ANTEPARTUM

HEMORRHAGE
 Definition :

Bleeding from or in the the genital tract ,

occuring from 24th weeks of
pregnancy and prior to the birth of
the baby ( RCOG )

- APH affects 3-5% of pregnancies

 CAUSES
LOCAL
- vulva , vagina , Cervix
-cervical ectropion , polyps , cervical
carcinoma
PLACENTAL
- Placenta praevia
- Abruptio placenta
 Severity of APH

SPOTTING : staining , streaking or blood spots

on underwear or sanitary protection

MINOR HEMORRHAGE: blood loss <50ml that

has settled

MAJOR HEMORRHAGE : Blood loss 50-1000ml,

with no sign of shock
 PLACENTA PRAEVIA
Placenta that is situated wholly or partially
within the lower segment at or after 28th week
POG
RISK FACTOR
 SCREENING & DIAGNOSIS OF
PLACENTA PREVIA
Clinical suspicion in all women with painless PV bleed after 20 th
week POG with:
High presenting part
Abnormal lie

Definitive diagnosis : transvaginal sonography ( TVS )

-Routine ultrasound scanning at 20 weeks of gestation should include
placental localisation by transabdominal scan , confirmed by TVS .
ACCURACY :
-TVS reclassify 26-60% cases of low lying placenta diagnosed by TAS (
fewer women will need follow-up )
- High levels of accuracy of TVS in predicting placenta praevia in the
second and third trimester
: sensitivity 87.5%, specificity 98.8%
SAFE
Numerous prospective observational trials have used TVS to diagnose
placenta praevia and none has experienced any haemorrhagic
complications, thus confirming the safety of this technique
 Further imaging :
Asymptomatic + minor PP = follow up imaging can be left until
36th week POG
Asymptomatic + major PP / placenta accreta = imaging at 32th
week
- for clarification of diagnosis
- allow plannning for 3rd trimester management
 ANTENATAL MANAGEMENT
Where should women with placenta praevia be cared for in the
late third trimester?
Major praevia who have previously bled should be admitted
from approximately 34 weeks of gestation
OR
remain close to the hospital of confinement for the duration of
the third trimester of pregnancy
(Royal Australian and New Zealand College of Obstetricians and Gynaecologists)

Minor previa or asymptomatic patient can be considered for

outpatient care

If to managed at home , need to ensure they have safety

precautions in place
o having someone available to help them should the need arise
o having ready access to the hospital
o attend immediately if experiences any bleeding, contractions
or pain
 PREPARATION FOR DELIVERY
HOW
Mode of delivery is based on clinical judgement supplemented
by sonographic information
WHEN
Uncomplicated placenta praevia delivery can be delayed until
3839 completed weeks of gestation
High-risk cases suspected of having placenta accreta, planned
delivery at around 3637 weeks of gestation (with corticosteroid
cover) is reasonable
---
Placenta praevia without previous caesarean section carries a
risk of massive obstetric haemorrhage and hysterectomy
and should be carried out in a unit with a blood bank and
facilities for highdependency care.
SURGICAL APPROACH FOR SUSPECTED PLACENTA PREVIA
ACCRETA
consider opening the uterus at a site distant from the placenta
delivering the baby without disturbing the placenta*,**
surgical avoidance of the placenta, and its separation, may be
associated with reduced maternal morbidity
If the placenta fails to separate :
-leaving it in place and closing
- or leaving it in place, closing the uterus and proceeding to a
hysterectomy
(both associated with less blood loss than trying to separate it)

* in order to enable conservative management of the placenta or

elective hysterectomy to be performed if the accreta is confirmed
** Going straight through the placenta to achieve delivery is
associated with more bleeding and a high chance of hysterectomy
and should be avoided.
 ABRUPTIO PLACENTA
Bleeding from genital tract due to
premature separation of the
normally sited placenta
( retroplacental hemorrhage)

Incidence : 0.49 to 1.8 %

Perinatal mortality as high as 14.4 67.3 %
 In abruptio placenta , amount of bleeding from the vagina
may not reflect total blood loss
Concealed abruption : the women may have considerable
retroplacental bleeding without any external loss at all .Plus
, it is the most hazardous .
-Retroplacental blood penetrate through the thickness of the uterine wall
( extravasate ) peritoneal cavity .

