Antepartum Hemorrhage

2. ANTEPARTUM HAEMORRHAGE

3. GOALS
1. To identify and recognize causes of APH
2. To be able to resuscitate effectively
3. To be able to manage appropriately

4. ANTEPARTUM HAEMORRHAGE
PV bleeding after 22 weeks till birth of baby
Incidence: 3 – 5%
Before 22 weeks – miscarriage/abortion
◦ E.g. threatened miscarriage
Have to differentiate from “show”
◦ blood-stained mucoid discharge

5. Causes
Indeterminate 45%
Abruptio Placenta 30%
Placenta Praevia 20%
Local causes 5%
(e.g. vaginitis, cervical polyp, ectropion, carcinoma)

6. History
Colour, quantity of bleeding
Precipitating factors e.g. trauma, intercourse
Contractions or persistent abdominal pain
Leaking liquor
Fetal movement
Previous ultrasound

7. Principles of Management
Assess maternal condition and stabilize if
necessary.
Then assess the fetal condition.
Determine the cause of the bleeding
Manage according to underlying cause.

8. General Measures
Identify APH
Call for help
Resuscitation:
◦ General resuscitation with DR A, B, C
◦ Fluid resuscitation
◦ 2 IV access
◦ Blood ix
◦ FBC, coagulation profile
◦ Rhesus
◦ Cross match blood 4 units
Identify Cause of bleeding
◦ Ultrasound
◦ NO VE until cause determined

9. PLACENTA PRAEVIA
Formation of lower uterine segment (> 28 weeks)
Upper segment
Lower segment

10. Old Classification
Grade I = minor previa
 Lower edge in the lower uterine
segment
Grade II = marginal previa
 Lower edge reaching internal Os
Grade III = partial previa
 Placenta partially covers the cervix
Grade IV = complete previa
 Placenta completely covers the
cervix

11. PLACENTA PRAEVIA (NEW)
 Placenta previa = placenta lies directly over the internal Os
 Low lying placenta = placental edge < 20mm, > 16w
American International Ultrasound of Medicine
→ better define risk of perinatal complication (APH, PPH)
→ has potential to improve management of PP

12. Placental Migration
•Apparent placental ‘migration’ - resolution of low
lying placenta in 90% of cases before term.
•Due to formation of lower uterine segment
formation in 3rd trimester
•But less likely to occur in previous caesarean
section

13. Risk Factors
Maternal
• Previous caesarean section (associated with placenta
accreta)
• Previous placenta praevia
• Grandmultipara
• Elderly
• Smoking
• Assisted reproductive technique

14. Complications
Maternal
◦ PPH
◦ Placenta accreta
◦ Maternal death
Fetal
◦ Prematurity
◦ IUGR
◦ Congenital malformations

15. Management
Diagnosis by U/S (ideally with transvaginal U/S)
No V/E
Active PV bleeding- immediate delivery
Bleeding stop- hospitalized till delivery

16. MORBIDLY ADHERENT PLACENTA
Placenta penetrates through the myometrium of uterus
Includes
- Placenta accreta
- Placenta increta
- Placenta percreta
Risk factors
- Previous scar
- Previous D&C

17. Women with previous caesarean section and at the same
time had placenta praevia at increase risk of morbidly
adherent placenta
Increase in maternal morbidity and mortality

18. LINK BETWEEN NUMBER OF PREVIOUS CAESAREAN SECTION
AND RISK OF MORBIDLY ADHERENT PLACENTA &
HYSTERECTOMY
NUMBER OF
PREVIOUS C-
SECTION
NUMBER OF
WOMEN
NUMBER OF
WOMEN WITH
PLACENTA
ACCRETA
CHANCE OF
PLACENTA
ACCRETA IF
PRAEVIA
NUMBER OF
HYSTERECTOMIES
0 6201 15 (0.24%) 3% 40 (0.65%)
1 15808 49 (0.31%) 11% 67 (0.42%)
2 6324 36 (0.57%) 40% 57 (0.9%)
3 1452 31 (2.13%) 61 % 35 (2.4%)
4 258 6 (2.33%) 67 % 9 (3.49%)

19. PLACENTA ABRUPTION
Premature separation of the placenta prior to
the 3rd stage of labour
Incidence: 1-2%

20. Placental separation if severe enough, can cause inadequate
nutrition and oxygenation of the fetus – fetal death

21. Can be concealed, revealed or mixed (most common)

22. Risk factors
Maternal
◦ Previous abruptio
◦ Grandmultipara
◦ PIH
◦ Trauma, fall, massage
◦ ECV
◦ Substance abuse
◦ Smoking
Fetal
◦ Twins
◦ Polyhydramnios (with sudden decompression on rupture of
membrane)

23. Management (Fetus alive)
Assess maternal and fetal stability
Expedite delivery
Continuous CTG monitoring
LSCS if any of them is compromised
Paeds for neonatal resuscitation
Watch for PPH

24. Management (Fetus dead)
Assess maternal stability and coagulopathy
Vigorous replacement of fluid and blood products
Correct any coagulopathy
Vaginal delivery unless severe haemorrhage
Watch for PPH

25. Maternal complications
Couvelaire uterus
 Blood seeping into uterus (myometrium) causing uterine atony
Coagulopathy
 Due to profuse bleeding
 Due to thromboplastin release from decidua
Hypovolaemic shock
Renal cortical necrosis
Amniotic fluid embolism
Maternal death

26. Fetal complications
IUGR
Birth asphyxia
Perinatal death

27. PRAEVIA ABRUPTIO
Painless Painful
Revealed Can be concealed
Uterus soft Uterus tense/ tender
FH usually present FH may be absent
May have abnormal lie
or malpresentation
May be hard to feel
fetal parts
How to differentiate? Clinical presentation

28. INDETERMINATE APH
If there is no identifiable cause of APH
Deliver by 40 weeks – due to possibility of minor abruption
(may lead to placental insufficiency)
Refer if undelivered by 40 wks + 0 days

29. VASA PRAEVIA
Bleeding with onset at rupture of membranes
Immediate delivery
High perinatal mortality from fetal exsanguination