Antepartum Hemorrhage

Presenters:
Adrian Lee Yan Xian
Asma
Lim Wan Ting
Muhammad Jabbar
Nur Aqilah
Madam S, 29 years old
• G2P1
• 32+4 weeks
• Unplanned pregnancy
• Singleton fetus
• EDD : 14.02.19 (LMP : 07.05.18)
• Executive in Panasonic
History of Presenting Illness
• Sudden onset of per vaginal bleeding • No abdominal trauma
while urinating at 11am on Friday, at her • No recent coitus
office building
• No previous abnormal
• Initially fresh blood per vaginal bleeding
• On the way to hospital, the fresh blood (intermenstrual bleeding, previous PV
mixed with leaking liqour, soaked upper bleeding in this pregnancy)
middle half of the trousers (not trickling
down)
• Felt unusually lethargic afterwards, able to
walk out to hospital from her car
• No other anaemic symptoms (palpitations,
light-headedness, dizziness, fainting,
shortness of breath)
• No history of anaemia in pregnancy
History of Presenting Illness
•Mild lower abdominal pain related with
uterine contraction
•Intermittent, lasting 60s-90s
•Not increasing in frequency or intensity
•Non-radiating
•Has no elevating factor
•3/10
• Reduced fetal movement
• Less powerful fetal movement on
the day of admission
• Noticed even before the
onset per vaginal bleeding
History of Presenting Illness
• No previous history of antepartum
hemorrhage
• No history of C-section/ gynae procedure
• Ultrasound detail scan at 29 weeks
shows placenta is at the upper segment,
no oligo/polyhydramnios, no gross
congenital anomalies
• No history of pregnancy-induced
hypertension
• No history of sexually-transmitted
infection (abnormal per vaginal
discharge, foul smelling, itchyness)
• Last pap smear 10 months ago was
normal
• No fever
• No urinary syptoms (dysuria,
cloudy urine, hematuria, increase in
fequency)
• No altered bowel habit
• No previous history of pre-eclampsia,
intrauterine growth restriction, preterm
delivery, pregnancy-induced
hypertension, gestational diabetes
mellitus, anaemia
• Has family history of pre-eclampsia
(mother)
Antenatal History of Index Pregnancy
• An unplanned pregnancy • Hemoglobin level throughout pregnancy is
• Last pregnancy was in 2016 normal
• At 5 weeks of period of 12.47 -> 11.5 -> 12 -> 11.8 -> 11 >11.3
amenorhhea – noted positive • Blood pressure throughout pregnancy is
urine pregnancy test normal
• In first trimester – experienced 121/85 -> 125/84 -> 122/78 -> 124/73
nausea with minimal vomiting, no
loss of weight, no hospital -> 121/77->123/74
admission (Readings throughout pregnancy from 7 weeks
• Had taken folic acid during until 29 weeks)
first trimester, not before
• On hematinic agents throughout
pregnancy (ferrous fumarate, folic
acid, ascorbic acid, vitamin B6,
vitamin B12)
• No anemic symptoms throughout
pregnancy
Antenatal history of Index Pregnancy
• Booked KK Dato' Harun at 7 weeks
• Booking Hb 12.47
• O+
• HIV, VDRL, Hep B Negative
• BP 121/85
• BMI is 23
• OGTT at 16 weeks 4.2/5.0
at 26 weeks 5.0/6.8
• Completed tetanus dose at 29 weeks
History of fetal monitoring
• USD Detail scan at 29 weeks shows appopriate growth for date
• Fetal movement noted at 20 weeks
• Mother mentally count 10 fetal movements every day from 9 am. Normal fetal
movements.
• No serial growth scan done
Past Obstetric/ Gynaecological History
Past Obstetric History
• First child born in 2016
• At 40+7 weeks
• A Girl
• Birth weight : 2.82kg
• Via spontaneous vaginal delivery
• No antenatal complication or
postnatal complication
• The child is thriving
Past Gynaecological History
• Menarche at 12 years old
• Regular, of 28-day cycle
• Normal flow, lasting 8 days
• No heavy menstrual bleeding
• No intermenstrual bleeding
• No dysmenorrhea
• No history of
fibroid/polyp/STI/PID/Gynae visit
• Last Pap smear on 02.18 - Normal
 Family History
Past Medical History • Father has DM, Mother is
• Nil hypertensive, both are still alive
• 3rd out of 8 siblings

