoma)

Characteristics cont
Previous pregnancy and delivery history
Previous successful vaginal delivery
No previous vaginal delivery
Interdelivery interval
Labor status
Not in labor
Spontaneous labor
Induced labor
With oxytocin
With prostaglandins
Augmentation of labor with oxytocin
Duration of labor
Obstructed labor

Characteristics cont
Obstetric management considerations
Instrumentation (forceps use)
Intrauterine manipulation (external

cephalic version, internal podalic version,

breech extraction, shoulder dystocia,
manual extraction of placenta)
Fundal pressure
Uterine trauma
Direct uterine trauma (motor vehicle
accident, fall)
Violence (gunshot wound, blunt blow to
abdomen)

Clinical presentation
Abnormal pattern in fetal heart rate
Prolonged deceleration in fetal heart

rate or bradycardia
Uterine tachysystole* or
hyperstimulation
Loss of intrauterine pressure or
cessation of contractions
Abnormal labor or failure to progress
Abdominal pain
Vaginal bleeding
Shock

Maternal consequences of
uterine rupture
Maternal bladder injury

Severe maternal blood loss or anemia

Hypovolemic shock
Need for hysterectomy
Maternal death

Fetal complications

Surgical treatment
Type of uterine rupture
Extent of uterine rupture
Degree of hemorrhage
General condition of the mother
Mother's desire for future childbearing

Uterine repair
Low transverse uterine rupture
No extension of the tear to the broad

ligament, cervix, or paracolpos

Easily controllable uterine hemorrhage
Good general condition
Desire for future childbearing
No clinical or laboratory evidence of an
evolving coagulopathy

THANKS