Antepartum & Postpartum

Hemorrhage (APH &PPH)

ANITA DEODHAR
Professor cum Nursing Advisor
College Of Nursing
Tata Memorial Hospital
Parel Mumbai400012
Antepartum & Postpartum Hemorrhage

• Obstetrics is "bloody business.“

• Death from hemorrhage still remains a
leading cause of maternal mortality.
• Haemorrhage was a direct cause of more
than 18 percent of 3201 pregnancy-related
maternal deaths.
• APH-Haemorrhage from genital tract after
28th wk of pregnancy-but before birth.
INDETERMINATE

 CERVICAL POLYP
 CERVICAL CARCINOMA
VARICOSE VEIN-VULVA
VAGINA
ANTEPARTUM HEMORRHAGE
• Per vagina blood loss after 28 weeks’ gestation.

• Complicates close to 4% of all pregnancies and

is an OBSTETRIC EMERGENCY!

• Is one of the leading causes of antepartum

hospitalization, maternal morbidity, and
operative intervention.
 COMMON CAUSES
• Placenta Previa
• Placental Abruption
• Uterine Rupture
• Vasa Previa
• Bloody Show
• Coagulation Disorder
• Haemorrhoids
• Vaginal Lesion/Injury
• Cervical Lesion/Injury
• Neoplasia
 Key point to Remember
• The pregnancy in which such bleeding
occurs remains at increased risk for a poor
outcome even though the bleeding soon
stops and placenta praevia appears to
have been excluded by sonography.
 Placenta Praevia
• Defined as a placenta implanted in the lower segment of
the uterus, presenting ahead of the leading pole of the
fetus.

4th degree -Total placenta praevia. - The internal cervical os is

covered completely by placenta.

3rd degree- Partial placenta praevia. The internal os is partially

covered by placenta.

2nd degree- Marginal placenta praevia. The edge of the placenta is

at the margin of the internal os.

1st degree - Low-lying placenta. The placenta is implanted in the

lower uterine segment such that the placenta edge actually
does not reach the internal os but is in close proximity to it.
Placenta Praevia

• Bleeding results from small disruptions

in the placental attachment during
normal development and thinning of
the lower uterine segment due to
dilatation of the os, causes
detachment of non-elastic placenta
from open maternal sinuses
 Placenta Praevia
• Incidence about 1 in 200 hospital
deliveries (5%)

• Perinatal morbidity and mortality are

primarily related to the complications of
prematurity, because the haemorrhage is
maternal.
 Placenta Praevia
• Etiology:
-Advancing maternal age
– Multiparity
– Multifoetal gestations
– Prior caesarean delivery
– Smoking
– Prior placenta praevia
– Formation of capsular placenta
– Low implantation of ovum & large placenta
 Placenta Praevia
• The most characteristic event in placenta previa
is painless apperantly causeless recurrent
hemorrhage.
• Pain in abdomen –absent, unless spontaneous
labour starts
• This usually occurs near the end of or after the
second trimester.
• The initial bleeding is rarely so profuse as to
prove fatal.
• It usually ceases spontaneously, only to recur.
 Placenta Praevia-- on
examination
• Vulval inspection- to note any active vaginal
bleeding
• Evidence of late pregnancy
• Evidences of blood loss -SHOCK may be present
depending upon degree of haemorrhage
• Abdomen- soft ,Uterus- of normal consistency,
Foetus is felt normally, Presenting part is non-
engaged, Malpresentation or unstable lie more
common, FHS-
audible & normal if no placental seperation
 Placenta Praevia
• Placenta praevia may be associated with
placenta accreta, placenta increta or
percreta.

• Coagulopathy is rare with placenta

praevia.
 Placenta Praevia
• Diagnosis.

– Placenta praevia or abruption should always be suspected in

women with uterine bleeding during the latter half of pregnancy.

– The possibility of placenta praevia should not be dismissed until

appropriate evaluation, including sonography, has clearly proved
its absence.

– The diagnosis of placenta praevia can seldom be established

firmly by clinical examination. Such examination of the cervix
is never permissible unless the woman is in an operating
room with all the preparations for immediate caesarean
delivery, because even the gentlest examination of this sort
can cause torrential haemorrhage.
 Placenta Previa
• The simplest and safest method of placental localization
is provided by transabdominal sonography.

• Transvaginal ultrasonography has substantively

improved diagnostic accuracy of placenta previa.