Past Surgical History • In 9th pregnancy, mother

had intrauterinde death due to PE
• Nil
Social History
• Diploma
Medication
• works as executive
• Nil
• husband, 29 years old , engineer
• RM 7k total household
Allergic
• lives in Taman Medan
• No known allergic to drugs,
antibiotic, seafood • Flat, 2nd floor rented house
• 1st child taken care of by babysitter
Differential Diagnosis
• Placenta Abruptio (painful vaginal bleeding)
• Placenta Praevia (painless vaginal bleeding)
• Vasa Previa (vaginal bleeding after SROM)
• Uterine Rupture (sudden tearing uterine pain, decreased
contractions, history of C-section)
• Cervical in origin – cervical infection, ectropion, cancer
• Vaginal in origin – vaginitis, trauma
• Preterm Premature Rupture of Membrane (bloody show)
• Acute surgical abdomen
Physical Examination Pre-Op
• Alert Abdominal Examination
• Not in respiratory distress • Soft, non-tender
• Appeared pale • No pedal oedema
• Tachycardia (120bpm)
• BP 85/57 Speculum/Vaginal Examination – not
• Temperature : 37.3 C
o done

• FHR : 70 – 87 bpm
Investigations (on admission)
Full Blood Count
Coagulation Profile
ABO Grouping
GXM
Full Blood Count
Test Unit Reference Range Results
Haemoglobin g/L 120.0-150.0 93
Haematocrit L/L 0.36-0.46 0.26
Red Blood Cell Count 10^12/L 3.80-4.80 3.02
Mean Corpuscular Volume fl 77-97 85
Mean Corpuscular Haemoglobin pg 27.0-32.0 30.8
Mean Corpuscular Haemoglobin g/L 315-345 360
Concentration
Red Cell Distribution Width % 11.6-14.0 12.9
White Blood Cell Count 10^9/L 4.0-10.0 23.7
Platelet 10^9/L 150-400 183
Coagulation Profile
PT Unit Reference Range Result
PT Patient sec 9.4-12.5 11.9
PT Ratio Ratio 1.0-1.2 1.1
INR INR 1.1

APTT
APTT- Normal secs 25.6-38.4 32.0
APTT-Patient secs 25.6-38.4 25.5
Group and Screen
ABO O
Rh Positive
Antibody Screening Negative
Number of Packs Crossmatched 4

Total Units Issued 9

Transabdominal Ultrasound (Bedside)
• Noted fetal bradycardia
• Abruptio placenta
Cardiotocography
• Taken for 5 minutes
• Baseline : 75
• Variability : 5-10
• Uterine contraction 2/5minutes (Amplitude 30-50 mmHg)
• No deceleration, no acceleration
Cardiotocography
Maternal Progress
• Delivered EMLSCS at 1pm due to
fetal distress (CTG - bradycardia)
• Estimated blood loss is 800 ml and
retroplacental clot is 700ml (Total
:1.5L)
• Intraoperative urine volume is 20cc
in ~1hour. Body weight is 50kg.
• Post-operatively, BP, HR, IO
charting, pad charting are
monitored
• IV Trenexamic acid 1g stat was
given
• IV Pitocin (Oxytocin) 40 units
stat
• 3 pints of crystalloids and 2
pints D5% over 24 hours
• Hematinics : PO Ferrous
fumarate 200mg OD, PO Folic
acid 5mg OD
• VTE Prophylaxis : TED stocking,
Subcut. Enoxaparin 40mg OD
Fetal Progress
• Baby boy weight of 2.02kg
• APGAR : 1 (1 min) / 4 (5 min) / 5 (10min)
• Baby has an episode of fit at 4 hours of life requiring loading dose of phenobarbitne.
He is warded in NICU for oxygen support.
Operative Consent
Risk and complication were explained.
• Bleeding requiring blood transfusion (risk of reaction / blood borne
infections)
• Severe PPH which may require hysterectomy
• Injury to adjacent organs (bowels / bladder) --> primary repair /
stoma
• Wound infection / breakdown
• VTE, PE.
• Hysterectomy - life saving procedure
Physical Examination Post-Op
• Alert, pink, not in respiratory Vital signs
distress, not on CBD, no obvious • BP 109/64 mmHg
bruises
• HR 105 bpm of regular rhythm,
• Abdomen is soft, non-tender good volume
• Contracted uterus at 18 weeks • RR 16 bpm
• Lower segment transverse surgical • Temperature 36.5’C
scar is not erythematous, no
discharge
• No pedal oedema
• Calf non-tender bilaterally
 ~3hours Post Op
Test Unit Ref. Range Flag Result
Complete Blood Count
HGB g/L 120.0 - 150.0 L 98
HCT L/L 0.36 - 0.46 L 0.28
RBC 10^12/L 3.80 - 4.80 L 3.22
MCV fl 77 - 97 87
MCH pg 27.0 - 32.0 30.4
MCHC g/L 315 - 345 H 350
RDW % 11.6 - 14.0 12.8
WBC 10^9/L 4.0 - 10.0 H 28.8
Platelet 10^9/L 150 - 400 180
Coagulation Screen
PT
PT Patient sec 9.4 - 12.0 11.8
PT Ratio Ratio 1.0 - 1.13 1.1
INR INR 1.1
APTT
APTT-Normal secs 25.6 - 38.4 32
APTT-Patient secs 25.6 - 38.4 L 24
Comment New reference range for APTT from 6 June 2018
 ~5hours Post Op
Test Unit Ref. Range Flag Result
RENAL FUNCTION TEST
Sodium (Serum) mmol/L 136 - 145 L 134
Potassium (Serum) mmol/L 3.6 - 5.2 4

