Antepartum Haemorrhage

1&2
BY

Dr. P. A. Awoyesuku
 Introduction:
 Definition: Ante-partum haemorrhage (APH), or late pregnancy bleeding, is vaginal bleeding from the 28th week of
gestation (period of fetal viability) and before the onset of labour or delivery of the baby. Sometimes 24 th
week in developed countries where fetal survival is not uncommon after the 24 th week.

 Incidence: The true incidence of APH is difficult to establish with accuracy in developing countries due to
lack of reliable data. However, geographical and socio-economic factors have been shown to affect its
incidence. The incidence is estimated as 2-5% of pregnancies; some books say 3% (1% praevia, 1%
abruptio & 1% other causes).
 Causes: (placental & non-placental)
1. Placenta Praevia; (most dangerous for mother; blood loss mainly maternal)
2. Abruptio Placentae; (more dangerous for fetus than mother; blood loss both fetal and maternal)
3. Vasa Praevia; (not dangerous for mother but nearly always fatal for fetus; blood loss is fetal)
4. Bloody (excessive) show (shedding of cervical mucous plug).
5. Local legions of the cervix (cervicitis, ectropion, cancer), vagina (trauma, infection) and vulva.
6. Indeterminate: when cause of bleeding not identified even after delivery and examining the placenta.
7. Uterine Rupture (occasionally described as intrapartum; however, it occurs before delivery of baby so it is
APH).
 A. Placenta Praevia:
 Definition & Terms: Abnormal location or implantation of the placenta at or near the internal cervical os (lower
segment of uterus). Many placentas are low-lying in early pregnancy but with development of lower uterine segment
appear to "move upward" as pregnancy nears term. Incidence is rising due to rising CS rates, especially repeat CS.

