Basics in APH

1. DR. SNIGDHA KUMARI
SENIOR RESIDENT
M.S., D.N.B.(OBG)
KOLKATA

2. Bleeding
In
Pregnancy
Bleeding in
early
Pregnancy
Antepartum
hemorrhage
(APH)
Post partum
Haemorrhage
(PPH)

3. ANTEPARTUM HAEMORRHAGE
Definition
Antepartum hemorrhage (APH, prepartum hemorrhage) is bleeding
from or into the genital tract, occurring from 24+0 weeks of
pregnancy and prior to the birth of the baby
(RCOG 2011)
Epidemiology
Affects 3-5% of all pregnancies
1/5th
of preterm babies born in association of APH
occurs in 2.8/1000 singleton pregnancies & 3.9/1000 twin pregnancies
This definition of gestational age is based on the UK professional guidance for viability cut-off point of 24 weeks

4. Obstetric emergency
Attention should be sought immediately
If left untreated can lead to death of the mother &/or fetus
Management reduce the risk of premature delivery & maternal/
perinatal morbidity/mortality
IMPORTANCE

5. Placental abruption - Most common pathological cause (1/100)
Placenta previa - Second most common pathological cause (1/200)
Vasa previa- Often difficult to diagnose, frequently leads to fetal demise
(1/2000-3000)
Uterine rupture - (<1% in scarred uterus)
CAUSES

6.  Bleeding from the lower genital tract
Cervical bleeding – Cervicitis
Cervical neoplasm
Cervical polyp
Cervical ectropion
Vaginal bleeding - Trauma
Neoplasm
Vulval varices
Infection
 Inherited bleeding problems - Very rare, 1 in 10,000 women
 Unexplained - No definite cause is diagnosed in about 40% of APH
CAUSES CONT.…

7.  GI bleed - Hemorrhoids, inflammatory bowel disease, etc.
 Urinary tract bleed – UTI, etc.
BLEEDING THAT MAY BE CONFUSED WITH VAGINAL BLEEDING

8. Maternal complications
•Anaemia
•Infection
•Maternal shock
•Renal tubular necrosis
•Consumptive coagulopathy
•Postpartum haemorrhage
•Prolonged hospital stay
•Psychological sequelae
•Complications of blood transfusion
Fetal complications
•Fetal hypoxia
•Fetal growth restriction
•Prematurity (iatrogenic & spontaneous)
•Fetal death
COMPLICATIONS OF APH

9. Definition
Insertion of the placenta, partially or completely, in the lower
segment of the uterus
PLACENTA PREVIA

10. Previous placenta previa (adjusted OR 9.7) Rasmussen 2000
Previous Caesarean section (RR 2.6, 95% CI 2.3, 3.0) Ananth 1997
•One previous Caesarean section OR 2.2 (95% CI 1.4, 3.4) Hendricks1999
•Two previous Caesarean sections OR 4.1 (95% CI 1.9, 8.8)
•Three previous Caesarean sections OR 22.4 (95% CI 6.4, 78.3)
Previous termination of pregnancy
Multiparity
Advanced maternal age (>40 years)
Multiple pregnancy
RISK FACTORS FOR PLACENTA
PREVIA

11. Deficient endometrium due to presence or history of:
•Uterine scar
•Endometritis
•Manual removal of placenta
•Curettage
•Submucous fibroid
Assisted conception
Smoking
(RCOG2011)
CONT.…

12. Four types:
Type I: Placenta encroaches lower
segment but does not reach the
internal os
Type II: Reaches internal os but does
not cover it
Type III: Covers part of the internal
os
Type IV: Completely covers the os,
even when the cervix is dilated
DEGREES OF PLACENTA PREVIA