-Myometrium becomes weakened and may rupture due to increase in

intrauterine pressure associated with uterine contractions .

-lifethreatening obstetric emergency requiring urgent delivery of the fetus

 RISK FACTORS
Previous history of abruptio placenta ( recurrence risk of
8.3% - 16.7% )
Hypertension (44%)
Preeclampsia
Trauma eg : MVA , falls , assault , domestic abuse
Smoking ( increase by 40% for each year of smoking prior
to pregnancy )
Alcohol
Maternal age <20 and > 35
Sudden membrane rupture
Retroplacental bleeding from needle puncture ( post
amniocentesis )
Idiopathic ( majority )
SIGN & SYMPTOMS
PV BLEED
Aching / dull PAIN in
* Dark red due to old the abdomen or lower
blood from a back
concealed abruptio

UTERINE
TENDERNESS
*tense woody-hard CONTRACTIONS
abdomen more frequents
*difficult to appreciate
fetal movement

FETAL HEART
ABSENT
fetal death is likely
 INVESTIGATION
1. FULL BLOOD COUNT
. Determine current hemoydnamic status , to anticipate bleeding
during emergency caesarean section

2. BLOOD & RHESUS TYPE

3. ULTRASONOGRAPHY
. Shows retroplacental clot but not all are detectable . +ve in
only 25% cases .
. Types of abruption : concealed or revealed
. Exclude other causes of antepartum hemorrhage

** depends on clinical judgement

TRANSFER CONSIDERATION
MANAGEMENT
-hemodynamically unstable/ shock transfer to ICU is necessary .
- Transfer to facility with NICU if the fetal is preterm

INITIAL MANAGEMENT

-CTG for continuous fetal and uterine contraction monitoring

- IV access using 2 large bore intravenous lines .
-Runs crystalloid fluid for fluid resuscitation
-Type and cross-match bood
-begin transfusion if hemodynamically unstable
-administer rhesus immuneglobulin if rhesus ve
-begin course of corticosteroid
VAGINAL DELIVERY
-The ability of the patient to undergo vaginal delivery depends on the
remaining hemodynamically stability
-delivery is usually rapid in these pt due to increase uterine tone and
contraction

CAESAREAN SECTION

-often necessary for fetal and maternal stabilisation

-facilitates rapid delivery and direct access to the uterus and the
vasculature
-however , complicates with the pts coagulation status ( if consumptive
coagulopathy occur )
-thus , vertical skin incision is used less blood loss
-if hemorrhage cannot be controlled caesarean hysterectomy may be
required to save thelife
 MANAGEMENT
CONCEALED REVEALED
TYPE TYPE REVEALED TYPE

resuscitation Patient in
labour Not in labour
+
Pregnancy <37
ARM ARM

Pt improve
No fetal No fetal
distress Continue until
distress term
Normal Normal
delivery delivery
Does not
Fetal distress Fetal distress improve
LSCS LSCS Proceed with
delivery
 INDETERMINATE APH
* diagnosis of exclusion
 Postpartum
Haemorrhage
 Definition
1. Loss of blood of 500ml or more during
vaginal delivery
2. Loss of blood of 1000ml or more during
caeserean section
3. Blood loss significant enough to cause
haemodynamic instability
. Primary PPH : within 24hours of delivery
. Secondary PPH : from 24 hours to
12weeks after delivery
 In Practice (Vaginal
delivery), we consider:
500-1000ML (MINOR)
>1000 ML (MAJOR)
should trigger emergency
PPH protocols

