Antepartum Haemorrage

(APH)

Dr. Mtumweni, MD
 Learning Objectives

 Define the terms: Antepartum haemorrhage, vasa

praevia, placenta praevia, abruptio placentae
 Describe causes of antepartum haemorrhage
 Describe clinical features of abruptio placentae
 Describe complications of abruptio placentae
 Describe management of abruptio placentae
 Definition of the terms

 Antepartum Haemorrhage: Vaginal bleeding that

occurs after 28 weeks of pregnancy up to the end of
second stage of labour.

 Abruptio Placentae: Early separation of the normally

implanted placenta after 28 weeks and before the end
of the second stage of labour.
 Placenta Praevia: Implantation of the placenta to the
lower segment of the uterus partially or completely
covering the cervix.

 Vasa Praevia: Aberrant feto-placenta vessels running

in the placental membranes.
• In Vasa praevia the foetal vessels cross the cervix and
they may rupture by spontaneous rupture of
membranes or be damaged by artificial rupture of
membranes leading to life threatening haemorrhage
(foetal blood).
Look at the normal placenta, no retroplacenta
blood/hematoma
 Abruptio placenta – look at the blood
collection/hematoma behind the placenta
Placenta praevia – look at the abnormally implanted
placenta, at the lower uterus blocking the cervical
opening
Vasa Previa – aberrant feto-placental blood vessels
running in placental membranes
 Causes of Antepartum Haemorrhage

 Antepartum haemorrhage affects 2-5% of

pregnancies.
 Causes include:
 Abruptio placentae
 Placenta praevia
 Vasa praevia
 Other unclassified causes, local causes
 During the 3rd trimester, these conditions occur in the
following proportions:
 Abruptio placentae (22%)
 Placenta praevia (31%)
 Vasa praevia (rare)
 Other unclassified causes, local causes (47%)
Abruptio Placentae/Placenta abruption
• Recall the definition of Abruptio placenta
 Abruptio Placentae: Risk factors

 Hypertensive disease in pregnancy

 Multiple pregnancy
 Direct trauma to abdomen
 Premature rupture of membranes
 Risk factors con’t…

 Polyhydramnios with rupture of membranes, caused

by sudden decrease of intrauterine pressure
 Uterine leiomyoma/fibroid, especially if located
behind the placental implantation site
 Previous history of abruptio placenta
 Features of Abruptio Placenta

 Vaginal bleeding
- Sometimes the amount of blood loss may not
correspond with the clinical presentation (concealed
haemorrhage) (remember another type of abruptio
placenta – revealed hemorrhage type)

 Difficult to palpate foetal parts

 Features con’t…

 Abdominal Pain, initially localized then becomes

generalized, tender and tense abdomen
 Maternal distress
 Foetal distress or intrauterine foetal death
 Hypotension
 Complications of Abruptio Placentae

 Shock
 Acute renal failure
- This may result from seriously impaired
renal perfusion secondary to reduced cardiac
output and intrarenal vasospasms as in pre-
eclampsia
 Disseminated intravascular coagulopathy
- Consumptive coagulopathy secondary to
hypofibrinogenemia along with elevated levels of
fibrin degradation products
 Postpartum haemorrhage (PPH)
 Couvelaire uterus
- This is caused by widespread extravasation of
blood into the uterine musculature and beneath the
uterine serosa.
 Sheehan syndrome
- Acute pituitary necrosis to massive haemorrhage
 Treatment of Abruptio Placentae

 Management depends on:

 Degree of severity
 Viability of the foetus/foetal distress

 Treatment modalities
 Induction/augmentation of labour
 Caesarean section (C – section)
• Note: This condition is best managed at the hospital
by a doctor, but at a dispensary or health centre level
the following general measures should be taken:

1. Resuscitation of the mother

- Infuse her with IV fluids preferably ringers
lactate or normal saline (two large bore IV lines,
oxygen)
2. Take vital signs
- Blood pressure, pulse rate and respiratory rate
3. Catheterization
- Monitor urine output
4. Obtain blood for Hb level, grouping and cross
matching
5. Urgently refer the patient to the hospital under escort
of a nurse and potential blood donors
 Management at Hospital

1. Continue with above general measures

2. Deliver the foetus
- Perform Artificial Rupture of Membranes
(ARM)
NB – ARM done only if placenta praevia has been
ruled out
- Induce/augment labour by Oxytocin infusion if
labour has not started or speed-up labour
 Management at hospital con’t…

3. Do bedside clotting time

- If does not clot within seven minutes suggests
coagulopathy.
- Then should be monitored every two hours
4. Ensure availability of fresh blood
- The patient might need blood transfusion
 Management at hospital con’t…

 Caesarean Section can be done if vaginal delivery is

contraindicated

 Indications for Caesarean Section

 Salvageable baby
 Ongoing haemorrhage
 Poor progress as in case of transverse lie, inadequate
pelvis
 Management at hospital cont…

 Post delivery -observe for PPH

Placenta Praevia
• Recall the definition of placenta praevia
 Classification of Placenta Praevia

i. Total/complete Placenta Praevia: Covers the

cervical os.
ii. Partial Placenta Praevia: Covers part of the os.
iii. Marginal Placenta Praevia: Lies close to, but does
not cover, the os.
Picture: Types of placenta praevia
 Risk Factors for Placenta Praevia

i. Multiparity/Multiple pregnancy
ii. Advanced maternal age
iii. Prior C/S or other uterine surgery
iv. Prior placenta praevia
 Features of Placenta Praevia

i. Average Gestation Age (GA) 32.5 weeks

ii. Up to 10% may have simultaneous abruption
iii. First episode usually moderate
iv. Painless vaginal bleeding in 2nd/3rd trimester
v. Bright red blood
vi. Placenta praevia is confirmed by ultrasound

NB – Do not perform digital vaginal examination in patient

with Placenta praevia as it may provoke bleeding
 Complications of Placenta Praevia

• Similar to those mentioned above for abruptio

placenta.

• Can you recall atleast five (5) complications?

 Treatment of Placenta Praevia

• Management depends on degree of severity, gestation

age (viability)
• Refer the patient to the hospital as soon as possible
when you make the diagnosis of placenta praevia.
• General measures are similar to those mentioned
above for abruptio placenta
 Treatment of Placenta praevia cont..

• Initial resuscitation
• Identify potential blood donors
• Refer the patient to the hospital with facilities for
blood transfusion, caesarean delivery
 Conservative Management

i. Patients with minimal PV bleeding and far from

term
ii. If possible, delay delivery until foetus is mature
iii. Give steroids (eg. dexamethasone to accelerate fetal
lung maturity)
 Indications for Immediate Delivery

I. Active labour
II. ≥ 37 weeks gestational age
III. Excessive bleeding
IV. Development of another obstetric complication
mandating delivery
 Mode of Delivery

 Often caesarean section is preffered

- Note that there is a higher rate of accreta, increta,
and percreta with placenta praevia

 Vaginal delivery may be indicated in patients with the

low lying placenta and presenting with minimal PV
bleeding
 What do you understand by the following

• Placenta accreta 
• Placenta increta
• Placenta percreta
 Summary

• Antepartum hemorrhage is one of the obstetric

emergencies needing timely and proper diagnosis and
management.
• The most common causes of antepartum hmorrhage
are placenta praevia and abruptio placenta.
• Clinician must be able to diagnose appropriately and
provide timely management.
 References

• Facilitator guide Obstetrics and Gynaecology I -

Ministry of health and social welfare 2010
• Textbook of Obstetrics by Dutta