1

• Bleeding from multiple sites: all APH

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(note: Before 24 weeks it’s miscarriage)

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Notes from ten teachers
• 5% of pregnancies and most cases involve relatively small amounts of blood
loss.
• However, significant blood loss poses a risk of mortality and morbidity to both
mother and baby.
• The causes can be classified into placental, fetal and maternal
• Placental causes are the most worrying, as potentially the mother’s and/or
fetus’s life is in danger and often the bleeding may be more severe than with
other causes such as cervical ectropion.
• However, any antepartum hemorrhage must always be taken seriously, and any
woman presenting with a history of fresh vaginal bleeding must be
investigated promptly and properly

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 (Placental causes)

(Fetal cause)

(Maternal causes)
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Notes from ten teachers
• The causes of APH are placental or local.
• The incidence of APH is 3%. It is estimated that 1% is
attributable to placenta praevia, 1% is attributable to placental
abruption and the remaining 1% is from other causes.
• It should always be investigated to rule out significant and
dangerous causes, but in many cases of minor bleeding, a
cause is never found.

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Figure 14.5 Placenta previa.

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Notes
• Women with placenta previa cant deliver vaginally
• A placenta covering or encroaching on the cervical os may be associated with bleeding, either
provoked or spontaneous. The bleeding is from the maternal not fetal circulation and is more likely to
compromise the mother than the fetus
Previa is divided into four grades depending on the relationship and distance to the internal cervical os:
• grade I: low-lying placenta: placenta lies in the lower uterine segment but its lower edge does not
abut the internal cervical os (i.e lower edge 0.5-2.0 cm from internal os).
• grade II: marginal previa: placental tissue reaches the margin of the internal cervical os, but does not
cover it
• grade III: partial previa: placenta partially covers the internal cervical os
• grade IV: complete previa: placenta completely covers the internal cervical os
• Sometimes grades I and II are termed a "minor" or "partial" placenta previa, and grades III and IV are
termed a "major" placenta previa

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Notes from ten teachers
• Prevention: avoidance of non-clinically indicated caesarean section.
• Risk factors: multiple gestation, previous caesarean section, uterine
structural anomaly, assisted conception.
• Warning signs: low-lying placenta at 20 week anomaly scan, maternal
collapse, feeling cold, light-headedness, restlessness, distress and
panic, painless vaginal bleeding

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Notes from ten teachers: clinical
presentation
• The characteristic presenting complaint of bleeding associated with a
placenta praevia is that of painless vaginal bleeding.
• The bleeding may trigger preterm labor so often patients with bleeding
from placenta previa will have irregular abdominal pain associated with
uterine contractions.
• A placenta previa is diagnosed using ultrasound, preferably transvaginal,
to allow accurate measurement of the placental edge from the internal
os.
• Often patients will have been highlighted as having a low-lying placenta
at their anomaly scan so there should be a high index of suspicion in any
of these patients presenting with vaginal bleeding.

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Morbidly adherent placenta
A. Placenta accreta: placenta is attached to myometrium
B. Placenta increta: placenta has invaded the myometrium
C. Placenta percreta: placenta has perforated the myometrium
• The risk of morbidly adherent placenta increases with an increased
number of previous C/S
Note: morbidly adherent placenta can present without bleeding, where
bleeding occurs internally (??)

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(extra)

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Note: risks of adher
• Prior CS
• Previa
• IVF
• Maternal age (35)
• Prior dc

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Schematic
representation
of placenta
accreta
spectrum (PAS)
on US[1]

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Notes
• The normal placenta typically appears crescentic in shape, relatively homogenous in appearance, and
hyperechoic relative to myometrium. The placenta is located immediately subjacent to the relatively
hypoechoic myometrium. As the gestational age increases, the placenta becomes more heterogenous
with focal hypoechoic areas and calcifications, especially late within the third trimester. Color Doppler
evaluation may demonstrate well-organized thin sub-placental blood flow paralleling the endometrium.
• In contrast, in placenta accreta spectrum (PAS), the placenta may demonstrate increased size and
number of hypoechoic areas, termed placental lacunae. These lacunae are felt to be one of the more
specific signs of abnormal placentation, especially when large and irregular. These lacunae usually are
scattered throughout the placenta and give the placenta a ‘‘swiss cheese’’ or ‘‘moth-eaten’’ appearance.
• Placenta previa is present in approximately 88% of women with PAS.
• Abnormally thin or distorted interfaces between the uterus/placenta and the urinary bladder wall can
be seen in PAS and may be indicative of a more invasive placenta on the PAS.
• Generally, the finding of turbulent high-velocity flow deep within the placenta has been shown to be
correlated with PAS
• Additional signs include myometrial thinning, and loss of the hypoechoic clear zone between placenta
and myometrium.