Chloride (Serum) mmol/L 99 - 109 105

Carbon Dioxide (Serum) mmol/L 20.0 - 31.0 L 18
Anion Gap (Serum) mmol/L 10 - 20 15
Urea (Serum) mmol/L 3.2 - 8.2 L 1.4
Creatinine (Serum) umol/L 44 - 71 L 29

eGFR > 90 > 90

 Upon discharge, Day 3 Post Op

Test Unit Ref. Range Flag Result

Complete Blood Count
HGB g/L 120.0 - 150.0 L 83
HCT L/L 0.36 - 0.46 L 0.24
RBC 10^12/L 3.80 - 4.80 L 2.75
Recv.
Lab
MCV: Date : 24-12-2018
Hematology08:12 Ref
fl : 8123400699
77 - 97
Location : Wad Antenatal
88 Print
MCH pg 27.0 - 32.0 30.2
MCHC g/L 315 - 345 343
RDW % 11.6 - 14.0 13.1
WBC 10^9/L 4.0 - 10.0 H 15.6
Platelet 10^9/L 150 - 400 229
Discharge Plan
• Analgesic : PO Tramadol 50mg OD, PO Paracetamol 1gm QID
• Hematinic due to Hb 8.3
• Discuss on contraception
• Early pregnancy and tertiary booking next follow-up
• Start early aspirin in next pregnancy
Discussion

• She has hypotension without end-organ failure. Oliguria is documented intra-

operatively, however urine output normalised after fluid resus, eGFR is normal, serum
creatinine is low, coagulation profile is normal.
• Most likely to it is grade 2 placenta praevia, concealed type - which has poor perinatal
outcome.
• Child had an episode of fitting at 4 hours of life needing phenobarbitone loading. He is
at risk of HIE, a precipitating factor for cerebral palsy
• Mother had post-partum hemorrhage (EBL of 800L + 0.7L of retroplacental clot, total of
1.5L).
• Post-operatively, she is clinically well and stable, evidenced by normal GCS, good vital
signs, PR 100bpm, BP 109/64 mmHg after fluid resuscitation, Hb 9.8 3hours post op.
Discussion
• Speculum and Vaginal examination should be done to rule out other cause of
antepartum hemorrhage such as vaginal or cervical in origin. If labour is established
and appropriate for delivery (ie. 10cm cervical dilatation), vaginal delivery with
instrumentation can be considered instead of EM C-section
• A more thorough/detailed documentation on Abdominal Examination is advised for
example, uterine height-date (if enlarged than date, often time is placenta abruptio
with concealed hemorrhage), presence of fetal heart sound (absence in placenta
abruptio due to contracted uterus) to better define the case.
• Often TAS was done first before SVE to rule out placenta praevia. SVE should not be
done in placenta praevia.
• Quantifying PV bleeding is often difficult, for example in this patient's dark-coloured
garment/not using pads.
• Identifying placenta abruptio needs high index of suspicion (therefore, detailed history
and examination required). In this patient, the history is not very classic of placenta
abruptio – leaking liquor?PPROM, show?sign of labour, abdomen is not rigid
2nd and 3rd Trimester Bleeding

• A.k.a Antepartum Haemorrhage (APH)

• Defined as

Any bleeding from the genital tract from the period of

viability (after 22 weeks) until before the delivery of baby
 2nd and 3rd a condition in which fetal blood
1st trimester
Trimester vessels cross or run near the internal
opening of the uterus
Miscarriage
Miscarriage
(12-23 weeks) • Placenta Previa
• Placenta Abruption
Ectopic Placenta • Vasa Praevia
Pregnancy Causes
• Cervicitis
• Cervical Ectropion
Molar
Local Causes • Cervical Ca
Pregnancy • Vaginal Trauma
• Vaginal Infection
Indetermine
Trauma
Causes

