Antepartum
Haemorrhage
DAMAR NAGHEER
Definition
ANTEPARTUM HAEMORRHAGE (APH) IS DEFINED AS BLEEDING FROM OR
INTO THE GENITAL TRACT, OCCURRING FROM 24 WEEKS OF PREGNANCY
AND PRIOR TO THE BIRTH OF THE BABY.
One of the
APH
leading cause
complicates 3-
of perinatal
5% of
and maternal
pregnancies
mortality
worldwide
worldwide
Epidemiology
Estimate to
cause About 1/5 of
approximately preterm babies
50% of are as a result
maternal of APH
mortality
Non obstetric - Cervical polyps ,
cervicitis, vaginal trauma (5%) , blood
disorders(<1%)
Obstetric – Maternal :
Causes of Placental abruption (35%)
Placenta Praevia (30%)
Antepartum
Indeterminate (30%)
Haemorrhage
Fetal:
Vasa praevia (<1%)
Placental abruption
Placental abruption is the separation of a normal situated
placenta from the inner uterine wall prior to delivery
causing hemorrhage from both the mother and fetal
vessels.
It is associated with the highest rate of fetal morbidity and
mortality of all APH causes.
Placental
abruption
Occurs most often in the 3rd trimester
It has a recurrent rate of 3-15%
Types of placental abruption
Factors associated with
placental abruption
• Hypertension
• Multiparity
Aetiology • Advanced maternal age
• Polyhydramnious
• Trauma
• Smoking and substance misuse
(cocaine &Amphetamine)
• Previous placental abruption
Initiated by bleeding into the deciduous basalis
The source of the bleeding in most cases is the small
arterial vessels in the basal layer of the decidua that
are pathologically altered and prone to rupture.
The resultant haemorrhage splits the decidua, leaving
Pathophysiology a thin layer attached to the placenta.
As the decidua hematoma expands there is further
separation and compression.
Ultimately, There is destruction of the placenta tissue in
the area resulting in loss of surface area for gaseous
exchange and nutrients.
In a few cases, it may be self-limited.
However, if the initial separation was towards the center of the placenta
there may be continued dissection and separation In the decidua as well
as extravasation into the myometrium and through to the peritoneal
surface.
This is results in couvelaire uterus.
Once the blood reaches the edge of the placenta it may continue to
dissect between the the decidua and the fetal membranes and gain
access to the vagina through the cervix.
It may pass through the membranes into the amniotic sac causing the
port wine discoloration.
The amount of blood that eventually reaches the cervix is often only a
small portion of the lost from the circulation and is not a reliable indication
of the severity.
However , 50% of cases
Mild abrupt is not of severe abruption
usually associated with with a dead foetus are
maternal hypertension. associated with
maternal hypertension.
Clinical Features
Dependent on the degree of separation of the placenta.
Vaginal bleeding ( revealed or mixed)
Suddenly onset of abdominal pain, which progressively worsens in intensity
and spreads.
Pain is constant
Symptoms of shock – palpitations, dizziness, weakness , syncope
Physical examination
Signs of anemia – pallor , pale MM, tachycardia
Shock
Tender, tense uterus ,‘woody hard’
Fetus difficult to palpate
Diminished or absence of fetal movements
Increase or Absence of fetal heart rate
Diagnosis is usually made clinically
Investigation
CBC & U&E’s
Coagulation studies
Ultrasound maybe done and may show the presence of retroplacental
clot , but is not a reliable tool
If ultrasound is normal , it doesn’t rule out a placental abruption.
Fetal heart monitoring
Management
Immediate hospitalization
ABC’s
Large bore IV line , U-cath
CBC , U&E, coagulation studies
Group and cross match – 2 packed RBC
RhoGAM if Rh-ve and not sensitized
Abdominal examination and vital signs
Vital signs are repeated every 15 mins
It foetus is alive , CTG monitoring for fetal distress
Management
Mild cases :
If mother <38 weeks , conservative management- bed rest ,
blood studies , vitals and fetal monitoring
If mother >38 weeks - vaginal delivery post induction of labour (
Amniotomy followed by synthocinon , fetal monitoring
If there is fetal distress -C-section.
Management
Moderate to severe cases :
Maintain blood volume , transfuse as necessary
Strict urine output monitoring via catheter
Immediate amniotomy and syntocinon infusion followed by vaginal
delivery
Complications
Maternal Fetal
Perinatal mortality (up to 50%) Fetal hypoxia
DIC Prematurity
Postpartum haemorrhage Fetal growth restriction
Hypovolemic shock
Acute renal failure
Amniotic fluid embolism
Placenta
Praevia
Placenta praevia
Abnormal placement of the placenta ( in the lower uterine segment)
where the placenta is low lying and may partially or completely obstruct
the internal OS.