• MRI

• At 18 weeks, 5-10% of placentas are low lying. Most

‘migrate’ with development of the lower uterine segment.
 Placenta Praevia
Management

• Admit to hospital

• NO VAGINAL EXAMINATION

• IV access

• Placental localization
 Placenta Previa
Management
Severe Caesarean
Resuscitate
bleeding section
>34/42
Moderate
Gestation
bleeding
<34/42
Resuscitate
Steroids Unstable

Stable
Mild
<36/42
bleeding Gestation Conservative
care
>36/42
 Conservative care
• If bleeding is slight hospitalization till it stops
• Speculum exam to rule out incidental cause---If
bleeding does not stop….hospitalization
continues
• Monitor placental function, Antenatal
cardiotocography & hormonal assay if possible.
• Repeated USG to observe placental position in
relation to cervical os
 contd
• If heavy bleeding & matured foetus, PV
under GA in well equipped OT
• If placenta is felt, caesarean section
• If placenta not covering the os or not felt
ROM & Oxytocin infusion
• Vaginal delivery in case of 1st,2nd degree
if anteriorly situated
 Placenta Praevia
Management

• Delivery is by Caesarean section 3rd,4th degree & 2nd

degree posterior even if foetus is dead.
• Any degree of placenta praevia with other high risk
pregnancy, Malpresentation, Elderly primigravida.
Prompt delivery of foetus –very important
• INJ.Methergin0.2mg i.v.&10 units oxytocin- in 500ml
glucose drip
• Occasionally Caesarean hysterectomy may be
necessary in case of uncontrollable torrential bleeding
 Complications of placenta
praevia
• Maternal mortality-- below .5% In developing
countries-due to preg. anaemia, lack of ANC,
Vaginal examination & plugging at home, poor
transport & inadequate blood transfusion—etc.
• In developed country-Nil
• Risks due toHaemorrhage-ante,intra,postpartum
Shock ( haemorrhagic )
Sepsis –due to anaemia &intervention
• Rupture of uterus
 Foetal Risks
• Perinatal mortality—20% in developing
countries & 10% in developed countries
• Causes- 1)Prematurity
2)Asphyxia
3) Birth trauma
4)Foetal Malformation
 Placental Abruption
• Defined as the premature separation of the
normally implanted placenta.
• Occurs in 1-2% of all pregnancies
• Perinatal mortality rate associated with placental
abruption was 119 per 1000 births, compared
with 8.2 per 1000 for all others.
• 20-50% cases - Hypertensive Disorders of
Pregnancy associated with abruptio placentae
Placental Abruption-Types

1)Revealed hemorrhage 2) concealed

haemorrhage
3)Mixed
haemorrhage
 Placental Abruption
Revealed—Retroplacental haemorrhage,
gets revealed vaginally– mild
Concealed—Haemorrhagic blood gets
collected between placenta & uterine wall-
remains entirely internal—severe
Mixed—Partly revealed & partly concealed–
severe type--severe
 Placental Abruption
The primary cause of placental abruption is unknown, but
there are several associated conditions.

• Increased age and parity • Cigarette smoking

• Preeclampsia • Thrombophilias
• Chronic hypertension • Cocaine use
• Preterm ruptured • Prior abruption
membranes • Uterine leiomyoma
• Multifoetal gestation • External trauma
• Hydramnios • Vascular accidents
 Placental Abruption
• Pathology
– Placental abruption is initiated by haemorrhage
into the decidua basalis.

– The decidua then splits, leaving a thin layer

adherent to the myometrium.

– development of a decidual haematoma that

leads to separation, compression, and the
ultimate destruction of the placenta adjacent to it.
 Placental Abruption
• Bleeding with placental abruption is almost
always maternal.

• Significant foetal bleeding is more likely to be

seen with traumatic abruption.