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Abruptio placentae (Placental abruption)
• Abnormal premature separation of normally situated placenta from
the uterine wall (note: before the delivery of the fetus)
Note: The bleeding is maternal and/or fetal and abruption is acutely
dangerous for both the mother and fetus
• Can occur before labor or occur intrapartum as well
• 1% of APH is due to placental abruption (0.4-2%)
• Usually placenta separates in the 3rd stage of delivery normally

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Notes from ten teachers
• Prevention: avoidance of precipitating factors such as control of blood
pressure, and avoidance of precipitants cocaine and smoking.
• Risk factors: hypertension (including preeclampsia), smoking, trauma
to the maternal abdomen, cocaine, polyhydramnios, multiple
pregnancy, fetal growth restriction (FGR).
• Warning signs: maternal collapse, feeling cold, light-headedness,
restlessness, distress and panic, painful abdomen, vaginal bleeding

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 (internal hemorrhage)

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Figure 14.4 (A)
Placental abruption
with revealed
hemorrhage; (B)
placental abruption
with concealed
hemorrhage.

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Notes from ten teachers: Clinical presentation
• The characteristic presentation of placental abruption is that of painful bleeding
associated with a tense rigid abdomen.
• The absence of a tense abdomen does not rule out a placental abruption. Placental
abruption may be diagnosed on ultrasound but the absence of any ultrasound changes
does not rule it out and patients should be managed on the basis of their clinical findings.
• Maternal signs and symptoms may include vaginal bleeding, abdominal pain, sweating,
shock, hypotension, tachycardia, absence or reduced fetal movements and tense
painful abdomen.
• CTG may reveal evidence of fetal distress.
• The degree of vaginal bleeding does not necessarily correlate with the degree of
abruption as abruptions may be concealed (i.e. significant separation between placenta
and uterus but blood is concealed between the placenta and uterus so there is little
vaginal bleeding seen)

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Note: Approach to APH (Ten teachers)
• The key questions are whether the bleeding is placental, and whether
the bleeding is compromising the mother and/or fetus (and whether
the bleeding has a less significant cause)
• A pale, tachycardic woman looking anxious with a painful, firm
abdomen, underwear soaked in fresh blood and reduced fetal
movements needs emergency assessment and management for a
possible placental abruption.
• A woman having had a small postcoital bleed with no systemic signs or
symptoms represents a different end of the spectrum.

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Note: Approach to APH (Ten teachers)
History Examination
• How much bleeding? • Pulse, blood pressure.
• Triggering factors (e.g. postcoital bleed). • Is the uterus soft or tender and firm?
• Associated with pain or contractions?
• Fetal heart auscultation/CTG.
• Is the baby moving?
• Speculum vaginal examination, with
• Last cervical smear (date/normal or particular importance placed on
abnormal)?
visualizing the cervix (having
established that placenta is not a
previa, preferably using a portable
ultrasound machine).

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Note: Approach to APH (Ten teachers)
Investigations
• Depending on the degree of bleeding, full blood count, clotting and, if
suspected previa/abruption, cross-match 6 units of blood.
• Ultrasound:
• fetal size
• Presentation
• amniotic fluid
• placental position
• morphology

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(Due to DIC)

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Note
• Renal failure is an important complication of Abruptio placentae.
• Disseminated intravascular clotting is the result of a widespread
exposure of the circulating blood to procoagulant activity capable of
activating fibrinolytic enzyme system converting fibrinogen into the
fibrin.
• Fibrin may in turn cause small blood vessel occlusion resulting in
tissue necrosis, and as the phenomenon occurs more often in the
glomerular capillaries, acute renal failure may ensue.

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(note: the bleeding could be due to cervical
cancer)

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Note: The “gestational age” of the uterus by fundal height increases
with repeated examination with abruption.

Note: FHR is normal in previa and abnormal in abruption.

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(Cusco speculum examination.)

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Note: Admission, ABC, wide bore cannulas, cross-matched blood, and prepare OR.

Note: Previa cant be delivered vaginally.

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What treatment options are appropriate
• If a diagnosis of placental abruption is suspected (based on the
absence of a low lying placenta on a scan, normal appearance of the
cervix on speculum), and there is no evidence of fetal compromise, an
artificial rupture of membrane (amniotomy) should be performed and
an oxytocin (Syntocinon) infusion commenced with continuous
monitoring of the fetal heart because of the increased risk of fetal
hypoxia.

