Antepartum

Haemorrhage
Presenters:
MBYALLU,Selemani L
RAMADHANI,Ahmed
Supervisor: Dr Kilewo
 Antepartum haemorrhage

 is defined as any episode of vaginal

bleeding that occurs between 28
completed weeks of pregnancy and
before delivery.

 Bleeding in late pregnancy is common

and requires medical evaluation in 5–
10% of pregnancies
 Causes of APH
 Obstetric causes
Abruptio placenta
Placenta praevia
Vasa Previa
Uterine rupture
 Non Obstetric Causes:
 Cervical Cancer
 Cervicitis
 Vaginitis
 Abruptio placenta
 Is the premature separation of a
normally implanted placenta after 28
weeks of gestation but prior to delivery

 Affects 1% of all pregnancies, with

perinatal mortality rate of 119 per 1000
and maternal mortality of 2-5% .

 AP severe enough to result in stillbirth

occurs in 1 in 830 deliveries
 Types of AP
1. External (Revealed)(Overt) Abruption
 Consists of 80% of AP cases.
 The blood drains through the cervix, placental
detachment is more likely to be incomplete.
 The complications are fewer and less severe.
Occasionally, the placental detachment involves
only the margin or placental rim.
 The most important complication is the possibility
of premature labor.
2. Internal (Concealed) abruptio
 Occurs in 20-35% of cases.
 the blood does not escape externally
but is retained between the detached
placenta and the uterus.
 the complications often are severe,
because of the possibility of
consumptive coagulopathy, but also
because the extent of the hemorrhage
is not appreciated and the diagnosis
typically is made later.
 Risk factors
      
                                                               
 Increased age and parity
 Preeclampsia
 Chronic hypertension
 Preterm ruptured membranes
 Multifetal gestation
 Polyhydramnios
 Cigarette smoking
 Thrombophilias
 Cocaine use
 Prior abruption
 Uterine leiomyoma
 Pathophysiology
1. Local Vascular Injury.
 results in vascular rupture into the
decidua basalis, bleeding, and
hematoma formation. The hematoma
shears off adjacent denuded vessels,
producing further bleeding and
enlargement of the area of separation.
 abrupt rise in uterine venous pressure
transmitted to the intervillous space.
This results in engorgement of the
venous bed and separation of all or a
portion of the placenta
 …
This is where factors which cause
vascular injury comes into play as
causes of AP.
The factors might include
Hypertension, cigarette smoking,
cocaine use, Diabetes Mellitus etc.
 2. Mechanical factors
They include transabdominal trauma,
extension of the uterus such as in
Polyhdramnios or Uterine muscles or
traction on a short umbilical cord.
 Clinical features
  Vaginal bleeding

 Abdominal pain

 Signs of haemorrhagic shock

 The FH is not proportional to the GA

 Uterine tenderness and / or irritability

 Features of pre eclampsia

 …
 The fetal heart may be absent,
 coagulopathy

 In mild cases the diagnosis may be

confirmed postpartum
 CLINICAL CLASSIFICATION
 Grade 1, mild (40% of abruptions):
– Vaginal bleeding is slight or absent (<100 ml).
– Uterine activity may be slightly increased.
– No fetal heart rate abnormalities are present.
– There is no evidence of shock or coagulopathy.
 Grade 2, moderate (45%):
– External bleeding may be absent to moderate
(100–500 ml).
– Uterine tone may be increased. Tetanic uterine
contractions and uterine tenderness may be present.
– Fetal heart tones may be absent and, when present,
often show evidence of fetal distress.
– Maternal tachycardia, narrowed pulse pressure, and
orthostatic hypotension may be present.
– Early evidence of coagulopathy may be present
(fibrinogen 150–250 dl).
 …
 Grade 3, severe (15%):
– External bleeding may be moderate or
excessive (>500 ml) but may be
concealed.
– The uterus is tetanic and tender to
palpation.
– Fetal death is common.
– Maternal shock is usually present.
– Coagulopathy is frequently present.
 Complications of abruptio
placenta
Maternal
 Hypovolemia and shock

 DIC

 Renal failure

 Couvelaire Uterus

 Embolism
 ……
Fetal
 Growth restriction

 Fetal hypoxemia or asphyxia

 Preterm birth

 Perinatal mortality
 investigations
 Ultrasound – is less reliable but a
retroplacental clot may be seen
 Haemoglobin level

 Blood grouping and crossmatch.

 Coagulation profile

 Urine for protein

 treatment
Aims at:
 Correction of hypovolemia and
restoration of the blood loss.
 Management of coagulation
disorders
 Delivery of the fetus to end the
process of abruption and achieve
uterine contraction and hemostasis.
 Correction of hypovolemia and
restoration of the blood loss
 intravenous access with two, wide-bore
intravenous lines
 A complete blood count, blood type and
Rh, and coagulation studies are done.
 monitor mother's hemodynamic status

 Give if possible fresh whole blood

 monitor maternal urine output hourly.

