Anterpartum haemorrhage

Amirah Zainab Binti

Mamat@Muhammad
111303208

Clinical cases
Case 1
I am 38 weeks pregnant and bleeding
vaginally .A 24 year old woman attends
the midwife at 38 weeks gestation . She
had previous uncomplicated deliveries
and she is concerned that over the past
few days she has been having a small
amount of fresh vaginal bleeding
intermittently. She has no abdominal pain
and the baby is active.

Differential diagnosis

Placenta praevia
Placental abruption
Cervical lesions
( erosion,polyp,cancer)

History to support
diagnosis
Painless small bleeds
supports diagnosis of
placenta praevia.
Additional patients
smear history should
be obtained. The
report of any previous
USSs in this pregnancy
should be checked in
order to identify the
location of placenta.

Clinical examination
Abdominal palpation

Fetal heart sound

auscultated
Speculum examination
No digital examination

Reasons of clinical
examination

Support PP - palpation, with

a soft non tender uterus m
high presenting part and an
abnormal lie
to exclude fetal distress
( ass placenta abruption)
If placenta is not low by
USS, to visualize the cervix
indicated.
Torrential bleeding can be
provoked if PP has been
falsely excluded as a cause

Investigations

FBC
Blood group and cross
match /Kleihaur test if
rhesus negative
USS
CTG

To detect anemia
In case bleeding increases
and a transfusion is required.
The patient should be given
anti-D if her blood group is
rhesus negative to prevent
isoimmunisation
To localize the placenta and
determine whether it is low
lying ,as well as to assess
fetal growth and well being.
To identify suspected fetal
compromise

Management
Admit patient to an obstetric unit. At term gestation with a history of
APH ,delivery is indicated to ensure a safe delivery of a mature fetus.
Caesarean section should be preformed in cases of major placenta praevia
Consider examination without anesthesia and artificial rupture of
membranes in cases with minor degrees of PP. This procedure should be
performed in an operating theater with a senior anesthetist present and
ready to administer a general anesthesia to expedite delivery if bleeding is
provoked on vaginal examination.
Cross-matched blood should be available in OT and can perform an
immediate C-sec if indicated
If diagnosis of placental abruption is suspected ( based on the low lying
placenta on scan ,normal appearance of the cervix on speculum? And
there is no evidence of fetal compromise, an artificial ruptures of
membrane should be performed and an oxytocin ( Syntocinon) infusion
commended with continuous monitoring of the fetal heart because of the
increased risk of fetal hypoxia.

Risks of Antepartum
haemorrhage
Hemorrhage and shock
Renal failure
Disseminated intravascular
coagulation(DIC)
Fetal hypoxia
Intrauterine death

Case 2
I am 32 weeks pregnant and having contractions
A 25 year old nulliparous woman at 32 weeks
gestation presents with abdominal pain associated
with uterine contractions. Fetal movements are
satisfactory. Her booking ultrasound scan (USS)
showed singleton pregnancy consistent with
menstrual dated and her anomaly scan at 20 weeks
gestation was normal. Her screening for Downs
Syndrome was reported ad low risk. She had been
a smoker but stopped in mid trimester. She had an
appendectomy as a child. She was assessed to be a
low risk pregnancy at booking

Differential diagnosis
Obstetric causes

Non obstetric causes

Pre term labor

Chorioamnionitis
Concealed abruptio
placenta
Fibroid degeneration
( usually at mid
trimester)

Urinary tract infection,

pyelonephritis ( can
precipitate pre term
labor)
Irritable bowel
syndrome,
constipation
Ovarian cyst
( hemorrhage, torsion)

ANTEPARTUM
HEMORRHAGE

DEFINITION

Antepartum haemorrage
Bleeding from the genital
tract from 22nd week of
pregnancy or
foetal weight is more than
500 grams

CAUSES
Diagnosis

Clinical findings

Placenta previa

Bleeding PV, painless

Abruptio placenta (revealed) Bleeding PV, Pain abdomen,

tender abdomen
Abruptio placenta
(concealed)

Bleeding PV, pain abdomen,

tender abdomen, SFH might
be more than POG (approx
2-3cm)

Vasa previa

Bleeding PV, painless

Excessive show

Bleedinf PV, Labor pain (+/-),

cervical os dilated.

PLACENTA PREVIA

Placenta which is
situated wholly or
partially within the
lower segment at
or after 28 weeks of
gestation.

