Antepartum Haemorrhage
Amir Hilmi Abd Aziz
Nur Aqilah Nasri
Case
HOPI:Mrs NMO, 29 y/o, Malay lady, G2P1
with POG of 33w, presented with painless
vaginal bleed on the day of admission. The
bleed was spontaneous and happened whilst
patient was sleeping and it soaked the back
of her sarong. This is her first episode. The
blood was red in colour and there was no clot
or mucus present. There was no contraction,
history of trauma, lethargy, palpitation, SOB
fever, vaginal discharge or passage of fluid.
Current Obstetric Hx:
LMP 2/2/14
Pregnancy confirmation was done by USS
at 12w viable fetus corresponding to date
EDD 9/11/14
Hb: 12 g/dL
BP: 130/95
Past Obstetric Hx:
2010, SVD, Boy, 3.0 kg, no
antenatal/postnatal complications
Menstrual Hx
Menarche at 12 y/o
Regular period with 7 days bleed and
cycle of 28 days
No dysmenorrhoea, menorrhagia,
intermenstrual bleed and post coital
bleed
Last pap smear: 2010 normal
No significant PMHx and PSHx
Drug Hx
NKDA, NKFA
Iron tablets, Folic Acid, Multivitamin
No significant FHx
SHx
Teacher, live in Seri Manjung. Husband
works with MPSM. Her baby sitter is
taking care of her son.
Never smoke and non drinker
Examination
On examination, patient is alert,
conscious, lying comfortably and not in
distress.
No conjunctival pallor and CRT < 2sec.
Vitals : PR 90, BP 130/95, RR 20, T
36.1oC
Abdomen is distended with gravid
uterus (straie gravidarum and linea
nigra). No dilated veins or scars. The
SFH is 32cm which correspond to
gestation date. There is a singleton with
longitudinal lie, cephalic presentation.
The head is not engaged and FHR was
Investigations
Diagnostic Tests:Transabdominal
Ultrasound
Number of Gestations: 1
Lie: Longitudinal
Presentation: Cephalic
Position: Right
Fetal Heart Rate: 144 x minute
Fetal Movements: Present
Placenta: Placenta edge lies approximately
2cm from margin of internal os
Differential Diagnosis
Placenta Previa
Placental abruption
Vasa Previa
Show
Local causes: infection of
cervix/vagina, trauma to
cervix/vagina
Antepartum Hemorrhage
Bleeding from the genital
tract > 24 weeks of gestation
before onset of labor
Causes of APH
Unexplained (97%)
Placenta previa (1%)
Placenta abruptio (1%)
others
Maternal
Fetal
Show
Vasa previa
Infection of cervix/
vagina
Trauma of cervix/ vagina
Cervical erosion
Genital tract tumor
Assessment of APH
Initial assessment (maternal & fetal condition)
History
Maternal assessment (vital signs, abdominal
examination)
*never perform VE in per vaginal bleed without excluding placenta
previa first.
Once excluded, do speculum examination to
assess the degree of bleeding, local causes and
determine if membrane is rupture or not.
Fetal assessment
CTG, USS
Management of APH
Placenta previa
Placenta abruptio
Abnormal implantation of
placenta, partially or entirely in
lower uterine segment after 24
weeks
Premature separation of normally
placed placenta from uterus after
24 weeks
Painless
Painful
Patient is less distressed
Patient is distressed
Soft abdomen
Tense, tender abdomen
Abnormal lie and malpresentation
Normal lie and presentation
CTG normal
CTG abnormal
Not associated with pre eclampsia
Associated with pre eclampsia
No coagulation defect, proportional
heamodynamic signs
has signs of hypovolemic shock
- High PR, low BP
Placenta previa
Placenta abruptio
Types:
Types:
Minor (SVD possible)
-type I: edge of placental does
not reach internal os or > 5cm
distant
-Type IIa: edge of placental at
margin of internal os but not
cover it - anterior
Concealed
-no external bleeding evident
-has uterine pain,
Possibly with maternal shock or
fetal distress without obvious
bleeding
Major (ELSCS)
-type IIb: edge of placental at
margin of internal os but not
cover it - posterior
Type III: placenta completely
covers internal os when os
closed, partially covers when
cervix dilate
Type IV: placenta covers internal
os completely
Revealed
-has vaginal bleeding
-has minimal or no pain
Management of placenta
previa
those with major previa who have
previously bled should be admitted from
approximately 34 weeks of gestation.
while outpatient care can be considered
for those with minor previa or those
who are asymptomatic.
RCOG Green-top Guideline No. 27
Management of placenta
previa
Maternal
Vital sign monitoring
Strict pad chart and inform if any immediate PV
bleeding
KNBM but if no PV bleeding, encourage oral intake
Weekly FBC if symptomatic or continuous PV bleed
Ask everyday any PV bleed or abdominal pain
Fetal
Fetal kick chart, inform any reduce fetal movement
Biweekly CTG and USS
Labor
Prolonged the pregnancy
Plan on mode of delivery depend on the type of
placenta previa
DONT FORGET ABOUT DEXAMETHASONE IF FOUND BEFORE 34 WEEKS
Management of placenta
previa
Delivery
ELSCS at 38 weeks of POG if placental
edge is <2cm from internal os and the
placenta is thick.
Allow SVD at term in minor PP unless
there is fetal or maternal compromised.
Management of placenta abruptio
Stabilization of mother condition
Draw blood for FBC, BUSE, coagulation profile
and GXM
Monitor BP and PR
Left lateral position
Oxygen mask 8L/min
IV fluid
If DIVC, give DIVC regime (6unit cryoprecipitate,
4unit platelet, 2unit fresh frozen plasma)
CBD for I/O monitoring
CTG and US for fetal well being and
labor +
Reactive
Non-reactive +/No fetal heart
Contraction
contraction
beat +/contraction
Active Phase
ARM and pitocin
SVD
SVD/LSCS
decided by
specialist
ARM +/- pitocin
SVD or LSCS
decided by
specialist
Latent Phase
SVD/LSCS
DONT FORGET ABOUT DEXAMETHASONE IF FOUND BEFORE 34 WEEKS
Management of Vasa Previa
With presence of active bleed of vasa
previa, with signs of fetal distress, EMLSCS
should be performed
In confirmed cases of vasa previa at term,
delivery should be carried out by elective
caesarean section in a timely manner.
In cases of vasa previa identified in the
second trimester, imaging should be
repeated in the third trimester to confirm
persistence.
In cases of confirmed vasa previa in
the third trimester, antenatal
admission from 28 to 32 weeks of
gestation to a unit with appropriate
neonatal facilities will facilitate
quicker intervention in the event of
bleeding or labour.
In view of the increased risk of
preterm delivery, administration of
corticosteroids for fetal lung maturity
should be considered.
Management of Local
Causes
Infections Treat with
antibiotics/antifungal accordingly
Trauma stop any active bleeding
and reassure patient. However, if
bleeding doesnt stop a surgical
intervention may be necessary.