13.  Recurrent painless vaginal bleeding (not always)
 Abdominal findings
 Uterus- soft, relaxed, non tender & proportionate to POG
 Contraction may be palpated
 Abnormal presentations
 High floating head in cephalic presentation
 Maternal cardiovascular compromise
 Fetal condition satisfactory until severe maternal compromise
 Vulval inspection- presence of bleeding, character of blood
 Vaginal examination- should not be done
PLACENTA PREVIA- CLINICAL FEATURES

14. Diagnosis by ultrasound scan (USS) showing placenta coming in to lower
segment
Transvaginal ultrasound (TVS) is safe & is more accurate than transabdominal
ultrasound (TAS) in locating placenta
Leading edge within 2 cm from internal os or completely covering internal os
is incompatible with normal vaginal delivery
Transperineal (TPS)
Colour Doppler flow study
MRI
INVESTIGATION

15. CONFIRMATION OF DIAGNOSIS
Localisation of placenta Clinical
Transabdominal ultrasonography By internal examination (double set up)
Transvaginal ultrasonography Direct visualization during CS
Transperineal ultrasonography Examination of placenta following delivery
Colour doppler flow study
MRI

16. Maternal
 Major hemorrhage, shock & death
Anemia in chronic hemorrhage
Morbid adherence of Placenta : placenta accreta complicates approximately 10%
of placenta previa cases
Sensitization of mother for fetal blood in Rh (-) patients
Post partum hemorrhage
 Renal tubular necrosis & acute renal failure
PLACENTA PREVIA- COMPLICATIONS

17. Fetal
Prematurity
Low birth weight
Chronic & acute fetal hypoxia
IUD
Congenital malformation- 3 times more common
PLACENTA PREVIA- COMPLICATIONS CONT….

18. Definition
Premature separation of a normally
situated placenta in a viable fetus
 Clinician should have high index of suspicion for diagnosis
PLACENTAL ABRUPTIONPLACENTAL ABRUPTION

19. The most predictive is abruption in previous pregnancy
A large observational study from Norway reported a 4.4% incidence of recurrent
abruption (adjusted OR 7.8, 95% CI 6.5-9.2).Rasmussen et al 2009
Abruption recurs in 19-25% of women who have had two previous pregnancies
complicated by abruption.(Tikkanen 2010)
RISK FACTORS FOR PLACENTAL ABRUPTION

20.  Increased age and parity
 Vascular diseases: hypertension in pregnancy, renal disease, SLE &
APS
 Mechanical factors: Trauma, amniocentesis, sudden decompression of uterus,
polyhydramnios, multiple pregnancy
 Smoking, cocaine use
 Uterine myoma, septum
 Supine hypotension syndrome
RISK FACTORS FOR PLACENTAL ABRUPTION

21. Spasm of vessels in uteroplacental bed (decidual spiral artery) anoxic→
endothelial damage rupture of vessels & hemorrhage in decidua basalis→ →
decidua splits decidual hematoma (retroplacental) separation,→ →
compression, destruction of the adjacent placenta
Large retroplacental clot
PATHOPHYSIOLOGY

22.  Concealed abruption
Revealed abruption
 Mixed type
TYPES OF ABRUPTION

23. Grade 0- Asymptomatic – small retroplacental clot
Grade 1 (40%) - External vaginal bleeding present. Uterine tenderness and
tetany may be present. NO SIGN OF MATERNAL SHOCK OR FETAL DISTRESS
Grade 2 (45%) - External vaginal bleeding may or may not be present. NO
SIGNS OF MATERNAL SHOCK, BUT FETAL DISTRESS IS PRESENT
Grade 3 (15%) - External bleeding may or may not be present. Marked
uterine tetany, a board-like rigidity on palpation. Persistent abdominal pain,
MATERNAL SHOCK and fetal distress are present. Coagulopathy may become
evident in 30% of cases.
CLASSIFICATION OF PLACENTAL
ABRUPTION

