ANTEPARTUM HAEMORRHAGE

Definition
Antepartum haemorrhage (APH) :
• Is defined as bleeding from or in to the genital tract of more than 5 ml ,
occurring from 24 weeks of pregnancy and prior to the birth of the baby.
• The incidence is 2_5% of all pregnacies

The causes are :

• Placenta preavia 15 – 25 %

• Placental abruption 10_ 15%

• Vasa preavia
• Local causes ( bleeding from cervix, vagina and vulva )
• excessive show: sign of labor, bleeding when mucus plug is shed from
the cervix
• Undetermined
 Severity
NO consistent definitions of the severity of APH.
It is recognized that the amount of blood lost is often
underestimated .

The amount of blood coming from the introits may not represent
the total blood lost (for example in a concealed placental
abruption).

It is important to assess for signs of clinical shock. The presence

of fetal compromise or fetal demise is an important indicator
of volume depletion.
 Different terminologies used:
• Spotting – staining, streaking or blood spotting noted on underwear
or sanitary protection

• Minor haemorrhage – blood loss less than 50 ml that has settled

• Major haemorrhage – blood loss of 50–1000 ml, with no signs of

clinical shock

• Massive haemorrhage – blood loss greater than 1000 ml and/or

signs of clinical shock.

• Recurrent APH more than one episode

 Placenta Praevia (PP)
• Implantation of placenta over or near the internal os of cervix
• Or placenta is partially or wholly implanted in the lower uterine
sigment.
• Most low lying placentae are diagnosed at the 20 week anomaly
scan and confirmed in the third trimester,
• As the lower sigment form late in pregnancy, placental
migration occur.
• Migration is less likely to occur with major degree of placenta
praevia, if the placnta is posterior or there is previous CS
• The incidence is 0.4 _ 0.8%
• Leading cause of vaginal bleeding in the 2nd and 3rd trimester.
Classification
 Clinical classification
• Minor placenta praevia :
The placenta is sited in the lower sigment but does not
cover the os
• Major : .

The placenta cover the os

• Clinical presentation :
Painless vaginal bleeding , occurs with the
development of the lower segment when
shearing forces disturb placental circulation
 Risk Factors of Placenta Praevia
 Previous placenta praevia (4-8%)
 Previous caesarean sections ( risk increased with numbers of c-section)
 Previous termination of pregnancy
 Multiparity
 Advanced maternal age (>40 years)
 Multiple pregnancy
 Smoking
 Deficient endometrium due to presence or history of:
- uterine scar
-endometritis
-manual removal of placenta
- curettage
-submucous fibroid
 Assisted conception
Placenta praevia causing breech presentation
Morbid adherent placenta
• Plcenta accreta : Abnormal adherence of the placenta to the
uterine wall
• Increta : occurs when the placenta invade deeply into the
myometrium
• Percreta :is the placental invasion thruogh the uterus to the
serosa – invasion of bladder and other pelvic structure can occur
 Abruptio Placentae (AP)
• Separation of normally located placenta after 24
weeks of gestation and prior to delivery of fetus.
• Revealed abruption: Blood tracks from the site of
placental separation between the decidua and
chorion to the cervix causing vaginal bleeding
• Concealed abruption: Blood forms a retroplacental
clott between the placenta and the uterus with no
vaginal bleeding
• Extravasation of blood into the myometrium giving
rise to the blue coloured (covelaire uterus)
 Risk factors:
- Previous history of AP
- Maternal hypertension
- Advanced maternal age
- Trauma ( domestic violence, accident, fall)
- Smoking/alcohol/cocaine
- Short umbilical cord
- Sudden decompression of uterus ( PROM/delivery of 1st
twins)
- External cephalic version for breech presentation
- Retroplacental fibroids
- Idiopathic (majority)
 Placental abruption is an Obstetric
Emergency!!
Diagnosed CLINICALLY :
• Painful vaginal bleeding -80%
• Tense and tender abdomen/back pain (70%)
• Fetal distress( 60%)
• Abnormal uterine contractions (hypertonic and high
frequency) , rigid abdomin
• Preterm labour ( 25%)
• Fetal death ( 15%)

Ultrasound is NOT USEFUL to diagnose AP. Retroplacental clots

(hyperechoic) easily missed.
 Vasa Praevia (VP)
• Rupture of fetal vessels that run in the
membrane below fetal presenting part which
is unsupported by placenta/ umbilical cord.
• Predisposing Factors:
-Velamentous insertion of the umbilical cord
-Accesory placental lobes
-Multiple gestations
 Vasa Praevia (VP)

• The term velamentous insertion is used to describe the

condition in which the umbilical cord inserts on the
chorioamniotic membranes rather than on the placental
mass , and the umbilical vessels run through the
membranes to the placenta. If this occur in the lower
sigment it is known as vasa praevia
• The vessel can be torn when the membrane rupture
(spontaneous or artificially) causing sudden fetal distress
Vasa praevia
 Diagnosis of VP

• Painless vaginal bleeding at the time of spontaneous rupture

of membrane or post amniotomy
• Fetal bradycardia
• Fetal shock or death can occur rapidly at the time of diagnosis
due to blood loss constitutes a major bulk of blood volume is
fetus ( 3kg fetus-300ml)
• Hence, ALWAYS check the fetal heart after rupture of
membrane or amniotomy.
• Definitive diagnosis by inspecting the placenta and fetal
membrane after delivery.
 Clinical assessment in APH
• First and foremost Mother and fetal well being
(mother is the priority)

• establish whether urgent intervention is required to

manage maternal or fetal compromise.