Occurs in 0.5% of all pregnancies
Associated factors of placenta praevia
includes:
Previous c section
Previous placenta praevia
Aetiology Prior uterine trauma
Multiparty
Multiple pregnancy
Smoking
Advance maternal age (40 years)
Previous induce abortion
Type 1: The placenta reaches the lower
segment but not the internal os
Types of Type 2: The placenta reaches the internal os
but does not cover it
placenta
Type 3: The placenta covers the internal os
praevia before dilatation but not when dilated
Type 4: The placenta completely covers the
internal os of the cervix even when dilated
Mean gestational age 30-32
weeks
Recurrent painless , bright red
Clinical vaginal bleeding which occurs
Features spontaneously or after coitus.
Warning haemorrhages – small
painless bleeds that occurs a few
weeks prior to a heavy bleed.
Maternal pulse and BP- Signs of anemia/shock
Uterus – soft & non tender
Abnormal Lie of the foetus
Physical High presenting part
examination
Fetal heart monitoring
Speculum vaginal examination
Digital vaginal examination may precipitate heavy
bleeding and is contraindicated
CBC , U&E , PT , PTT
Group and cross match
Transabdominal ultrasound (95% accuracy)
Maybe affected by : maternal obesity , over-
distended bladder
Investigations
➢ Transvaginal ultrasound
➢ NB: 90-95% of praevias diagnosed in T2
resolve by T3. This is due to differential growth
upper and lower segments of the uterus. In
this case, if patient still asymptomatic at 32
weeks, repeat ultrasound
Management
Admission
ABC’s
Set up large bore IV
Full hx and exam
If Rh-ve give RhoGAM
Monitor vitals
Monitor blood loss by the number of sanitary pads used
Aim- to prolong pregnancy to 38 weeks
depends on the extent of bleeding
Optimal delivery is at 38 weeks by
elective lower segment C-section under
spinal anesthesia
Management Grade I , where the presenting part is
below the lower edge of the placenta –
safe to wait until labour , vaginal
delivery
Grade iii and IV- C section
Complications
Fetal
1.Perinatal mortality low but still higher than with a normal pregnancy
2. Prematurity
3. Intrauterine hypoxia
4. Fetal malpresentation
Maternal
1. < 1% maternal mortality
2. Hemorrhage and hypovolemic shock , Anaemia or Acute renal failure.
3.Placenta accreta - especially if previous uterine surgery, anterior placenta
praevia
4. PPROM
5. Hysterectomy
Vasa praevia
Definition
Refers to fetal vessels running through the membranes over the cervix and
under the presenting part , unprotected by the placenta or umbilical
cord.
A velamentous insertion of
the umbilical cord
Aetiology
Joining an accessory
(succenturiate) placental
lobe to the main disk of
placenta
Once baby is
Associated with
alive and
high perinatal
diagnosis is
mortality from
suspected –
fetal
emergency c
exsanguination.
section
Risk Factors
2nd trimester Pregnancies Placenta with
Multiple
low lying from in vitro accessory
pregnancies
placenta fertilization lobes
Kleihauer test- fetal haem
resistance to alkalinization
Apt test – NaOH with blood,
Investigations supernatant – pink ( fetal ) ,
yellow- maternal
Wright stain- nucleated red
cells on blood smear - fetal
Scanty bleeding at time of membrane rupture
CTG- bradycardia, alterations in fetal heart rate
Diagnosis
U/S- succenturiate lobe on the opposite side of the internal
os to the placenta
Diagnosis is suspected when there is either spontaneous or
artificial rupture of the membranes is accompanied by
painless fresh vaginal bleeding from rupture fetal vessels
Management
Deliver the foetus as soon as possible and prepare to transfuse as needed.
Reference
Hamilton-Fairley, D. (2004) Lecture notes on obstetrics and gynaecology. (2nd
Edition) Blackwell Publishing Ltd.
Kenny LC., Baker PN. (2011) Obstetrics by Ten Teachers. (19th Edition)
Hodder Arnold, an Hachette UK Company
Thomson AJ.,Ramsay JE, et al. (2011) Antepartum Haemorrhage. The Royal
College of Obstetricians and Gynaecologists. Green–top Guideline No.
63. reteived:https://www.rcog.org.uk/globalassets/
documents/guidelines/gtg_63.pdf
ps://next.amboss.com/us/article/UO0b7T?q=antepartum%20hemorrhage#Z10
d2395a0456b5fa18cc3bbcbd3335bb
https://emedicine.medscape.com/article/262063-overview#a3
Textbook of obstetrics by roopnarinesingh
