This document defines antepartum haemorrhage (APH) as bleeding from or into the genital tract occurring after 22 weeks of pregnancy but before birth. APH complicates 3-5% of pregnancies and is a leading cause of perinatal and maternal mortality. The main causes of APH are placenta praevia, abruptio placenta, and vasa praevia. Placenta praevia is when the placenta implants over or near the cervical opening and is diagnosed using ultrasound. Abruptio placenta occurs when the placenta separates from the uterus prematurely. Vasa praevia occurs when fetal blood vessels in the membranes are not supported by

1. AHMED FARRASYAH B MOHD KUTUBUDIN
071303511
BATCH 24 GROUP A2
ANTEPARTUM HAEMORRHAGE

2. reference
• RCOG Guidelines
• Obstetrics today

3. Definition
• Antepartum haemorrhage (APH) is defined as
bleeding from or in to the genital tract, occurring
from 22 weeks (>500g) of pregnancy and prior
to the birth of the baby.
• complicates 3–5% of pregnancies
• leading cause of perinatal and maternal mortality
worldwide.
• Up to one-fifth of very preterm babies are born in
association with APH
• Most of the time unpredictable.

4. Different terminologies used:
• Spotting – staining, streaking or blood spotting noted on
underwear or sanitary protection
• Minor haemorrhage – blood loss less than 50 ml that has
settled
• Major haemorrhage – blood loss of 50–1000 ml, with no
signs of clinical shock
• Massive haemorrhage – blood loss greater than 1000 ml
and/or signs of clinical shock.
• Recurrent APH - > one episode

5. Etiology
• Placenta praevia
• Abruptio placenta
• Vasa praevia
• Excessive show
• Local causes ( bleeding from cervix, vagina and
vulva )
• Inderterminate APH

6. Placenta Praevia (PP)
• Implantation of placenta over or near the internal
os of cervix.
• Confirm diagnosis of PP can be done at 28
weeks when LUS forming.
Leading cause of vaginal bleeding in the 2nd
and 3rd
trimester.

7. Classification

8. LOW LYING MARGINAL
PARTIAL TOTAL

9. Risk Factors of 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
-submucous fibroid
• Assisted conception

10. Clinical classification
• Minor :
• Type 1 (anterior/posterior)
• Type 2 anterior
• Major:
• Type 2 posterior (dangerous type)
• Type 3
• Type 4
Deliver vaginally
Type 1 Posterior > likelihood of
fetal distress
Caesarean section
Type 2 posterior >
chance of fetal distress
Type 3 & 4 anterior –cut
through placenta to deliver.
Hence need to be fast and
efficient.

11. Abruptio Placenta (AP)
• Separation of normally located placenta after 22
weeks of gestation ( > 500g) and prior to delivery
of fetus.

12. Risk factors
- Previous history of AP
Maternal hypertension
Advanced maternal age
Trauma ( domestic violence, accident, fall)
Smoking/alcohol/cocaine
Short umbilical cord
Sudden decompression of uterus
( PROM/delivery of 1st
twins)
Retroplacental fibroids
Idiopathic

13. Obstetrics Emergency
Diagnosed CLINICALLY :
• Painful vaginal bleeding -80%
• Tense and tender abdomen/back pain (70%)
• Fetal distress( 60%)
• Abnormal uterine contractions (hypertonic and high
frequency)
• Preterm labour ( 25%)
• Fetal death ( 15%)
Ultrasound is NOT USEFUL to diagnose AP.
Retroplacental clots (hyperechoic) easily missed.

14. Vasa Praevia (VP)
• Rupture of fetal vessels that run in membrane
below fetal presenting part which is unsupported
by placenta/ umbilical cord.
• Predisposing Factors:
-Velamentous insertion of the umbilical cord
-Accesory placental lobes
-Multiple gestations

15. The term velamentous
insertion is used to
describe the condition in
which the umbilical cord
inserts on the
chorioamniotic
membranes rather than on
the placental mass.