 Major degree: placenta covers internal os; Minor degree: placenta situated within lower segment but not covering os.
 Total: placenta completely covers the internal os or Partial: placenta partially covers the internal os.
 Marginal: within 2 cm of the os but does not cover any part of the os.
 Low lying (NOT a praevia): placenta in lower segment but clear of the os, can also bleed, usually later in labour.
 Aetiological factors:
1. Faulty implantation of blastocyst.
2. High parity – more common in multipara than nullipara
3. Advanced maternal age – more common in women >35 years.
4. Uterine fibroid – multiple submucous fibroids in upper uterine segment.
5. Large placental surface – in multiple pregnancy or placenta membranacea can encroach on lower segment.
6. Previous uterine injury – previous CS scar, frequent D & C or evacuation of retained products of conception.
A. Placenta Praevia:
Incidence: In Nigeria varies from one
institution to another. In some western
countries rates of 0.2 to 1.0% of all
deliveries have been reported. 5 per 1000
in UK.
Classification: based on location
(anatomical); now abandoned for
major/minor;
1. Type 1: placenta encroaches on lower
segment but does not reach the
internal os.
2. Type II: placenta reaches internal os but
does not cover it. A – anterior, B –
posterior.
3. Type III: placenta covers the os by
reaching across the farther margin but
may cease to do so when cervix dilates.
4. Type IV: placenta covers the os to such
a degree that even with dilatation of
the cervix it still covers it.
 A. Placenta Praevia:
 Clinical history:
 Complaint usually of painless, bright red, vaginal bleeding in the 3 rd trimester.
 initially, bleeding may be minimal and cease spontaneously but can be catastrophic later.
 bleeding at onset of labour can occur with marginal placenta previa.
 Some women may have experienced “spotting” during 1 st and 2nd trimester.
 Clinical findings:
 There may be pallor with repeated episodes of bleeding or shock following heavy bleeding episode.
 On abdominal exam, the uterus is soft, relaxed and non-tender and the presenting part is high or
displaced.
 The Lie of the fetus may be abnormal – oblique or transverse, due to placenta occupying lower segment.
 Fetal heart sounds are usually heard and regular, except in some cases complicated by hypovolaemic
shock.
 Vaginal exam at time of admission is forbidden, so as not to provoke further haemorrhage.
 Investigations:
 Estimate HB or PCV.
 Ultrasound Scan to determine fetal viability, gestational age and placental location.
 MRI is a newer, superior technique with better quality of imaging than ultrasound, but too expensive for routine
use.
 Exam in theater – careful gentle VE in theater where placenta is felt in lower segment (doughy consistency),
usually done from 38 weeks and with “double-setup”. Previously commonly done when ultrasound scan was
not available.
A. Placenta Praevia:
 Complications:
 fetal:
 perinatal mortality; much lower, but still higher than with a normal pregnancy
 prematurity (bleeding often dictates early C/S)
 intrauterine hypoxia - acute (birth asphyxia) or chronic (IUGR)
 fetal abnormal lies and malpresentation
 risk of fetal blood loss from placenta, especially if incised during C/S
 Maternal:
 maternal mortality, currently quoted as < 1%
 haemorrhage and hypovolemic shock > anaemia + acute renal failure
 pituitary necrosis (Sheehan syndrome)
 postpartum haemorrhage (because lower uterine segment is atonic)
 hysterectomy
 placenta accreta (abnormally or morbidly adherent placenta)
A. Placenta Praevia:
 Management: Management decision depends on praevia characteristics (amount of bleeding
& degree of praevia), fetal condition (GA, level of distress, presentation), and uterine activity.
Rhogam if mother is Rh negative. In all cases ensure at least 2 units of blood is crossmatched
and made available for the patient.
 Expectant management (watchful waiting): observation of mother and fetus if the initial
bleeding episode is slight and GA < 37 weeks
 Admit to hospital; limited physical activity; estimate PCV and transfuse if indicated; if diagnosis
is confirmed, the patient remains in hospital until delivery. Provide IV line & fluids/blood for
emergency.
 Consider corticosteroids to enhance fetal lung maturity.
 Delivery when fetus is mature, or haemorrhage increase or persist.
 Active management if GA >36 weeks or if bleeding is profuse irrespective of fetal maturity.
 immediate resuscitation with blood is mandatory if there is massive bleeding.
 Caesarean section immediately if baby is to be salvaged & also safer for mother.
 Asymptomatic patients discovered incidentally on ultrasound scan with no bleeding:
 If minor degree praevia, can be managed on outpatient basis and patient asked to report to
hospital if any bleeding occurs; should be reserved for patients within an easy reach of the
hospital; should be advised against travelling and coitus; should be admitted at 38 weeks for
delivery.
B. Abruptio Placentae
Definition & Terms:
Abruptio placenta is the premature
separation of the whole or part of a
placenta implanted in the upper segment of
the uterus.
Normally, the placenta separates after the
delivery of the fetus, in the third stage of
labor.
The cause is unknown.
Classified as total (fetal death inevitable)
vs. partial
External/revealed/apparent; blood dissects
downward through the cervix to vagina.
Internal/concealed (20%); blood dissects
upward toward fetus and is contained in
uterus.
Most cases are mixed.
Incidence: 1/100 deliveries.
B. Abruptio Placentae:
 Associated factors:
 Previous abruption (recurrence rate 10%).
 Maternal hypertension (chronic or PIH) in 50% of abruptios; Maternal vascular diseases.
 Cigarette smoking & excessive alcohol consumption.
 Multiparity – high parity
 Advanced maternal age > 35 years.
 PPROM
 Short umbilical cord.
 Uterine overdistension (as in multiple gestation)
 Polyhydramnios - Sudden decompression of the uterus.
 Uterine anomaly, fibroids – where site of placental attachment covers a fibroid nodule.
 Trauma (e.g., road transport accident, maternal battering)
 Low socio-economic status.
 Cocaine use – uncommon in our environment; & Folic acid deficiency – has remained
disputable.
B. Abruptio Placentae:
 Clinical history:
 Classically there is painful vaginal bleeding; blood is menstrual-like (dark).
 Abdominal discomfort, backache or severe abdominal pain; proportional or increases
with severity.
 Uterine contractions may be superimposed thus causing additional intermittent pain.
 There may be complain of lack of fetal movement.
 Symptoms of shock – dizziness, fainting, collapse. Remember: some cases may be
without external bleeding.
 Clinical findings:
 Clinical signs of shock – sweating, pallor, rapid pulse, cold clammy extremities,
 Uterus will be tense, tender and woody hard esp if concealed type, less marked in
revealed and mixed type.
 Fetal parts are difficult to palpate, and FHR is invariably absent.
 The uterus may be noted not to relax in between contractions if patient is in labour.
 The above signs may not be significant in mild cases, but abdominal tenderness (local
or generalized) is usually present.
Clinical Grades of Abruptio Placentae
GRADE Uterine Maternal Maternal FHR
Irritability Haemodynamics Fibrinogen level

MILD Mild Normal Normal Normal

MODERATE Moderate-severe BP normal but with Low (reduced) Fetal Distress:

+/- tetany postural drop; Loss of variability
Increased HR (pulse) Late decelerations