• Assess the extent of vaginal bleeding, cardiovascular

condition of the mother

• Assess fetal wellbeing (check fetal heart rate) .

 Full History
Should be taken after the mother is stable.
associated pain with the haemorrhage?
Continuous pain : Placental abruption.
Intermittent pain : Labour.
 Risk factors for abruption and placenta praevia should be
identified.
 reduced fetal movements?
 If the APH is associated with spontaneous or iatrogenic rupture
of the fetal membranes : ruptured vasa praevia
 Previous cervical smear history possibility of Ca cervix.
Symptomatic pregnant women usually present with APH (mostly
postcoital) or vaginal discharge.
 Examination
• General: PULSE & BP ( a MUST!)
• Abdomen:
- The tense, tender or ‘woody’ feel to the uterus
indicates a significant abruption.
- Painless bleeding, high fetal presenting part –
Placenta praevia
- soft, non-tender uterus may suggest a lower
genital tract cause or bleeding from placenta or
vasa praevia.
 Examination
• Speculum :
-identify cervical dilatation and visualize a lower
genital tract cause.

• Digital vaginal examination

- Should NOT be done until Placenta Praevia has
been excluded by US.
 Investigations
• FBC
• Coagulation profile
• Blood Grouping and cross match at least 4-6 units of blood.
• Ultrasound- to role out placenta praevia and intrauterine fetal
death
• Fibrinogen and fibrin degradation product : AP if DIC
suspected
• colour doppler : VP
• In all women who are RhD-negative, a Kleihauer test should be
performed to quantify feto_maternal haemorrhage to gauge
the dose of anti-D Ig required.
Fetal monitoring:
• CTG monitoring
 Management
• WHEN to admit ?
• Based on individual assessment
• All women with APH heavier than spotting and women with
ongoing bleeding should remain in hospital at least until the
bleeding has stoped.

-Discharge after reassurance and counselling :

Women presenting with spotting who are no longer bleed, and
where placenta praevia has been Excluded.
However, a woman with spotting + previous fetal death due to
placental abruption, an admission would be appropriate.
 Management
• If preterm delivery is anticipated, a single course of antenatal
corticosteroids ( dexamethasone 12mg 12 hourly ,2 doses) to
women between 24 and 34 weeks& 6 days of gestation.
• Tocolytics should NOT be given unless for VERY preterm fetuses
who need time to transfer to hospital with NICU.

• For very preterm ( 24-26 weeks) ,

-conservative management if mother is stable .
At these gestations, experienced neonatologists should be involved
in the counseling of the woman and her partner
 Management
For Placenta Praevia
• Conservative – MaCafee’s regime
( premature < 37 weeks ; mother haemodynamically
stable , no active bleeding, fetus stable)
-advise bed rest, keep pad chart, vital signs monitoring ,
Ultrasound, steroids, Daily CTG and biophysical profile,
fetal movement count.
• Recheck Hb every 2 weeks and correct aneamia
• Renew cross matching weekly
• Plan for delivery ( >37 weeks) - elective CS
• Cross match 4 - 6 units of blood.
 Management
• For Rh negative mothers,
Anti-D Ig should be given to all after any presentation with APH,
independent of whether routine antenatal prophylactic anti-D
has been administered.

In the non-sensitised RhD-negative woman for all events after 20

weeks of gestation, at least 500 iu anti-D Ig should be given
followed by a test to identify fetomaternal hemorrhage, if
greater than 4 ml fetal red blood cells; additionalanti-D Ig
should be given as required.
 Management
For Abruptio placentae
(Top obstetric emergency)
• ICU admission : Close monitoring and resuscitation!
- ABC ( high flow O2, aggressive fluid resuscitation)
- Continuous Vital signs monitoring and urine output
- Monitor vaginal bleeding – strict pad chart
- Continuous CTG for fetal heart rate
- Cross match 6 units of blood
- FFP – coagulopathy
- Dexamethasone if preterm preterm
 Management

Abruptio Placentae
Decide Mode of delivery
• Vaginal delivery – when fetal death occur and
mother is stable
• Emergency Caesarean section – if maternal/
fetal health compromised , also indicated
when early DIC sets in
- Consent should be taken for hysterectomy in
case bleeding could not be controlled.
 Management
• For Rh negative mothers,
Anti-D Ig should be given to all after any presentation with APH,
independent of whether routine antenatal prophylactic anti-D
has been administered.

In the non-sensitised RhD-negative woman for all events after 20

weeks of gestation, at least 500 iu
anti-D Ig should be given followed by a test to identify FMH, if
greater than 4 ml red blood cells; additional
anti-D Ig should be given as required
 Complications of APH
Maternal complications Fetal complications
Anaemia Fetal hypoxia
Infection Small for gestational age and fetal
growth restriction
Maternal shock & death Prematurity (iatrogenic and
spontaneous)
Renal tubular necrosis Fetal death
Consumptive coagulopathy(DIC)
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Complications of blood transfusion