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Note: antiD is normally given at 28 and 34 weeks and after delivery within 72 hours
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Notes from ten teachers: Management
• If there is minimal bleeding and the cause is clearly local vaginal bleeding, symptomatic management may be
given (for example antifungal preparations for candidiasis) as long as there is reasonable certainty that cervical
carcinoma is excluded by smear history and direct visualization of the cervix.
• Placental causes of bleeding are a major concern. A large-gauge intravenous cannula is sited, blood sent for full
blood count, clotting and cross-match, and appropriate fetal and maternal monitoring instituted.
• If there is major fetal or maternal compromise, decisions may have to be made about immediate delivery
irrespective of gestation; an attempt at maternal steroid injection should still be made. If this is the situation, and
bleeding is continuing, emergency management is required.
• If bleeding settles, the woman must be admitted for 48 hours, as the risk of rebleeding is high within this time
frame.
• Rhesus status is important: if the mother is rhesus negative, send a Kleihauer test (to determine whether any, or
how much, fetal blood has leaked into the maternal circulation) and administer anti-D.
• When there is substantial vaginal bleeding (in excess of 500 ml) antenatal corticosteroids should be considered if
gestation is under 35 weeks as the risk of preterm delivery is significant.

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Lab tests
• Prolonged coagulation times APTT, PT
• Thrombocytopenia
• High level of fibrin degradation product FDPs
• Elevated D dimer level
• Schistocyte microangiopathic pathology sign in peripheral blood
• If soluble fibrin is elevated (note: occurs due to massive fibrin production[1]) the diagnosis of DIC made
with confidence
• Low serum fibrinogen level may not be found in 50% of DIC
• Note: Fibrinogen concentrations may be low from consumption but are not low in every case.[1]
• Note (extra): measurement of fibrinogen is not very helpful in the diagnosis of DIC as fibrinogen acts as an acute
phase reactant and can remain well within the normal range for a long time.[1]

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Management
• Management of the underlying cause (e.g., if it’s septicemia the
infection must be managed and antibiotics are used, if it’s a dead fetus
it must be removed, etc.)
• Administration of platelet concentrate, plasma coagulation factor
concentrate

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Note: vasa previa
• Vasa previa occurs when fetal vessels traverse the fetal membranes over the
internal cervical os.
• These vessels may be from either a velamentous insertion of the umbilical cord
or may be joining an accessory (succenturiate) placental lobe to the main disc
of the placenta.
• The diagnosis is usually suspected when either spontaneous or artificial
rupture of the membranes is accompanied by painless fresh vaginal bleeding
from rupture of the fetal vessels.
• This condition is associated with a very high perinatal mortality from fetal
exsanguination. If the baby is still alive, once the diagnosis is suspected the
immediate course of action is delivery by emergency caesarean section.

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Note: key learning points
• Placenta previa is most dangerous for the mother.
• Placental abruption is more dangerous for the fetus than the mother.
• Vasa previa is not dangerous for the mother but is nearly always fatal
for the baby.
• Management involves resuscitation and stabilization of mother and
senior input regarding timing of delivery.

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• If placenta completely separated can’t be diagnosed by ultrasound

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• DIC causes: IUD, missed miscarriage, placenta abruptio,
chroioamnionitis, septicemia

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Note:
• US to confirm the placenta adherently
• Scar ectopic (in 13 weeks), in 18-22 weeks (become increta or
percreta)
• Management:
• 1. Resuscitated APH, PPROM, contractions = planned preterm del
around 34 weeks
• 2. Stable = planned in 36 weeks

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Note: Preoperative preparation
• Operation:
• Repeat history
• Investigations: serum virology, CBC & BG, ECG
• 6-8 fasting
• Prepare 12 pints of blood if severe,
• Consent and counseling
• Before surgery can used tranexemic acid, no use of uterotonics
• Operation: uterine incisions (vertical, LsCs, j shaped, inverted T)
• Management: vertical incision, hysterectomy, if invading bladder need urologist, if retained
tissue we give methotrexate , we may need artery ligation or embolization (ballon
occlusion catheter)

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Note:
• Accreta: conservative management maybe possible, stable & want
fertility, give tranexemic acid & oxytocin & misoprostol, inflate three
way ballon and put it there, and then suture uterus, for 48 hours, and
follow up, if bleeding start again laparotomy
• It’s located in loower segment which is non contractile so there is
ongoing bleeding

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