17. Diagnosis of 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 blood loss constitutes a major bulk
of blood volume is fetus ( 3kg fetus-300ml)
• Hence, ALWAYS check the fetal heart after rupture of
membrane or amniotomy.
• Definitive diagnosis by inspecting the placenta and
fetal membrane after delivery.

18. Complications of APH
Maternal complications Fetal complications
Anaemia Fetal hypoxia
Infection Small for gestational age and fetal growth
restriction
Maternal shock Prematurity (iatrogenic and spontaneous)
Renal tubular necrosis Fetal death
Consumptive coagulopathy
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Complications of blood transfusion

19. Clinical assessment in APH
• 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.

20. Full History
Should be taken after the mother is stable.
• associated pain with the haemorrhage?
Continuous pain : Placental abruption.
Intermittent pain : Labour.
• Risk factors for abruption and placenta praevia
should be identified.
• reduced fetal movements?
• If the APH is associated with spontaneous or
iatrogenic rupture of the fetal membranes : ruptured
vasa praevia
• Previous cervical smear history possibility of Ca
cervix. Symptomatic pregnant women usually present
with APH (mostly postcoital) or vaginal discharge.

21. Examination
• General: PULSE & BP ( a MUST!)
• Abdomen:
The tense, tender or ‘woody’ feel to the uterus
indicates a significant abruption.
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.

22. Examination
• Speculum :
-identify cervical dilatation or visualise a lower
genital tract cause.
• Digital vaginal examination
Should NOT be done until Placenta Praevia has
been excluded by USG.

23. Investigations
• FBC
• Coagulation profile
• Blood Grouping and CXM, GSH.
• Ultrasound- TRO PP/ IUD
• D-dimer : AP
• colour doppler TVS – VP
• In all women who are RhD-negative, a Kleihauer test
should be performed to quantify FMH to gauge the
dose of anti-D Ig required.
Fetal monitoring:
• CTG monitoring

24. Management
• WHEN to admit?
• Based on individual assessment
-Discharge after reassurance and counselling
Women presenting with spotting who are no longer
bleeding and where placenta praevia has been
Excluded.
However, a woman with spotting + previous IUD 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.

25. Management
• 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 should NOT be given unless for VERY preterm
women who need time to transfer to hospital with NICU.
• For very preterm ( 24-26 weeks) ,
-conservative management if mother is stable .
-Delivery of fetus – life threatening
At these gestations, experienced neonatologists should
be involved in the counselling of the woman and her
partner

26. Management
For Placenta Praevia
• Conservative – MaCafee’s regime
( 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 delivery ( >37 weeks)
Crossmatch 4 units of blood.

27. Definitive treatment
Type I,II(ant) Type II( post), III,IV
ARM +/- oxytocin
Satisfactory progress
without bleeding
Vaginal delivery
Bleeding continues
Caesarean section
Caesarean section

28. Management
Conservative (McCafee’s regime) Method of delivery
Preterm & hemorrhage not
present:
1. Bed rest along with pad chart
2. Vital signs monitoring
3. USG every two weeks
4. Fetal monitoring: CTG, USG,
daily fetal movement count
chart
5. Dexamathasone (if baby is <34
weeks gestation)
2 doses, 12mg I.M. 12 hours apart
Vaginal delivery:
Type I anterior
Type I posterior
Type II anterior
Caesarean section:
Type II posterior
Type III (anterior &
posterior)
Type IV

29. Induction of labour

30. For Abruptio placenta,(obs emergency)
• ICU admission : Close monitoring and
resuscitation!
 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
 Crossmatch 4 units of blood
 FFP – coagulopathy
 Dexamethasone – preterm

31. Abruptio Placenta
Decide Mode of delivery
• Vaginal delivery – when fetal death
• 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.

32. Management
• For Rh negative mothers,
Anti-D Ig should be given to all after any presentation
with APH, independent of whether routine antenatal
prophylactic anti-D has been administered.
In the non-sensitised RhD-negative woman for all
events after 20 weeks of gestation, at least 500 iu
anti-D Ig should be given followed by a test to identify
FMH, if greater than 4 ml red blood cells; additional
anti-D Ig should be given as required.

33. Thank You