24. Mild type
 Abruption≤ 1/3
 Vaginal bleeding may be
present or absent
Severe type
 Abruption > 1/3
 Large retroplacental hematoma
 Vaginal bleeding associated with
persistent abdominal pain
 Tenderness on the uterus
 “Woody” hard uterus
 Change of fetal heart rate – CTG
changes
 Features of hypovolemic shock
 Painful vaginal bleeding
 Pain- usually continuous
DIAGNOSIS- CLINICAL FEATURES

25. Maternal
Sensitization of Rh(-) mother for fetal blood
Amnionic fluid embolism
Post partum hemorrhage
Hypovolemic shock
Renal tubular necrosis & acute renal failure
Disseminated intravascular coagulopathy (DIC)
Puerperal sepsis
Sheehan’s syndrome
Maternal death
COMPLICATIONS OF PLACENTAL ABRUPTION

26. Fetal
Prematurity
IUGR in chronic abruption
Hypoxic ischemic encephalopathy
Cerebral palsy
Fetal death
COMPLICATIONS OF PLACENTAL
ABRUPTION

27. Ultrasonography
 Mainly to exclude placenta previa
 Can detect
• Retroplacental hematoma
• Fetal viability
Most of the time findings will be negative
Negative findings does not exclude placental abruption
CTG – Sinusoidal pattern, Fetal tachycardia or bradycardia
Laboratory investigations
Investigation for Consumptive coagulopathy – Platelet count/BT/CT/PT/INR &
APTT
Liver and Renal function tests
INVESTIGATIONS

28. Fetal blood vessels from placenta or umbilical cord cross the internal os
beneath the baby
Rupture of membranes lead to damage of the fetal vessels leading to
exsanguination and death
High fetal mortality (50-75%)
VASA PRAEVIAVASA PRAEVIA

29. Eccentric (velamentous) cord insertion
Bilobed or succenturiate lobe of placenta
Multiple gestation
Placenta praevia
In vitro fertilization (IVF) pregnancies
History of uterine surgery or D & C
RISK FACTORS OF VASA PREVIA

30.  Moderate vaginal bleeding + fetal distress
 Vessels may be palpable through dilated cervix
 Vessels may be visible on ultrasound (TV colour Doppler ultrasound)
 Difficult to distinguish from abruption
 Can look for fetal Hb (Kleihauer-Betke test) or nucleated RBC’s in shed blood
 Tachycardia or bradycardia in CTG
DIAGNOSIS - VASA PRAEVIA

31. Management of APH

32.  Advised to report all vaginal bleeding to antenatal care provider
 Admit to hospital for clinical assessment & management
 Senior staff must be involved – Senior obstetrician, anesthetist, neonatologist
 May need resuscitation measures if in shock or severe bleeding
 Airway(A), breathing(B) & circulation(C)
 Two wide bore cannula
 Take blood for Grouping, CBC, coagulation profile, Liver & renal function
 Volume should be replaced by Crystalloid /colloid until blood is available
 Severe bleeding or fetal distress: Urgent delivery of baby irrespective of
gestational age
MOTHER IS THE PRIORITY IN ABOVE MENTIONED CONDITIONMOTHER IS THE PRIORITY IN ABOVE MENTIONED CONDITION
MANAGEMENT OF APH

33. What is the role of clinical assessment in women presenting with an APH?
To establish whether urgent intervention is required to manage maternal or
fetal compromise
The process of TRIAGE includes –
•history taking to assess coexisting symptoms such as pain
•an assessment of the extent of vaginal bleeding
•cardiovascular condition of mother
•assessment of fetal well-being
MANAGEMENT OF APH

34. History
Obtain history if no maternal compromise –
 Colour and consistency of bleeding
 Quantity & rate of blood loss
 Precipitating factors i.e. Sexual intercourse, Vaginal examination
 Degree of pain, site and type
 Placental location-review ultrasound report if available
 Ascertain fetal movements
 Ascertain blood group
 Previous cervical smear history if available
MANAGEMENT OF APH CONT…