CLASSIFICATION
Type 1

low lying placentaimplanted in lower uterine

segment. Edge of placenta
is near the internal os but
not reach it

Type 2

marginal placenta-located
at the margin of the
internal os

Type 3

partial placenta previa,

when placenta partially
covering the internal os

Type 4-

total placenta
previa,placenta
completely covering the

PLACENTA PRAEVIA

PREDISPOSING FACTORS
Abnormal placental implantation
Advanced maternal age (>35years are 3 times
more likely to have placenta previa)
Multiparity 5% in grand multiparous patients
Multiple gestation
Previous abortion
Previous caesarean section
Smoking
Prior placenta previa (4-8%)
Increase risk among blacks and asian (rare
condition)

MECHANISM OF BLEEDING
Growth of placenta slows
down cause the dilatation of
lower segment and inelastic
placenta is shared off the
lower segment wall. This
leads to opening of uteroplacental vessels and causes
the episode of bleeding

DIAGNOSIS - HISTORY
Vaginal bleeding occurs suddenly
during the third trimester
Bleeding is usually bright red
and painless
Initial bleeding is not usually
profuse but it is known to recur
The first bleed usually occurs at
27-32 weeks of gestation
Contraction may or may not
occur simultaneously with the

LABORATORY STUDIES
Full blood count hemoglobin
estimation
Group, screen and hold for at least 4
units of blood
Fibrin split products (FSP) and
fibrinogen level
Prothrombin time (PT)/ activated
partial thromboplastin time (aPTT)
APT test to determine fetal origin of
blood (as in thecase of vasa previa)

IMAGING STUDIES
Trans abdominal sonography
A simple, precise and safe method to visualize the
placenta
Have an accuracy of 95%
False positive can occur secondary to focal uterine
contractions or bladder distension.
Trans vaginal sonography
Safer and more accurate than trans abdominal method
Especially when it comes to the diagnosing type 1 and 2
placenta previa
MRI
Useful in determining placenta accreta. But is not a cost
effective diagnostic tools

COMPLICATIONS
PPH
Intrauterine growth retardation
(IUGR)
Congenital anomalies
Fetal anemia and Rh
isoimmunization
Maternal mortality due to
hemorrhage

MANAGEMENT

If the
Pregnancy less than 37weeks
No active bleeding
Mother with Hb is >10gm%
Fetal well being assured- FHS by
CTG, USG

EXPECTANT MANAGEMENT
(Macafee Conservative
Management)

CONSERVATIVE MANAGEMENT
(McCafees Regime)
Vitals are monitored in the ward
USG monitoring for localization of
placenta is done every 2 weeks to
look for placental migration which is
a possibility prior to 34w since the
lower segment formation is in the
process of completion
Fetal monitoring by CTG and
biophysical profiling should be done
to ensure fetal well being.
Keep a daily fetal movement count
chart
2 doses of Dexamethasone (12mg)

CAESAREAN SECTION
If the
Bleeding occurs at or after
37weeks of pregnancy
Pt is in labour
Bleeding persists (profuse
hemorrhage and pt has
hypotension and other features
of shock)
Immediately delivery the fetus
by CS

Cont
If profuse bleeding occur,
hemodynamic stability of the patient
should be addressed first.
Establishment of 2 large- bore IV
access lines with IV crystalloids or
blood products
Urinary catheterization is done with
Foleys Catheter
Blood is taken for investigation
Anemia treated with blood
transfusion

TYPE 1 (ANTERIOR &

POSTERIOR)

Can deliver vaginally

More likelihood of fetal
distressin post type when the
lowest edge of the placenta is
almost reaching the internal
os margin

TYPE II ANTERIOR

Can deliver vaginally

TYPE II POSTERIOR

C-section : as when the head

enters the pelvis, it impacts
on the placenta which is
located posteriorly against
sacrum.
Lead to uteroplacental
insufficiency and fetal
hypoxia and distress

TYPE III (ANTERIOR &

POSTERIOR)

C-section
Anterior is more dangerous
since obstetrician has to cut
through the placenta to
deliver baby and it has to be
fast and efficiently done

TYPE IV

Absolutely C-section

ABRUPTIO PLACENTA

Premature
separation of normally
placed placenta after
20 weeks of gestation
and prior to the birth
of the infant.