However, estimation of
blood loss is notoriously
inaccurate, thus if a woman
demonstrates evidence of
CVS compromise or
continued bleeding,
protocols should be
instituted even if EBL are
<1000ml.
 Pathogenesis
In late pregnancy uterine artery
blood flow is 500 to 700mL/minand
accounts for about 15 percent of
cardiac output.
Hemostasis is mediated by two
mechanism:
1. Contraction of the myometrium,
which compresses the blood vessels
supplying the placental bed and
causes mechanical hemostasis.
2. Local decidual hemostatic factors
(tissue factor , type-1 plasminogen
activator inhibitor, systemic
coagulation factors [eg, platelets,
circulating clotting factors]), which
cause clotting.
 RISK FACTORS (MATERNAL)
Pre-existing : Intrapartum :
Raised maternal age Prolonged labour
Primiparity Operative delivery
Grandmultiparity Instrumental delivery
Uterine Fibroids Pyrexia in Labour
Previous CS Chorioamnionitis
Bleeding Augmented/induced
Obesity Labour
APH Precipitated (rapid)
Previous PPH Labour
Placenta praevia Episiotomy
Abruptio placenta Internal podalic version
PIH
 RISK FACTORS (FETAL)
Large baby (macrosomia)
Multiple Pregnancy
Polyhydramnios
Shoulder dystocia - Obstructed labour whereby
after the delivery of the head, the anterior
shoulder of the infant cannot pass below, or
requires significant manipulation to pass below,
the pubic symphysis. Maternal complications of
shoulder dystocia include post-partum
hemorrhage, vaginal lacerations, anal tears, and
uterine rupture.
 CAUSES
4Ts
1. TONE
2. TISSUE
3. TRAUMA
4. THROMBIN
PRIMARY PPH
TONE : UTERINE ATONY
UTERINE ATONY-DIAGNOSIS
Feel abdomen for poorly contracting
uterus.
Presenting signs:
Excessive vaginal bleeding
A large, soft, relaxed uterus

**Alternate sources of bleeding, such as

vaginal or cervical lacerations or retained
placental fragments, must be excluded.
 UTERINE ATONY-
MANAGEMENT
Initial treatment consists of bimanual compression, uterine
massage.
If continue to bleed, set up IV line and send blood for group
and cross matching.
Uterine contraction medications: Oxytocin (syntocinon 40-
100U*), Methylergonovine (ergometrine), and
Prostaglandins (F2alpha grp-carbofrost**)
Surgery: uterine vessel ligation or hysterectomy (the latter
is rarely used)
Blood and fluids must be replaced as needed.
*depends on degree of bleeding & unresponsiveness of
uterus to fundal massage.
**direct to fundus
UTERINE
MASSAGE
TISSUE : RETAINED
PLACENTA
 RETAINED PLACENTA-
DIAGNOSIS
EXAMINE WHETHER PLACENTA IS
COMPLETE!!
IF NOT MOST LIKELY CAUSE
RETAINED PLACENTA! (MANUAL
EXPLORATION OF UTERINE CAVITY IN
OT)
RETAINED PLACENTA-MANAGEMENT
 TRAUMA : GENITAL TRACT
LACERATIONS

Examine in lithotomy position!

perineum, vagina, cervix
 ACUTE INVERSION OF
UTERUS
Uterus pushed inside out, fundus at the introitus
First Degree (Incomplete)-inverted fundus reached the
external os. Diagnosed by VE
Second degree (Complete)-whole body of the uterus is
inverted and protudes into the vagina
Third Degree prolapse of inverted uterus, cervix and
vagina outside the vulva
 Management of acute inversion of
uterus
Patient usually in shock due to vaso-
vagal attack.
If early discovered, manually reduced
the inversion.
If late, patient shall be resuscitated
and bring to theatre and manage
under anaesthesia: OSullivan
method (hydrostatic reduction)
THROMBIN : ABNORMAL BLOOD
CLOTTING
 Management of postpartum hemorrhage

Assess the patient condition: if the patient is shock, give fresh

blood of the patient blood group and rhesus, until the systolic
BP>100mmHg, urine output>30mL/h. If the blood group is
unknown, group O Rve is prefer.

