Antepartum-Hemorrhage

(APH)
 Definition:

• Vaginal bleeding after 24weeks and before the delivery of the fetus.
• It complicates (3-4%) of all pregnancies.
• It is an obstetric emergency because it endanger the life of both the
mother and fetus.
• Hemorrhage remain the most frequent cause of maternal deaths.
• Mild= <50 mL loss of blood, Major= 50-1000mL loss, Massive=
>1000mL loss.
• Bleeding >1 occasion regarded as recurrent APH.
Etiology:

• In 30% of cases no cause can be found.

• Placenta previa and abruptio placenta are the main

causes of APH and will be discusses in details
Initial
Evaluation
• How much bleeding?
• What is the nature and duration of bleeding?
• What are the patients Vital Signs?
• Are fetal Heart Rates Present?
• What is fetal status?
• Is there pain or contraction?
• Last cervical smear (date/normal or abnormal)?
• What is the location of placental implantation?
Examination

• Pulse, blood pressure.

• Is the uterus soft or tender and firm?
• Fetal heart / CTG.
• Speculum vaginal examination, with particular importance
placed on visualizing the cervix (having established that
placenta is not a previa, preferably using a portable
ultrasound).
Initial
Investigations

• CBC
• DIC Workup
• (Platelets, PT, PTT (partial), Fibrinogen, D-Dimer).
• Type and Crossmatch
• US (location of Placenta)

Never Perform PV or Speculum exam Until you exclude

Placenta previa by U/S.
Initial
Management
• IV line with a large bore needle

• If maternal signs are unstable, run Isotonic Fluid Without dextrose

wide open and Place a urinary catheter to monitor urine output

• If fetal jeopardy is present or gestational age is + 36 weeks, the

goal is delivery
Placental
Abruption
Placental Abruption:

• Third trimester bleeding due to premature separation of a normally

sited placenta.
• It complicates 0.5-2% of pregnancies.
• It could be of two types:
1. Revealed (Overt) and External Bleeding: there is obvious
external vaginal bleeding (2/3 of cases)

2. Concealed or Internal Bleeding: bleeding in the uterus with no

external bleeding. (1/3 of cases).
Classification of Abruptio Placenta:

A. MAJOR
• This is clinically obvious and may result in the death of the fetus.
• It is also life-threatening to the mother and usually involves
separation of more than one-third of the placenta.

B. MINOR
• Premature separation of small areas of the placenta may result in
placental infarcts.
• Several small abruptions may precede a large abruption.
 Moderate Severe
MILD abruption Abruption
Abruption Tachy., Variability Severe late
Normal FHR Mild late deceleration, brady,
decelerations death!

Percentage of placenta separated

0% 50 % 100 %

Placental abruption is a continuous process

Abruptio placenta
Character of bleeding

Painful
 Abruptio placenta

Placental Location
Normal
Not Lower segment
 Ob-Gyn Key phrases

Painful late- trimester

bleeding
Abruptio placenta
Normal Placental implantation:
• Fundal
• Anterior
• Posterior
 Overt
Abruptio placenta
 Concealed
Abruptio placenta
 Most common cause of

Late Abruptio
pregnancy bleeding Abruptio
Abruptio
placent
a
Painful Late
placent
pregnancy bleeding

Obstetric DIC
placenta
a
 Ob-Gyn key TRIADS

Abruptio placenta
Late trimester painful bleeding
Normal placental implantation
DIC
Risk factors

1. Idiopathic: (Majority).
2. There is an association with defective trophoblastic invasion, as with pre-
eclampsia and intrauterine growth restriction.
3. Direct trauma e.g. RTA and external cephalic version.
4. High parity.
5. Uterine over distention (as in polyhydramnios and multiple pregnancy).
6. Sudden decompression of the uterus e.g. after delivery of 1st twin or release
of polyhydramnios.
7. Hypertension.
8. Smoking.
9. Folic acid deficiency.
Diagnosis

• This is based on the presence of Painful, late trimester vaginal

bleeding with a normal Fundal or Lateral uterine wall placental
implantation not over the lower Uterine segment.
• U/S can be helpful in some cases, demonstrating retro placental
clot and excluding placenta previa.
• However as the bleeding may be concealed ,it’s absence does not
exclude the diagnosis.
• Abruptio placenta usually occurs near term and frequently during
labor.
Clinical Presentation:

A. MAJOR
• Women present with abdominal pain and varying degrees of shock.
• The blood loss that is visible (revealed haemorrhage) is often less
than the degree of shock.
• On examination:
1. The uterus is woody hard; due to a tonic contraction.
2. The fetal parts cannot be felt.
3. The fetus may be dead.
Clinical Presentation:

