ANTEPARTUM

haemorrhage
• Antepartum haemorrhage (APH) is
defined as bleeding from the genital
tract after the gestation of potential
viability (approximately 24 weeks)
and before the birth of the baby.
• in many developed countries, hemorrhage
is a leading reason for admission of
pregnant women to intensive care units
• 12 percent of maternal deaths were caused
by obstetrical hemorrhage.
 Causes of ANTEPARTUM haemorrhage

4% of women may develop APH.

• Abruptio Placentae (1/100)
• Placenta praevia (1/200-300)
• Vasa Praevia (1/2000-3000)
• uterine rupture (<1% in scarred uterus)
• Local causes
• Unknown origin
• Slight vaginal bleeding is common during
active labor.
• This "bloody show" is the consequence of
effacement and dilatation of the cervix,
with tearing of small vessels.
Placenta Praevia
• A low implantation of the placenta in
the uterus, causing it to lie alongside
or in front of the presenting part.
• Placenta previa is used to describe a
placenta that is implanted over or
very near the internal cervical os.
• The incidence of placenta praevia is
0.4-0.8%. ( placenta previa complicated
almost 1 in 200 deliveries ) and accounts
for nearly 20% of all antepartum
hemorrhage.
• Previa occurs in as many as 1% to 4%
of women with a prior cesarean section.
 Risk factors:
• Multiparity
• Advanced maternal age
• multifetal gestations
• Previous C/S or other uterine surgery
1 CS between 1% and 4%
4 CS the risk is 10%
 Risk factors:

• Previous placenta previa

• Smoking
• Asian and African ethnic background
• Previous dilation and curettage
• unexplained elevated (MSAFP) are at
greater risk for previa
 grading (Types):
 Minor ( I+II)
I. Type I :The placenta is low but doesn’t
reach the cervical OS (LATERALIS)
II. Type II : The placenta reach the
cervical OS (MARGINALIS)
 grading (Types):
MAJOR(III+IV)
• Type III: The placenta covers the OS
partially
• Type IV: The placenta covers the OS
completely
 Grading

• This grading is important as

major degrees of placenta
praevia are likely to require
operative delivery whereas the
minor grades may manage a
successful vaginal delivery.
 Placenta Previa: Diagnosis
• Painless vaginal bleeding
• This commonly occurs around the 32nd week
but may begin as early as the late mid-
trimester of pregnancy.
• The bleeding is painless because blood is not
normally retained within the uterine cavity.
 Placenta Previa: Diagnosis
• Confirmed by ultrasound
• Vaginal exams are avoided
• Up to 10% may have simultaneous
abruption
• Maternal shock is uncommon with 1st
presentation of bleeding
 The cause of hemorrhage
• when the placenta is located over the internal os,
the formation of the lower uterine segment and
the dilatation of the internal os result inevitably in
tearing of placental attachments.
• The bleeding is augmented by the inherent
inability of myometrial fibers of the lower uterine
segment to contract and thereby constrict the
avulsed vessels.
 Bleeding may occur in the following
circumstances

• During rest or activity (70% of bleeding occurs

during rest)
• After trauma, coitus, or pelvic examination
• During labor, when the lower uterine segment
begins to efface and dilate.
• Placenta previa should be suspected in all
patients who present with vaginal bleeding
after 24 weeks.
• Women suspected of having a placenta
previa should undergo an ultrasound to
determine the position of the placenta.
• Digital and pelvic examination is deferred
until the diagnosis of placenta previa is
excluded by ultrasound.
• Digital cervical examination is never
permissible unless the woman is in
an operating room with all the
preparations for immediate cesarean
delivery—even the gentlest digital
examination can cause torrential
hemorrhage.
 The classic presentation is:

« recurrent pain-free antepartum

haemorrhage
« abnormal fetal lie
» non-engagement of the fetal presenting
part.
• Abdominal palpation will usually
reveal a soft uterus with readily
palpable fetal parts, an abnormal lie
and a high presenting part.
• The fetal heart is most commonly
audible except where there has been
overwhelming haemorrhage.
 ultrasound scanning
• The diagnosis may be confirmed
using ultrasound scanning to localize
the placenta.
• This is performed transabdominally
where the maternal bladder
delineates the upper edge of the
lower uterine segment anteriorly.
• Without this landmark a posterior
placenta praevia is more difficult to
diagnose.
• The presenting part also obscures vision
posteriorly
 Vaginal scanning
• Give more accurate measurement of the
distance from the edge of the cervical os to
the edge of the placenta
• placental location greater than 2 cm from
the cervical os would not be expected to
cause any clinical problem.
• Transvaginal scanning is used with caution
for fear of precipitating catastrophic
haemorrhage.
Magnetic resonance imaging (MRI)