• In this circumstance, foetal bleeding results from

a tear or fracture in the placenta rather than from
the placental separation itself.
 Placental Abruption
• The hallmark symptoms of placental abruption is pain
which can vary from mild cramping to severe pain.
• A firm, tender uterus and a possible sudden increase
in fundal height found on exam.
• The amount of external bleeding may not
accurately reflect the amount of blood loss.
• Importantly, negative findings with ultrasound
examination do not exclude placental abruption.
Ultrasound only shows 25% of abruptions.
 Placental Abruption
• Shock-moderate to severe degree
• Incidence of pre-eclampsia is high
• Foetus is felt with great difficulty &
foetal heart sound--absent
• Vaginal examination-Placenta not
detected but soft & friable blood clot can
be felt
 Placental Abruption
COMPLICATIONS
• Shock
• Consumptive Coagulopathy
• Renal Failure
• Fetal Death
• Couvelaire Uterus
 Complications of Abruptio
Placenta
• Maternal- Revealed- No mortality
Concealed – 2.1-6.4 % mortality.
Responsible factors are-a)SHOCK-
haemorrhage,trauma b)
Haemorrhage---ante,intra &postpartum c)Sepsis-
bleeding and intervention d)
Coagulation defects- Low platelet, fibrinogen
count, increased fibrinolysis
e)Renal Failure-as a result of hypovolaemia &
consequent poor perfusion of kidneys
 complications contd….
• Couvelaire Uterus—Retained blood from
retroplacental site is forced into the
myometrium, infilters into muscle fibers,
interfering with contraction appears bruised &
oedematous, also known as Uterine Apoplexy
• Foetal- Risk-Mortality 25% in revealed 100% in
concealed due to Prematurity & Anoxia due to
placental seperation
 Placental Abruption
• Management: Treatment for placental abruption varies
depending on gestational age and the status of the
mother and fetus.
– Admit
– History & examination
– Assess blood loss
• Nearly always more than revealed
– IV access, X matched biood, DIC screening
– Assess fetal well-being
– Placental localization
 Obstetric Treatment
• Revealed Type- If mild vag bl- Pregnancy before
38 wks- Expectant Tr. i.e.-Bedrest,Proper diet,
tranquilizer, NO TOCOLYTICS
• After 38 wks-Termination of pregnancy—
Induction of labour If os is dilatable. If closed-
With high risk factors…..LSCS
• If Vag bl continues- Induction of labour—If it
fails, Caesarean section
• Constant foetal monitoring- very essential
 Contd---
• Concealed & Mixed type- Not in labour—Induction
of labour—ARM,5units of oxytocin-primi& 2 units
–multi in dextrose---Quick vaginal delivery. Early
Concealed—Caesarean section if foetus is alive
or if labour fails to progress
• If in labour- Spontaneous vag delivery if os is
dilating, low rupture of membrane,--75% cases
vag delivery & Caesarean Section in 25%
• Casarean hysterectomy for couvelaire ut.
• Anti –D 300microgm in Rh incompatibility
 Uterine Rupture
• Reported in 0.03-0.08% of all delivering women, but
0.3-1.7% among women with a history of a uterine
scar (from a C/S for example)

• 13% of all uterine ruptures occur outside the hospital

• The most common maternal morbidity is hemorrhage

• Foetal morbidity is more common with extrusion

 Uterine Rupture
• Classic presentation includes vaginal bleeding,
pain, cessation of contractions, absence/
deterioration of fetal heart rate, loss of station of
the foetal head from the birth canal, easily
palpable fetal parts, and profound maternal
tachycardia and hypotension.

• Patients with a prior uterine scar should be

advised to come to the hospital for evaluation of
new onset contractions, abdominal pain, or
vaginal bleeding.
 What are the risk factors
associated with uterine rupture?
 Uterine Rupture
• Excessive uterine • Multiparity
stimulation
• Non-vertex fetal
• Hx of previous C/S presentation

• Trauma • Shoulder dystocia

• Prior rupture • Forceps delivery

• Previous uterine surgery

 Uterine Rupture
•
Management: Emergent laparotomy
 Vasa Previa
• Rarely reported condition in which the fetal
vessels from the placenta cross the entrance to
the birth canal.

• Incidence varies, but most resources note

occurrence in 1:3000 pregnancies.

• Associated with a high foetal mortality rate (50-

95%) which can be attributed to rapid foetal
exsanguination resulting from the vessels
tearing during labor
 Vasa Previa
• There are three causes typically noted
for vasa previa:

1. Bi-lobed placenta
2. Velamentous insertion of the umbilical cord
3. Succenturiate (Accessory) lobe
Vasa Previa
Vasa Previa
 Vasa Previa
• Risk Factors:
– Bilobed and succenturiate placentas
– Velamentous insertion of the cord
– Low-lying placenta
– Multiple gestation
– Pregnancies resulting from in vitro fertilization
– Palpable vessel on vaginal exam
 Vasa Previa
• Management:
– When vasa previa is detected prior to labor, the baby
has a much greater chance of surviving.
– It can be detected during pregnancy with use of
transvaginal sonography.
– When vasa previa is diagnosed prior to labor, elective
caesarian is the delivery method of choice.
 Kleihauer-Betke Test
• Is a blood test used to measure the
amount of fetal haemoglobin transferred
from a fetus to the mother's bloodstream.

• Used to determine the required dose of Rh

immune globulin.