Feel uterus contraction through abdomen, gently rub the

fundus of the uterus

Intravenous infusion of 40 units of syntocinon

intramyometrial injection of ergometrine/prostaglandin of
F2alpha group(carboprost) directly into uterus fundus.

Examine placenta-complete?

Examination of vagina and cervix in the lithotomy position.

Look for any genital tract laceration
If there is no laceration but still bleed, bring patient to the
operation theatre and examination under anaesthesia.

Check for vaginal or cervical tear again. Then insert a hand

into the uterine cavity and check for retained placenta/
uterine tear/ uterine rupture.
Retained placenta: manual removal except placenta excrete
Uterine tear/ uterine rupture: repaired or hysterectomy
(depend on the need for further childbearing)

If bleeding continues and unable identified the causes,

exploratory laparotomy shall be done:
Stable: bilateral internal iliac artery ligation/ bilateral
uterine artery ligation + B lynch suture( tightening the
uterus)
Life-threatening: hysterectomy

If all of above options failed, hysterectomy is

the last option.
PRIMARY PPH-MANAGEMENT
 Symptoms and signs of shock that are usually present:

Fast, weak pulse (110 per minute or more)

Low blood pressure (systolic less than 90 mmHg)

Other symptoms and signs of shock include:

Pallor (especially of inner eyelid, palms or around
mouth)
Sweatiness or cold clammy skin
Rapid breathing (rate of 30 breaths per minute or
more)
Anxiousness, confusion, or unconsciousness
Scanty urine output (less than 30 mL per hour)
PRIMARY PPH-PREVENTION
STREATEGIES (ANTENATAL)
Prevention strategies During labor
and second stage
Use a partograph.
Ensure early referral when progress of labor is
unsatisfactory.
Encourage the woman to keep her bladder empty.
Limit induction or augmentation use for medical and
obstetric reasons.
Limit induction or augmentation of labor to facilities
equipped to perform a cesarean delivery.
Do not encourage pushing before the cervix is fully dilated.
Do not use fundal pressure to assist the birth of the baby.
Do not perform routine episiotomy.
Assist the woman in the controlled delivery of the babys
head and shoulders.
Prevention strategies During third
stage

Provide AMTSL.
Do not use fundal pressure (apply pressure
on a woman's abdomen to help expel the
placenta) to assist the delivery of the
placenta.
Do not perform controlled cord traction
without administering a uterotonic drug.
Do not perform controlled cord traction
without providing countertraction to
support the uterus.
 Prevention strategies
after placenta delivery
Routinely inspect the vulva, vagina, perineum, and
anus to identify genital lacerations. Inspect the
placenta and membranes.
Massage the uterus at regular intervals after placental
delivery to keep the uterus well contracted and firm (at
least every 15 minutes for the first two hours after
birth).
Teach the woman to massage her own uterus to keep it
firm. Instruct her on how to check her uterus and to call
for assistance if her uterus is soft or if she experiences
increased vaginal bleeding.
Encourage the woman to keep her bladder empty
during the immediate postpartum period.
SECONDARY PPH
 SECONDARY PPH-CAUSES
RARE CAUSE OF MASSIVE BLEEDING
USUALLY DUE TO:
1. RETAINED PRODUCTS OF
CONCEPTION
2. UTERINE INFECTION
3. INHERITED COAGULATION DEFECT

. Clinical signs:
. delayed uterine involution
. Signs of infection : febrile, tachycardia
SECONDARY PPH-
DIAGNOSIS
SECONDARY PPH-
MANAGEMENT
 PPH-PROGNOSIS

PPH can progress to death in 2

hrs if not treated!!!