• Give more clear views of the pelvis, fetus

and placenta .This is not widely available.
 Management

 Management depends on the clinical

condition , severity of bleeding , type
of PP , gestation age
 Resuscitation , delivery is required if
the bleeding is severe or doesn’t settle
 Management

 Hospitalization, conservative
management until 37 weeks
 If preterm delivery seems likely then
steroids may be given to accelerate fetal
lung maturation.
 Caesarean section is ideal
 Vaginal delivery ? Minor degree
 Placenta Previa:
Obstetric Management
• If possible, delay delivery until fetus is mature
• Indications for delivery:
• active labor
• documented fetal lung maturity
•  37 weeks gestational age
• excessive bleeding
• development of another obstetric
complication mandating delivery
 Maternal and fetal complications
• Maternal shock can result from acute blood
loss.
• Severe postpartum hemorrhage (PPH) can
occur after the delivery because the placental
implantation is in the lower uterine segment,
which has decreased muscle content.
• Muscle contraction may be less effective in
controlling the bleeding.
PPH may lead to the following conditions:

• Renal damage (acute tubular necrosis),

which may result from prolonged
hypotension
• Pituitary necrosis (Sheehan syndrome)
and resulting panhypopituitarism
• Disseminated intravascular coagulation
(DIC) due to excessive blood loss and
possible death
• Placenta accreta (growth of placenta into
the myometrium), or any of its variations,
due to the absence of decidua basalis.
Placenta accreta should always be
considered in the presence of placenta
previa.
 There are three types of placenta
accreta
• Placenta accreta. The placenta is
attached directly to the myometrium.
• Placenta increta. The placenta invades
the myometrium.
• Placenta percreta. The placenta
penetrates completely through the
myometrium.
• The incidence of placenta accreta (with
placenta previa) is 4%.
• The incidence of placenta accreta
increases to 16% to 25% after a previous
cesarean section.
• The presence of a placenta accreta may
necessitate a cesarean hysterectomy to
control the blood loss.
 Fetal Complications Associated
with Placenta Previa
• Preterm delivery and its complications
• Preterm premature rupture of
membranes
• Intrauterine growth restriction
• Malpresentation
• Vasa previa
• Congenital abnormalities
 Fetal morbidity
• Preterm delivery may be necessary
secondary to maternal bleeding, and the
infant may experience the complications
of prematurity
 Placental Abruption
abruptio placentae, and in UK
accidental hemorrhage.

Waleed Afana
 General Consideration
• Definition premature separation of a
normally implanted placenta after 24
weeks' gestation.
Placental abruption occurs in about 0.5% to
1.5% of pregnancies and is responsible for
30% of cases of third-trimester bleeding
and 15% of perinatal mortality.
• The severe form  fetal death 1 in 1500-
deliveries.
• Fifty percent of abruptions occur before
labor and after 30 weeks of gestation, 15%
occur during labor, and 30% are identified
only on placental inspection after delivery.
• Large placental separations may result in
premature delivery, uterine tetany,
disseminated intravascular coagulation
(DIC), and hypovolemic shock.
 Etiology
• Uncertain (primary cause)
Risk factors
• Hypertension
• Previous placental abruption
• Advanced maternal age
• Multiparity
• Uterine distension
• Multiple pregnancy
 Etiology
• Hydramnios
• Throbophilia
• Vascular deficiency
• Diabetes mellitus
• Collagen vascular disease
• Cocaine use
• Cigarette smoking
• Alcohol use (>14 drinks/wk)
• Circumvallate placenta
• Short umbilical cord
Precipitating factors
• Trauma
• External/internal version
• Motor vehicle accident
• Abdominal trauma
• Sudden uterine volume loss
• Delivery of first twin
• Rupture of membranes with polyhydramnios
• Preterm premature rupture of membranes
 Pathology
• Main change
(Vascular rupture) hemorrhage
into the decidua basalis →
decidua splits → decidual
hematoma → compression,
destruction, and separation of
the placenta
 Pathology
• Another mechanism is initiated
by an abrupt rise in uterine
venous pressure transmitted to
the intervillous space.
• This results in engorgement of
the venous bed and the
separation of placenta.
Types
• revealed abruption,
• concealed abruption
• mixed type
 Revealed haemorrhage
• Most of the retroplacental bleeding
tracks down inside the uterus to be
revealed as vaginal bleeding.
• The amount of uterine irritation
caused by this bleeding may be less,
pain not being such a great feature.
 Concealed haemorrhage