35. Examination
To assess amount & cause of APH
 Assess maternal & fetal well-being
 Pallor, record temperature, pulse & BP
 Perform abdominal examination
• Note areas of tenderness & hypertonicity
• Determine gestational age of fetus, presentation
• & position, auscultate fetal heart
No vaginal examination should be attempted at least until placenta previa is
excluded
Do speculum examination to assess cervix / bleeding & exclude local lesions
MANAGEMENT OF APH CONT…

36. Investigations
 Arrange urgent ultrasound scan
Does not exclude abruption
Glantz and colleagues reported the sensitivity, specificity, and positive
and negative predictive values of ultrasonography for placental abruption
to be 24%, 96%, 88%, and 53%, respectively. Glantz C et al 2002
 Fetal monitoring
Continuous electronic fetal monitoring indicated
where knowledge of fetal condition influence timing &
mode of delivery
MANAGEMENT OF APH CONT…

37.  Rhesus negative woman should have a Kleihauer test &
be given prophylactic anti-D immunoglobulin
 For preterm delivery between 24+0 & 34+6 weeks POG, antenatal
corticosteroids - to promote fetal lung maturity (RCOG 2011)
• Betamethasone
• Dexamethasone
MANAGEMENT OF APH CONT…

38. Role of tocolytic therapy in women presenting with APH having uterine
activity –
• preterm needing transfer to hospital with NICU facility
• incomplete course of corticosteroids
Calcium antagonist (Nifedipine) best avoided with cases of maternal hypotension
Drug of choice should have fewest maternal cardiovascular side effects
(RCOG 2011)
MANAGEMENT OF APH CONT…

39. Depend on -
 Cause of APH
 Extent of bleeding
 Presence of fetal distress
 Gestational age & fetal maturity
FURTHER MANAGEMENT OF APH

40.  Near term / Term
Delivery is considered
Type Ia, Ib & IIa - May be able to deliver vaginally
Type IIb, III and IV - Will require caesarean section by senior obstetrician
Should anticipate PPH
 Pregnancy below 34 weeks POG
Continuation of pregnancy better if possible
• Need bed rest
• Educate patient regarding condition & risk
• cross matched blood should be reserved till delivery
• Fetal well being & growth should be monitored –BPP,CTG,USS
• Medications may be given to prevent premature labor- Nifedipine, Atosiban
PLACENTA PRAEVIA - MANAGEMENT

41. Small abruption
Conservative management depending on gestational age
Careful monitoring of fetal condition
Moderate or severe placental abruption
•Restore blood loss
•Ideally measure central venous pressure (CVP) & adjust transfusion accordingly
•Prevent coagulopathy
•Monitor urinary output
•Delivery
1.Caesarean section
2.Vaginal- If coagulopathy present
If fetus is not compromised
If fetus is dead
PLACENTAL ABRUPTION – MANAGEMENT

42. •Urgent delivery
•Most of the time urgent LSCS
•Neonatologist involvement
•Aggressive resuscitation of the baby with blood transfusion following
delivery
VASA PREVIA MANAGEMENT

43.  Women presenting with APH before 37+0 weeks POG, where there is no
maternal or fetal compromise & bleeding has settled, there is no evidence to
support elective premature delivery of fetus
 Following an episode of major APH that has settled or recurrent unexplained
APH it is reasonable to arrange delivery of the fetus after 37+0 weeks POG
 If presenting after 37+0 weeks it is important to establish if the bleeding is an
APH or blood stained „show ; if the blood is streaked through mucus it is‟
unlikely to require active intervention
 in the event of major APH, IOL with aim of achieving vaginal delivery should be
considered in order to avoid adverse consequences potentially associated with
a further APH
POINTS TO REMEMBER

44. Fetus may die from hypoxia during heavy bleeding
Perinatal mortality more than 50 per 1000 even with tertiary care facilities
High rates of maternal mortality
PROGNOSIS OF APH