PREDISPOSING FACTORS
Maternal HTN
Maternal trauma (motor vehicle accident,
asault, falls)
Cigarette smoking
Alcohol consumption
Cocaine use
Short umbilical cord
Sudden decompression of the uterus
Retroplacental fibroid
Advanced maternal age
Idiopathic

ABRUPTIO PLACENTA

Premature separation of the normally implanted

placenta

CLASSIFICATION
CLASS 0
Asymptomatic
Finding an organized blood clot and depressed
area on a delivered placenta

CLASS 1

Upto mild vaginal bleeding

Tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress

 CLASS 2
Upto moderate vaginal bleeding
Severe uterine tenderness with possible tetanic
contractions
Maternal tachycardia with orthostatic changes in BP
and heart rate
Fetal distress
Hypofibrinogenemia

CLASS 3

Upto heavy vaginal bleeding

Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia
Coagulopathy
Fetal death

PATHOPHYSIOLOGY
Presence of blood in the decidua basalis
lead to separation of placenta
Hematoma formed causes further
separation of placenta
Leading to compression of placenta and
compromise the uteroplacental perfusion
Retroplacental blood later penetrate
through the thickness of the uterine wall
into the peritoneal cavity
This phenomenon is known as Couvelaire

 Myometrium in this area become

weakened
May give away and rupture with
increased intrauterine pressure
during contraction
Can cause fetal hypoxia

SYMPTOMS
Vaginal bleeding
Abdominal or back
pain
Fetal distress
Abnormal uterine
contractions
Preterm labor
Fetal death

COMPLICATIONS
MOTHER
Hemorrhagic
shock
Coagulopathy/
DIC
Uterine
rupture
Renal failure
Ischaemic
necrosis of
distal organs

FETUS
Hypoxia
Anemia
Growth
restriction
CNS anomalies
Fetal death

LABORATORY STUDIES
Hemoglobin, hematocrit, platelets
Prothrombin time / activated partial
thromboplastin time
Fibrinogen, fibrin/fibrinogen
degeneration products
D-dimer

DIFFERENTIAL DIAGNOSIS
Blunt abdominal trauma
Acute appendicitis
Disseminated intravascular
coagulation
Ovarian torsion
Placenta previa
Ectopic pregnancy
Hemorrhagic shock

TREATMENTS
Assess Blood Loss
Maturity of Fetus
Whether she is in labor
Send Investigations

Secure IV line
Monitor maternal &fetal
condition

VASA PREVIA
The fetal blood vessels traverse the
LUS in advance of presenting part in
close proximity to the inner cervical os
These vessels traverses within the
membrane
Not supported by umbilical cord or
placental tissue putting them at risk of
rupture when the supporting
membrane rupture

PATHOPHYSIOLOGY
The vessels may arise from a
velamentous insertion of the
umbilical cord or may be joining
an accessory placental lobe to
the placenta
Occur when these fetal vessels
rupture and the bleeding is from
fetoplacental circulation
Lead to fetal exsanguination and
death

PREDISPOSING FACTORS
Velamentous insertion of the
umbilical cord
Accessory placental lobes
(succenturiate or bilobed
placenta)
Multiple gestations

DIAGNOSIS
Clinically
Present of painless vaginal bleeding at the
time of spontaneous rupture of membrane
or amniotomy.
Fetal bradycardia depend on rapidity of the
hemorrhage
Can lead to fetal shock or death
Most often the fetus is already dead when
the diagnosis is made because the blood
loss constitutes a maor bulk of blood
volume of the fetus.

MANAGEMENT AND TREATMENTS

Obstetrician must be vigilant whenever
amniotomy is performed,as all cases of vasa
previa cannot be identified antenatally
Immediate delivery should be considered
and aggressive resuscitation of the neonate
Necessary to avoid fetal shock or demise
when vaginal bleeding occur during labour.
Emergency caesarean section strongly
considered for the first sign of bleeding
following amniotomy associated with fetal
distress

Questions
What are the causes of APH
What is major and minor PP
Can abruption placenta and placenta praevia
occur together?
Should we do speculum examination in PPjustify
What is couvelaire uterus
Stallworty sign
Which is more dangerous pp. type 3 anterior
or posterior. Give justification

 Slowing of fetal heart rate on pressing the

head down I to the pelvis and
promptrecovery on release of pressure is
termedStallworthy's sign
Couvelaire uterus(also known as
uteroplacental apoplexy) is a life-threatening
condition in which loosening of the placenta
(abruptio placentae) causes bleeding that
penetrates into theuterinemyometrium
forcing its way into the peritoneal cavity.