• May have only very slight vaginal

bleeding with a large amount of
retroplacental clot, causing a tense
uterus.
 'mixed'
• In the case of mixed haemorrhage
there will be some vaginal bleeding
and perhaps passage of clots but
also a build-up of some clot behind
the placenta.
• Uteroplacental apoplexy (Couvelaire uterus):
• when the margins of the placenta remain
adherent, and central placenta separation may
result in hemorhage that infiltrates the uterine
wall and extensive intramyometrial bleeding 
disruption of the muscle bundles  loss of its
contractile power.
• Possibly with free blood in the intraperitoneal
cavity. With haemorrhage of this degree it is
likely that the fetus will be dead.
Pathology
 Placental examination

• The extent of placental abruption of the

maternal surface of the placenta on
which a clot is detect at the time of
delivery.
• In mild cases, the diagnosis is not made
until after delivery, when a retroplacental
clot is revealed.
 Diagnosis
• The basis of diagnosis consists of
history, clinical examination, and a
high index of suspicion.
• The triad of vaginal bleeding,
uterine or back pain uterine
contractions, and fetal distress is
common.
 Signs and Symptoms
• Abdominal pain which may be severe and
constant.
• Pain is greatest when there is a substantial
'concealed' bleed and may be minimal or
absent where bleeding is entirely 'revealed'.
• The severity of the clinical presentation is
variable.
• Partial placental abruption Mild type ≤ 1/3 in
which no maternal or fetal compromise is
noted
• Complete placental abruption Severe type >
1/3 with profuse bleeding, signs of maternal
DIC, and a stillbirth
 Definition of different grades of
placental abruption
Grade Definition
0 Asymptomatic with a small retroplacental clot
1 Vaginal bleeding with no signs of maternal or fetal
Compromise
2 Vaginal bleeding with signs of fetal compromise
3 Vaginal bleeding accompanied by uterine tetany,
abdominal pain and signs of fetal and maternal
Compromise
Coagulopathy in 1/3 of cases
 Diagnosis
• sign and symptom
1. Vaginal bleeding
2. Uterine tenderness or back pain
3. Fetal distress
4. High frequency contractions
5. Hypertonus
6. Idiopathic preterm labor
7. Dead fetus
 Differential Diagnosis

• Mild and early cases of abruption are

difficult to distinguish from normal labour
with excessive 'show'.
• The diagnosis of an established mixed
haemorrhage is not usually difficult but
concealed abruption may need to be
distinguished from:
 Differential diagnosis
• Placenta previa ( Painless bleeding)
• Pre-rupture of uterus
• Preterm labour
• Acute polyhydramnios
• Degeneration of fibroid
• Other causes of acute abdomen.
• (Peritonism from perforation of a peptic
ulcer, appendicitis or other cause.)
 Adjunctive Examination
• Ultrasonography
1. Position of placenta, severity of
abruption, survival of fetus
2. Signs: retroplacental hematoma
3. Negative findings do not exclude
placental abruption
 Adjunctive Examination
• Laboratory examination
1. consumptive coagulopathy: reduce
plateler count, low fibrinogen and the
release of fibrin split products
2. The degree of anemia will probably
be considerably less than the amount
of blood loss.
 Coagulation abnormalities
• Placental abruption is the most
common cause of consumptive
coagulopathy in pregnancy.
 Coagulation abnormalities

• Hypofibrinogenemia
• Increaseing levels of fibrin degradation
products
• decreasing platelet count
• Increasing prothrombin time and partial
thromboplastin time
• Decreasing other serum clotting factors
 Complication
• DIC (evidence of a clotting deficiency)
• Hypovolemic shock
• Amnionic fluid embolism
• Acute renal failure
• Uterine apoplexy.
 Treatment
• Treatment will vary depending upon
gestational age and the status of mother
and fetus
• Treatment of hypovolemic shock:
intensive transfusion with blood
• Assessment of fetus
 Treatment
• Expectant management is
appropriate when the mother is
stable and the fetus is immature and
FHR is reassuring
• Continuous fetal and uterine
monitoring should be maintained.
• Termination of pregnancy: CS or
Vaginal delivery
 Delivery
• When the fetus is mature,vaginal delivery
is preferable unless there is evidence of
fetal distress or hemodynamic instability.