B. MINOR
• Minor abruptions are often not diagnosed until after
delivery.

• They may present with:

 Mild abdominal pain associated with threatened preterm
labour.
 Unexplained APH.
 Tenderness over one area of the uterus only.
Management of Placental Abruption:

The management depends on:

1. The severity of bleeding.
2. The gestational age.
3. The fetal and maternal condition.
 Management of Abruptio placenta

Emergency Maternal or Fetal

C/S jeopardy
Vaginal Term, in labour, Mom and
delivery fetus is stable
Conservative Preterm, UC subsides,
In-Hospital Mom and fetus stable
Complications of placental abruption:

Maternal complications:
• Acute Tubular Necrosis
• DIC.
• Couvelaire uterus: refers to blood extravasating between the myometrial fibers.
• Postpartum Hemorrhage
• Feto-maternal haemorrhage.
• Maternal mortality
• Recurrence: 10% After 1st attck, 25% After 2nd attck

Fetal complications:
• Impaired fetal growth and/or hypoxic ischaemic encephalopathy (HIE)……C.P
 Blue
Uterus
Couvelaire Uterus
Placenta
Previa
 Placenta previa (P.P.)

Means implantation of the placenta in the lower uterine segment (28 wks).

• Usually the lower implanted placenta atrophies and the upper placenta
hypertrophies, resulting in migration of the placenta.
• At term placenta previa is found in only (0.4-0.8%) of pregnancies.
• Symptomatic placenta previa occurs when painless vaginal bleeding
develops through avulsion of the anchoring villi of an abnormally
implanted placenta as lower uterine segment stretching occurs in the
latter part of pregnancy.
• Bleeding from placenta previa account for about 30% of all cases of APH.
Predisposing Factors:
1. Multiple gestation.
2. Previous C/S scar.
3. Multiparity
4. Previous placenta previa
5. Assisted conception
6. Endometritis
7. Uterine structural anomaly (e.g. septate uterus).
8. Smoking
9. Fetal Cong. Anomaly or Malpresentation
 Placenta PREVIA

Mechanism of “MIGRATION”

Differential Atrophy
& Hypertrophy
 Prevalence of Placenta PREVIA

At 16 Weeks 20 %
At 40 Weeks 0.5 %
Why the difference?
TROPHO TROPISM
Placental movement
 1. Theonplacenta
Factors covers
2nd trimester the internal
ultrasound os with
are associated an
with the persistence of a placenta previa in the 3rd
overlap
trimester:
of more than 1.5 cm.

2. The leading edge of the placenta is thick .

3. The placenta is posterior.
4. There is a uterine scar.
Diagnosis
• This is based on the presence of recurrent painless late-trimester
vaginal bleeding (small bleed or no. of small bleeds precede a larger one)
• The uterus is non-tender and non-irritable and fetal heart is
normal.
• Per vaginal (PV) examination is contraindicated
• Persistent malpresentation or high head in late pregnancy
• An ultrasound scan will show the position of the placenta.
• If the placenta lies in the anterior part of the uterus and reaches
into the area covered by the bladder, it is known as a low-lying
placenta (before 24 weeks) and placenta previa after 24 weeks.
 Placenta PREVIA
CHARACTER of bleeding

Painless
 Ob-Gyn Key phrases
Painless late-
trimester bleeding

Placenta previa
Ob-Gyn key TRIADS

Placenta Previa
Late trimester bleeding
Low segment plac. implant
No pain
 Placenta PREVIA
Pathophysiology of bleeding

Avulsion of villi
Stretching of
lower uterine segment
 Grading of placenta previa:

Grade .1 (lateral placenta):

The placenta implanted in the lower uterine segment but not reach the internal os.
Grade .2.(marginal placenta):
The edge of the placenta reaches the internal os but not cover it.
Grade.3.(partial placenta previa):
The placenta partially covering the internal os.
Grade.4.(complete placenta previa):
The placenta completely cover the internal os completely.
Grade (1&2) called minor P.P. grade (3&4) major P.P.
 Marginal
Placenta previa
MATERNAL
blood
 Partial
Placenta previa
MATERNAL
blood
 TOTAL
CENTRAL
MATERNAL Placenta previa
blood
Management: varies
 Management:

A. ASYMPTOMATIC LOW-LYING PLACENTA

• All women with a low-lying placenta diagnosed in early pregnancy
should be rescanned at 34weeks’ gestation.
• There is no need to restrict work activities or sexual intercourse in
women with a low-lying placenta on ultrasound unless they bleed.
• If the placenta previa is still present at 34 weeks’ Gestation and is Grade
I or II, the woman should be Rescanned on a fortnightly basis but
doesn’t need to be admitted unless they bleed.
• Clinically, a high presenting part or abnormal lie at 37 weeks implies that
the placenta is covering the cervix and a Caesarean section should be
performed electively.
 Management:
B. PLACENTA PRAEVIA WITH BLEEDING
• Admit to hospital.
• Insert a wide-bore i.v. cannula with i.v. fluid
• Take blood for cross-matching and Hb. estimation.
• If the woman is anaemic, she is no longer bleeding and the baby is <37
weeks then she should be transfused aiming for a haemoglobin of
>10.5g/dl.
• Avoid all digital vaginal examinations. (Just speculum examination)
• Perform ultrasound as soon as possible because this is more precise.
• Cross-matched blood should be kept permanently available.
• Placental position and fetal growth should be monitored.
Management of Placenta PREVIA

Emergency C/S Maternal or Fetal jeopardy

Conservative Preterm, stable Mom and
In-Hospital fetus

Vaginal Marginal placenta previa

delivery >2cm from os
Scheduled C/S Term, stable Mom and fetus
At 36–37 weeks’ presentation, a final ultrasound should be performed and
acted upon:

A. Grades III and IV placenta praevia should have a C/S between 37

and 38weeks’ gestation by an experienced obstetrician particularly if
the placenta is on the anterior wall of the uterus.

B. If the presenting part is below the lower edge of the placenta in

Grade I, then it is safe to wait until labour and these women can be
expected to deliver vaginally.
 Complications of placenta
previa
A- Maternal complications:
• There is increased maternal mortality and morbidity.

• Profound hypotension can cause anterior pituitary necrosis

(Sheehan syndrome) or acute tubular necrosis.

• If placenta previa occurs over a previous uterine scar, the villi may
invade into the deeper layers of the decidua basalis and
myometrium, This can result in intractable bleeding requiring
cesarean hysterectomy.
 Complications of placenta previa:

B- Fetal complications:
The perinatal mortality of patients with placenta previa is higher than the
general population and this is related to:
1. Prematurity (which is the main cause).
2. Higher incidence of IUGR (about 20% of pregnancies with placenta
previa) Malpresentation (in 30% of cases).
3. Higher risk of preterm premature rupture of membranes.
4. The presence of vasa previa which carry a perinatal mortality of 75%.
Advice for the
patient
• After several days without bleeding, she may be ambulate and even
discharged if she lives nearby.

• Instruct the patient to return at the first sign of further bleeding.

• Her hematocrit should be followed her haemoglobin should be not less

than 11gm.

• Blood should always be available for the patient.

VASA
Previa
1 in 3000 pregnancies
 Vasa Previa:

• This is a rare condition

• Velamentous insertion of the umbilical cord in the
membranes.
• At the time of rupture of membranes (whether
spontaneous or artificial) the umbilical vessels will
rupture causing massive bleeding which is of fetal
origin.
• It is suspected when fetal heart shows sever
bradycardia after rupture of membranes.
• Treatment is by immediate C/S.
Ob-Gyn key TRIADS

Vasa Previa
ROM
Vaginal bleeding
Fetal bradycardia
What is the diagnosis &
Why?

A 32-year-old multigravida at 31 weeks’ gestation is admitted to the

birthing unit after a motor-vehicle accident.
She complains of sudden onset of moderate vaginal bleeding for the
past hour.
She has intense, constant uterine pain and frequent contractions.
Fetal heart tones are regular at 145 beats/min.
On inspection her perineum is grossly bloody.
• Placental Abruption
What is the diagnosis &
Why?

A 34-year-old multigravida at 31 weeks’ gestation comes to the birthing

unit stating she woke up in the middle of the night in a pool of blood.
She denies pain or uterine contractions.
Examination of the uterus shows the fetus to be in transverse lie.
Fetal heart tones are regular at 145 beats/min.
On inspection her perineum is grossly bloody.
• Placenta previa
What is the diagnosis &
Why?
• A 21-year-old primigravida at 38 weeks’ gestation is admitted to the
birthing unit at 6-cm dilation with contractions occurring every 3 min.
• Amniotomy (artificial rupture of membranes) is performed, resulting in
sudden onset of bright red vaginal bleeding.
• The electronic fetal monitor tracing, which had showed a baseline fetal
heart rate (FHR) of 135 beats/min with accelerations, now shows a
bradycardia at 70 beats/min.
• The mother’s vital signs are stable with normal blood pressure
and
pulse.
Vasa previa
• Vasa previa
References:
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