Antepartum Hemorrhage

TUTORIAL 6 CASE 1.
VAGINAL BLEEDING
 ANTEPARTUM HAEMORRHAGE
• antepartum haemorrhage (APH), also prepartum hemorrhage, is bleeding from
the vagina after 20 weeks’ gestation.

• It should be considered a MEDICAL EMERGENCY (regardless of whether there is

pain) and medical attention should be sought immediately, as if it is left untreated
it can lead to death of the mother

• CAUSES :
Placental: Non-placental:
• Abruptio placenta. • Vasa previa.
• Placenta previa. • Bloody show
• Carcinoma.
• Idiopathic.
• Trauma.
• Uterine rupture.
• Cervicitis.
 PLACENTA PREVIA
Is the implantation of the placenta in the lower uterine segment with different
grades of encroachment on the cervix.

• Bleeding is: -painless

-causless
• CLASSIFICATION :
• Total placenta previa occurs when the internal cervical os is completely
covered by the placenta.
• Partial placenta previa occurs when the internal os is partially covered by
the placenta.
• Marginal placenta previa occurs when the placenta is at the margin of the
internal os.
• Low-lying placenta previa occurs when the placenta is implanted in the
lower uterine segment. In this variation, the edge of the placenta is near
the internal os about 2-3 cm but does not reach it
 RISK FACTORS
 Prior cesarean delivery/myomectomy

 Prior previa (4-8% recurrence risk)

 Previous abortion

 Increased parity

 Multifetal gestation

 Advanced maternal age

 Abnormal presentation

 Smoking
 Pathophysiology

• The exact etiology of placenta previa is unknown.

The condition may be multifactorial and is postulated
to be related to multiparity, multiple gestations,
advanced maternal age, previous cesarean delivery,
previous abortion, and possibly, smoking.
 Symptoms

• Vaginal bleeding

– It is apt to occur suddenly during the third trimester.

– Bleeding is usually bright red and painless.

– Initial bleeding is not usually profuse enough to cause death; it

spontaneously ceases, only to recur later.

– The first bleed occurs (on average) at 27-32 weeks' gestation.

– Contractions may or may not occur simultaneously with the

bleeding.
 Physical Examination
• Profuse hemorrhage

• Hypotension

• Tachycardia

• Soft and nontender uterus

• Normal fetal heart tones (usually)

• Vaginal and rectal examinations

– Do not perform these examinations in the ED because they may

provoke uncontrollable bleeding.

– Perform examinations in the operating room under double set-up

conditions (ie, ready for emergent cesarean delivery)
 Abruptio placenta

• Abruptio placentae refers to separation of the normally

located placenta after the 20th week of gestation and prior to
birth.
 RISK FACTORS
 Maternal hypertension  Prolonged PROM

 Abdominal trauma  Uterine decompression

 Smoking  Short umbilical cord

 Prior abruption  Chorioamnionitis

 Preeclampsia  Multiparity

 Multiple gestation
• Pathology
- hemorrhage into the decidua basalis
→ decidua splits, leaving thin layer adherent to the
myometrium
→ decidual hematoma leads to separation, compression,
and destruction of placenta
- in early stage, no clinical symptom, a few centimeters
in diameter (dark and clotted blood)
→ a very recent separated placenta appear no different
from a normal placenta
- decidual spiral artery ruptures

→ retroplacental hematoma

→ expands disrupts more vessel & placenta

→ separation rapidly to the margin

(because, the uterus still distended by conception,

so it is unable to contract to compress the torn

vessels that supply the placental site)

 SYMPTOMS
• Vaginal bleeding

• Abdominal or back pain and uterine tenderness

• Fetal distress

• Abnormal uterine contractions (eg, hypertonic, high frequency)

• Idiopathic premature labor

• Fetal death
 Physical Examination
• Do not perform a digital examination on a pregnant patient with vaginal bleeding without first
ascertaining the location of the placenta. Before a pelvic examination can be safely performed, an
ultrasonographic examination should be performed to exclude placenta previa.

• Vaginal bleeding

• Contractions/uterine tenderness

• Shock

Patients may present with hypovolemic shock, with or without vaginal bleeding, because a
concealed hemorrhage may be present.

• Absence of fetal heart sounds

• Fundal height

This may increase rapidly because of an expanding intrauterine hematoma

Vasa Previa
 Introduction
• Vasa previa refers to vessels that traverse the membranes in
the lower uterine segment in advance of the fetal head.

• Rupture of these vessels can occur with or without rupture of

the membranes and result in fetal exsanguination.
 Associated Conditions
• Low-lying placenta.

• Bilobed placenta.

• Multi-lobed placenta.

• Succenturiate-lobed placenta.

• Multiple pregnancies.

• Pregnancies resulting from IVF.

 Diagnosis
• The diagnosis of vasa previa is considered if vaginal bleeding occurs
upon rupture of the membranes.

• Concomitant fetal heart rate abnormalities, particularly a sinusoidal

pattern.

• Ideally, vasa previa is diagnosed antenatally by US with color flow

Doppler.
Uterine Rupture
 Risk Factors
• The most common risk factor is a previous uterine incision.

• The rate is higher with classical & T-shape uterine incision in

comparison to low vertical & transverse incisions.

• The rate increases with the number of previous uterine incisions.

 Risk Factors
• High parity. • Trauma.

• Labor complications: • Delivery complications:

1. CPD. 1. Difficult forceps.

2. Abnormal presentation. 2. Breech extraction.

3. Unusual fetal enlargement 3. Internal podalic version.

(hydrocephalus).
 Presentation
• Sudden severe fetal heart decelerations

• Abdominal pain & PV bleeding ( <10%).

• Diaphragmatic irritation.

• Loss of fetal station.

• Cessation of uterine contractions.