 Management of coagulation
disorders
 Asses PT, PTT and fibrinogen levels
 Give platelets

 Fresh frozen plasma

 Delivery of the fetus
 Live fetus at or near term 
 By caesarean section.
 Live fetus remote from term 
 Delaying delivery of pregnancies under
34 weeks (Expectant Management).
 Fetal demise 
 Vaginal delivery is preferable unless
urgent delivery is needed.
 PLACENTA PRAEVIA
 Definitions:
 The placenta is said to be praevia
when all or part of the placenta
implants in the lower uterine
segment and therefore lies in front of
the presenting part
 Placenta praevia - incidence
 Itcomprises about 1/3 of cases of
APH
 Incidence is 0.5- 1% amongst
hospital deliveries.
 Only 10 % of low lying placentas
identified at the 16-20 week USS will
remain low at term.
 Risk factors
 Maternal age. three times more
common at age 35 than at age 25.
 Increasing parity.

 Previous uterine scar.

 Prior placenta previa.

 Tobacco use.

 Multiple gestation.
 classification
.Complete placenta previa: The placenta
completely covers the internal cervical
os.
.Marginal placenta previa: The edge of
the placenta is implanted at the
margin of the internal cervical os,
within 2 cm.
. Partial placenta previa. The internal os
is partially covered by placenta
 etiology
 The exact cause is unknown
 Postulated theories are:-
o dropping down theory
o Persistence of chorionic activity

o Big surface area of the placenta-

twins
 Cause of bleeding
mechanical separation of the placenta
from its implantation site,
 either during the formation of the
lower uterine segment
 during effacement and dilatation of
the cervix in labor,
 result of intravaginal manipulation
 Placentitis

 rupture of poorly supported venous

lakes in the decidua basalis that have
become engorged with venous blood
 Symptoms and signs
.Painless and recurrent bright red vaginal
bleeding
 may occur during the second and third
trimesters of pregnancy
 After spontaneous rupture of the
membranes
 At onset of labor

.General condition and anemia are

proportionate to the visible blood loss.
 ……

 Soft relaxed uterus with no

tenderness
 FHS usually present.

 Fetal malpresentation is common

 No digital examination

 May be an incidental ultrasound

finding
 Diagnosis
 History

 Trans-vaginal sonography
 Management.
Expectant management ( if the bleeding
is light or stop and the fetus is alive
and premature)
 The objective is to prolong pregnancy to
achieve fetal maturity (up to 34 or 37
weeks)
.blood and cross match
.Fe and folic acid to correct anemia
. dexamethasone (4 doses of 6 mg
intravenously or intramuscularly separated
by 12 hours)
 ……
 Tocolytic agent
 Ultrasound scan every 2 weeks

 Elective caesarian section after 37

weeks if stable
Management (active severe bleeding)
 Intravenous access 2 large bore cannula

 adequate fluid replacement(Normal saline

or Ringer lactate 3L)
  Group and cross match 4 units of whole
blood
 Maternal close monitoring of vital signs.

 consider delivery immediately despite of

gestation age(Caesarean section )
 Complications of placenta
praevia
 Haemorrage with shock
 Malpresentation

 Preterm labor

 PROM

 Cord prolapse

 Increased incidence of operative

delivery
 PPH
 ……
 Retained placenta
 Low birth weight babies

 Asphyxia

 IUFD

 Congenital malformations
 Vasa Praevia
 Rare - 1 in 3000
 Fetal vessels run in the membrane below the
presenting fetal part, unsupported by placental
tissue or umbilical cord
 Spontaneous or artificial rupture of membranes
- rupture these vessels - fetal exsanguination.
 Hypoxia if the vessels are compressed
between baby & birth canal.
 Fetal mortality 33-100%, if not diagnosed
prenatally.
 ……
Risk factors
 Low lying placenta
 bilobed or succenturiate placenta
 Velamentous insertion of cord
 Multple pregnancies
 IVF pregnancies
 Symptoms
 Asymptomatic

 sudden onset of painless bleeding in

2nd or 3rd trimester or at ARM/SRM.
 Heavy or small amount of bleeding.
No sign symptom of Placenta praevia
or abruption.
 Maternal risk: bleeding
 Antenatal Diagnosis
 Can be diagnosed as early as 16
weeks .
 All suspected cases should be
checked for vasa praevia
 transvaginal scan with color doppler.
 Management
 If diagnosed prenatally
 tocolytics,
bedrest
no vaginal exams
avoid heavy lifting, straining during
bowel movement
regular scans
 ……
 Planned cesarean
 Baby requires aggressive
resuscitation & blood transfusion
 Management

 If PV bleeding intrapartum

 Speculum - fetal vessels.

 Investigate for the source of

bleeding

 If fetal bleeding confirmed,

immediate cesarean section.
Thank You