Physiological

Local Causes
In velamentous cord insertion, vessels from
the umbilical cord run through part of the
chorionic membrane rather than directly into
the placenta. Thus, the blood vessels are not
protected by Wharton jelly within the cord,
making fetal hemorrhage more likely to occur
when the fetal membranes rupture.
2 Trimester Miscarriage
nd

Maternal Fetal Others

Cervical Impotency
Uterine Chromosomal Teratogen Exposure
Abnormalities Abnormalities

APS*
Trauma
Infection
Thrombophilia Congenital
Abnormalities
Uncontrolled PPROM
medical illness

*APS- Antiphospholipid syndrome

History • How much bleeding?
• Triggering factor eg post coital bleeding
• Associated with pain or contraction
• Is the baby moving?
• Last PAP smear
Physical Examination • Vital Signs
• Uterus soft/ tender and firm
• Fetal heart auscultation/ CTG
• Speculum examination
Investigation • FBC
• Coagulation Profile
• Cross match
• Ultrasound (Fetal size, presentation, amniotic fluid,
location of placenta and morphology)
Abruption of Placenta
Premature separation of a normally implanted
placenta , after the viability, before the delivery
of fetus
Type of Placenta Abruptiom

Revealed Concealed Mixed

Haemorrhage Haemorrhage Haemorrhage
History
• PAINFUL vaginal bleeding, uterine tenderness, uterine contraction
• Pain: sudden onset, constant, localised to back and uterus
• +/- Fetal distress, fetal demise, bloody amniotic fluid
• Present with pregnancy induced hypertension
Physical Examination

General Inspection Abdominal Examination

• Vital Signs
• Uterine hypertonicity and
• Signs of shock
contraction
• Pallor
• Uterine rigidity
• Absent or slow fetal heart

** Vaginal examination can be done in patients with APH after excluding

placenta previa**
Diagnosis
Grade 0 Grade 1 Grade 2 Grade 3
External Absent Slight Mild -Moderate Moderate-
Bleeding severe
Uterine Absent Uterus irritable Present Tonic uterine
Tenderness (Uterine contraction and
tenderness may/ marked uterine
may not present) tenderness
Abdominal Pain Absent +/- Present Severe
FHR Present, good Present, good Fetal Distress Fetal death
Maternal shock Absent Absent Absent Present
Perinatal Good Good Poor Extremely poor
Outcome
Complications Absent Rare May be present Present (DIC,
oligouria)
Volume of <200ml 150-500ml >500ml
retroplacenta
Investigation

• Blood Investigation- Full Blood Count, coagulation profile

• Ultrasound

**Placental abruption is a clinical diagnosis and there are no sensitive or

reliable diagnostic tests available. Ultrasound has limited sensitivity in the
identification of retroplacental haemorrhage.**
Management

Depends on : Treatment Modalities:

• Fetal Maturity • Expectant Management of

• Severity of placenta abruption Pregnancy
• Induction/ Augmentation of
• Maternal status
labour
• Viability of fetal/Fetal distress • Caesarean section
Management
• Physical Examination
• Resuscitation
• IV fluid and blood transfusion
• Correct coagulopathy
• Blood Investigation
• Assess Fetal Heart Rate
Management- Mild
Mild

Aim: To delay the < 37 week >37 week

pregnancy until fetal
maturity is reached

• Stable maternal Status

• POG <37 weeks Expectant Management Delivery
• Fetal wellbeing is
reassured by US
• No active bleeding
present
Until 37 Artificial Rupture of Membrane
weeks (ARM) + oxytocin Infusion
Management- Moderate
Moderate
<37 weeks >37 weeks

Bishop
Expectant Management Os closed
scoring

FHR ↓ ARM +
Emergency C
Oxytocin
Mother unstable Sec
Infusion

Emergency C sec
Management-
Severe Fetal and
Maternal
Assessment

Intrauterine
Fetus is Alive
Death

ARM +
Emergency C
Oxytocin
Sec
Infusion
Management- Indication for C Sec

• Fetal distress
• Bleeding occurs despite ARM + Oxytocin infusion
• Poor labour progress despite ARM + Oxytocin infusion
• Deterioration of maternal/ fetal condition
• Present of malpresentation
• Associated obstetric factors
• Complication (DIC, oligouria)
Complication
• Maternal mortality
• Perinatal • Postpartum uterine atrophy
Mortalality • Post partum Haemorrhage
• Prematurity • Uteroplacental apoplexy
• Intrauterine • DIC
Hypoxia • Acute Renal Failure
• Haemorrhagic Shock
• Pituitary necrosis (Sheehan
Syndrome)
• Amniotic Fluid embolism