SEVERE Tetany Decreased BP Markedly low Fetal death

Increased HR
Shock
B. Abruptio Placentae:
 Investigations:
 Diagnosis is usually clinical and ultrasound scan is not sensitive for abruptio (sensitivity = 15%). Ultrasound diagnosis
depends on formation of retroplacental clots or haematoma.
 Scan will only help to locate placenta to exclude praevia and confirm fetal status. Note: in 10% of cases abruptio can
occur with praevia.
 Diagnosis is confirmed at third stage, on exam of placenta following delivery.
 HB or PCV estimation.
 Coagulation profile might be deranged: clotting time (bedside in emergency), Platelet count, Fibrinogen, Prothrombin
time (PT), partial thromboplastin time (PTT), fibrin degradation products (FDP).
 Group & crossmatch fresh whole blood (or fresh frozen plasma where available) because of DIC risk.
 Complications:
 Fetal:
 perinatal mortality 25-60%;
 prematurity; acute intrauterine hypoxia (birth asphyxia).
 Maternal:
 maternal mortality; DIC (in 20% of abruptio); acute renal failure;
 hemorrhagic shock; anaemia; pituitary necrosis (Sheehan syndrome);
 amniotic fluid embolism; PPH – coagulopathy & atony;
B. Abruptio Placentae:
 Conservative mgt: only in mild cases and GA <36 weeks.
 admit to hospital and put on bed rest; treat hypertension if present; close observation of fetal well-
being (serial ultrasound scans) and bleeding.
 Transfuse to correct anaemia; give Rhogam if Rhesus negative; aim to deliver not later than 38
weeks.
 Active mgt:
Moderate abruption: hydrate and restore blood loss and correct coagulation defect if present.
 vaginal delivery if no evidence of fetal or maternal distress and if cephalic presentation, or with
dead fetus
 labour must progress actively – ARM & augmentation.
❏ Severe abruption and live fetus: do C/S if fetal or maternal distress develops despite fluid/blood
replacement; or if labour is not advanced; or if non-cephalic fetal presentation.
 Mode of delivery: The preferred mode of delivery in abruptio placenta is vaginal. Cesarean section is
indicated for severe bleeding endangering maternal life and where vaginal delivery seems unlikely
within a reasonable time. Besides, Cesarean section is done for other obstetrics indication (e.g.
transverse lie).
 In abruptio placentae, coagulation defects must be looked at seriously. The treatment includes
amniotomy to release intrauterine pressure; termination of pregnancy; and management of shock.
 The use of Dextran if fresh frozen plasma is not available is C/I. dextran forms a complex with
fibrinogen > more bleeding. Haemaccel can be given as blood substitute in Jehovah’s witnesses.
C. Vasa Praevia:
 Definition:
 when unprotected fetal vessels traverse the fetal membrane over the internal os.
 The vessels may be from velamentous insertion of cord into membranes of placenta or may be joining a
succenturiate lobe to main disk of placenta
 Very rare; incidence is 1 in 5,000 deliveries
 Presentation: Diagnosis is usually suspected when either spontaneous or artificial membrane rupture results
in painless fresh vaginal bleeding and fetal distress (tachy- to brady- arrhythmia)
 Investigations: Apt test (Alkali denaturation test; 1% NaOH mixed with the blood) can be done immediately
to determine if the source of the bleeding is fetal (supernatant turns pink) or maternal (supernatant turns
yellow); a crude, non-quantitative method based on resistance of fetal HB to alkali denaturation.
 Management:
 If baby is still alive once diagnosis is suspected, emergency C/S.
 Complications:
 50% perinatal mortality, increasing to 75% if membranes rupture (most infants die of exsanguination)
 since bleeding is from fetus, a small amount of blood loss can have catastrophic consequences
Comparison of Clinical Findings in Placenta Praevia and Abruptio Placentae
Clinical Findings Placenta Praevia Abruptio Placentae

Vaginal bleeding Painless Painful

Causeless Presence hypertension, trauma, etc.
Recurring Non-recurring
Bright red Menstrual like (dark blood)

Shock Degree of shock Proportionate to Degree of shock out of proportion to

vaginal blood loss amount of vaginal bleeding seen

Uterus Soft; quite or relaxed between Irritable; not relaxing between labour
labour contractions contractions (tetanic contraction),

Fetal Presentation Abnormal lies & mal- Usually normal, but difficult to palpate
presentation (transverse, fetus
breech),
Unengaged, high head Engaged head

Fetal Condition Usually normal fetal condition Fetal distress, Fetal death, IUGR