• When the fetus is not mature and

placental abruption is limited,observation
with close monitoring of both fetal and
maternal status.
 Treatment
Treatment of consumptive coagulopathy
Supplement of coagulation factors:
fresh blood, fresh frozen plasma,
fibrinogen, cryoprecipitate packs
and blood platelet.
 Prevention of renal failure

• An attempt should be made to improve

renal circulation and promote diuresis by
increasing fluid volume.
• If oliguria or anuria persists, renal necrosis
is probable and fluid intake and output must
be carefully monitored.
• If renal function is impaired peritoneal
dialysis or hemodialysis may required.
Uterine Apoplexy:
• If bleeding from the placental bed is not controlled
hysterectomy may be necessary.
• Childbearing future is requested bilateral of the
ascending branches of the uterine arteries, if
ineffective bilateral ligation of the hypogastric
arteries.
• Following ligation collateral circulation should be
adequate to preserve uterine function.
Uterine Rupture
 Uterine Rupture vs. Dehiscence
• Uterine scar dehiscence:
• fetal membranes remain intact,
fetus is not extruded
intraperitoneally, separation
limited to old scar, peritoneum
overlying is intact
• usually no fetal distress / mat.
hemorrhage
 Uterine Rupture vs. Dehiscence
• Uterine rupture:
• separation of scar  extension,
rupture of fetal membranes with
extrusion
• results in fetal distress / mat.
hemorrhage
• fetal mortality = 35%
• Diagnostic features:
• vaginal bleeding
• hypotension
• cessation of labor (Uterine contraction)
• fetal distress
• pain present in only 10%
• postpartum hemorrhage may be a sign
• Treatment:
uterine repair, arterial ligation,
hysterectomy (may be preferred)
 Comparison of Presentation of
Abruption v. Previa v. Rupture
abruption previa rupture

abd. Pain present absent variable

vag. blood old fresh fresh
DIC common rare rare
fetal distress common rare common
Vasa Previa
• Rare - 1 in 3000-6000 pregnancies.
• Vasa previa describes fetal vessels coursing
through the membranes over the internal
cervical os and below the fetal presenting
part, unprotected by placental tissue or the
umbilical cord
• the unprotected fetal vessels are at risk of
disruption with consequent fetal
haemorrhage .leads to fetal exsanguination.
• Fetal mortality 33-100%, if not diagnosed
prenatally.
• Velamentous cord insertion (VCI) is a
condition in which the umbilical cord
inserts into the chorioamniotic membranes
rather than the placental mass.
• The incidence of VCI has been reported to
range from 0.1% to 1.8% among all
pregnancies
Velementous Insertion
• and the risk is up to 10-fold higher in multiple
pregnancies .
• The risk of VCI has been shown to increase in
cases with cord insertion low in the uterus
compared to normal cord insertion .
• Women with VCI suffer placenta previa ,
placental abruption, and adverse pregnancy
outcomes in singleton pregnancies more often than
those without VCI .
• VCI is associated with increased risks of
preterm delivery, low birth weight, infants
that are small for their gestation age, low
Apgar scores at 1 and 5 min , and abnormal
fetal heart rate
• Overall, VCI affects fetal wellbeing
substantially, and requires an emergency
cesarean section more often than is the case
for births with normal cord insertion.
 Risk factors

Low lying placenta

bilobed or succenturiate placenta
Velamentous insertion of cord
Multiple pregnancies
IVF pregnancies
Succenturiate Lobe
 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.
• IUGR/ Congenital malformation
 Antenatal Diagnosis
• An avoidable tragedy.
• Changing ultrasound protocol for checking
placental cord connection.
• Can be diagnosed as early as 16 weeks .
• All suspected cases should be checked for
vasa praevia
• transvaginal scan with color doppler.
• Vasa praevia can be accurately diagnosed
with colour Doppler ultrasound, and should
be excluded when assessing low-lying
placenta in the third trimester of pregnancy.
• If detected, a caesarean section should be
offered as vasa praevia is associated with
significant fetal mortality
 Management
• If diagnosed prenatally
tocolytics,, bed rest, no vaginal exams
avoid heavy lifting, straining during bowel
movement
regular scans
• Planned cesarean section
• Delivery can be planned early enough to avoid
emergency, but late enough to avoid
prematurity
 Management
• If PV bleeding intrapartum
Speculum - fetal vessels.
Investigate for the source of bleeding
Can look for fetal Hb (Kleihauer-Betke
test) or nucleated RBC’s in shed blood
 If fetal bleeding confirmed, immediate
cesarean section.
 Other Causes of Third-Trimester
Bleeding
• Bloody show is a normal part of labor,
bleeding is usually minimal, and the
blood is mixed with mucus.
 Nonobstetric causes
• Vaginal lacerations from trauma
• Vaginal infections, such as bacterial
vaginosis or Trichomonas
• Cervical pathology, such as gonorrhea,
chlamydia, cervical polyps, or cervical
cancer
 Cervical carcinoma

• This is a very rare condition in

pregnancy. However, it is possible
for a cervical carcinoma to bleed,
especially as the patient goes into
labour and the cervix starts dilating.
 Cervical lesions

• Occasionally a cervical polyp or an infected

cervix may bleed.
• Speculum examination of the cervix is
therefore helpful in the differential
diagnosis of antepartum haemorrhage.
END