• Used for detecting foetal-maternal

hemorrhage.
 Apt test
• The test allows the clinician to determine whether the
blood originates from the infant or from the mother.
– Place 5 mL water in each of 2 test tubes
– To 1 test tube add 5 drops of vaginal blood
– To other add 5 drops of maternal (adult) blood
– Add 6 drops 10% NaOH to each tube
– Observe for 2 minutes
– Maternal (adult) blood turns yellow-green-brown; foetal blood
stays pink.
– If foetal blood, deliver STAT.
 Postpartum Hemorrhage
• In spite of marked improvements in management, PPH
remains a significant contributor to maternal morbidity
and mortality both in developing and developed
countries.

• One of the most challenging complications a clinician

and nurses will face.

• Prevention, early recognition and prompt appropriate

intervention are the keys to minimizing its impact.
Haematological Changes in Pregnancy
• 40% expansion of blood volume by 30 weeks

• 600 ml/min of blood flows through intervillous space

• Appreciable increase in concentration of Factors I

(fibrinogen), VII, VIII, IX, X

• Plasminogen appreciably increased

• Plasmin activity decreased

• Decreased colloid oncotic pressure secondary to 25%

reduction in serum albumin
 PPH
• Excessive bleeding affects approximately 5 to 15 percent
of women after giving birth.

• Haemorrhage that occurs within the first 24 hours of

postpartum is termed early postpartum hemorrhage.

• While excessive bleeding after 24 hours is referred to as

late postpartum hemorrhage.

• In general, early PPH involves heavier bleeding and

greater morbidity.
 PPH
• The mean blood loss in a vaginal delivery is
500 ml & 1000 ml for cesarean section.

• Definition:
– Blood loss greater than 500 ml for vaginal and 1000
ml for cesarean delivery.
– However, clinical estimation of the amount of blood
loss is notoriously inaccurate.
– Another proposed definition for PPH is a 10% drop
in haematocrit.
 Types Of PPH

1)Third Stage Haemorrhage-without expulsion of

placenta
2)Primary Postpartum Haemorrhage-after 3rd stage
within 24 hrs
3)Secondary postpartum or Puerperal
Haemorrhage—after 24hrs during puperium
PPH
 PPH
• The etiologies of early PPH are most easily understood as
abnormalities of one or more of four basic processes.

• Bleeding will occur if for some reason the uterus is not able to
contract well enough to arrest the bleeding at the placental site.

• Retained products of conception may cause large blood losses

postpartum

• Genital tract trauma may cause large blood losses postpartum

• Coagulation abnormalities can cause excessive blood loss alone or

when combined with one of the other processes.

• The four “T” processes.

The Four “T”

Tone
Tissue
Trauma
Thrombin
 PPH Risk Factors
• Many factors responsible for a woman’s
risk of PPH.

• Each of these risk factors can be

understood as predisposing her to one or
more of the four “T” processes.
PPH Risk Factors
PPH Risk Factors
PPH Risk Factors
PPH Risk Factors
 PREVENTION OF PPH
• Although any woman can experience a PPH, the
presence of risk factors makes it more likely.

• For women with such risk factors, consideration

should be given to extra precautions such as:
– IV access
– Coagulation studies
– Crossmatching of blood
– Anaesthesia backup
– Referral to a tertiary centre
 PREVENTION OF PPH
• UTEROTONIC DRUGS

– Routine oxytocic administration in the third stage of

labour can reduce the risk of PPH by more than 40%

– The routine prophylaxis with oxytocics results in a

reduced need to use these drugs therapeutically

– Management of the third stage of labour should

therefore include the administration of oxytocin after
the delivery of the anterior shoulder.
 MANAGEMENT OF PPH
• Early recognition of PPH is a very
important factor in management.

• An established plan of action for the

management of PPH is of great value
when preventive measures have failed.
MANAGEMENT OF PPH
MANAGEMENT OF PPH
DRUG THERAPY FOR PPH
MANAGEMENT OF PPH
MANAGEMENT OF PPH
MANAGEMENT OF PPH
Summary: Remember 4 Ts
• Tone
• Tissue
• Trauma
• Thrombin
 Summary: remember 4 Ts
• “TONE” • Palpate fundus.
• Rule out Uterine • Massage uterus.
Atony • Oxytocin
• Methergine
• Haemabate
 Summary: remember 4 Ts
• “Tissue” • Inspect placenta for
• R/O retained placenta missing cotyledons.
• Explore uterus.
• Treat abnormal
implantation.
 Summary: remember 4 Ts
• “TRAUMA” • Obtain good
• R/O cervical or exposure.
vaginal lacerations. • Inspect cervix and
vagina.
• Worry about slow
bleeders.
• Treat haematomas.
 Summary: remember 4 Ts
• “THROMBIN” • Check labs if
suspicious.