Guidelines on APH

1. GUIDELINES ON APH

2. DEFINITION OF APH
BLEEDING FROM OR INTO THE GENITAL TRACT , OCCURING FROM 24 WEEKS OF PREGNANCY AND PRIOR
TO THE BIRTH OF THE BABY.

3. CAUSES OF APH
 PLACENTAL ABRUPTION
 PLACENTA PREVIA
 APH COMPLICATES 3-5% OF PREGNANCIES AND IS THE LEADING CAUSE OF PERINATAL AND
MATERNAL MORTALITY WORLDWIDE.

4. RISK FACTORS OF PLACENTAL ABRUPTION
 ABRUPTION IN PREVIOUS PREGNANCY (19-25%)
 PRE ECLAMPSIA
 FETAL GROWTH RESTRICTION
 NON-VERTEX PRESENTATIONS
 POLYHYDROMINOS
 ADVANCED MATERNAL AGE
 MULTIPARITY
 PREMATURE RUPTURE OF MEMBRANES

5. RISK FACTORS OF PLACENTA PREVIA
 PREVIOUS PLACENTA PREVIA
 MULTIPARITY
 ADVANCED MATERNAL AGE
 ASSISTED CONCEPTION
 SUBMUCIOUS FIBROID

6. OTHER DEFINATIONS :
 SPOTTING : STAINING , STREAKING OR BLOOD SPOTTING NOTED ON SANITARY PROTECTION .
 MINOR HAEMORRAGHE : BLOOD LOSS LESS THAN 50ML THAT HAS SETTLED .
 MAJOR HAEMORRAGHE : BLOOD LOSS OF 50-1000ML , WITH NO SIGNS OF CLINICAL SHOCK.
 MASSIVE HAEMORRAGHE : BLOOD LOSS GREATER THAN 1000ML WITH SIGNS OF CLINICAL SHOCK.

7. PREVENTATION OF APH
 WOMEN SHOULD BE ADVISED ,ENCOURAGED AND HELPED TO CHANGE MODIFABLE RISK FACTORS
(SMOKING ,DRUG MISUSE)

8. UNEXPLAINED APH
 PREGANCIES COMPLICATED BY UNEXPLAINED APH ARE AT INCREASED RISK OF ADVERSE MATERNAL
AND PERINATAL OUTCOMES
 GREATER RISK OF PRE TERM BABY AND ADMISSION IN NEONATAL ICU

9. BASIC MANAGEMENT OF APH
 IT IS RECOMMENDED THAT WOMEN BE ADVISED TO REPORT ALL VAGINAL BLEEDING TO THEIR
ANTENATAL CARE PROVIDER.
 ROLE OF CLINICAL ASSESMENT IN WOMEN WITH APH IS TO ESTABLISH WHETHER URGENT
INTERVENTAION IS REQUIRED TO MANAGE MATERNAL OR FETAL COMPROMISE
 A MULTIDISCIPLINARY TEAM INCLUDING SENIOR OBSTRETICIAN AND STAFF, NEONATAL AND
ANESTHETIC TRAM WITH IMMEDIATE ACESS TO LABORATORY AND THEATRE SERVICES

10. PROCESS OF TRAIGE
 HISTORY TAKING TO ASCESS CO EXISTING SYMPTOMS SUCH AS PAIN
PAIN IS CONTINOUS : PLACENTAL ABRUPTION
PAIN IS INTERMITTENT : LABOUR SHOULD BE CONSIDERED
 ASSESMENT OF EXTENT OF VAGINAL BLEEDING – NO ADMISSION REQUIRED AND CAN GO HOME IF
SPOTTING IS SETTLED .
 HAEMODYNAMICS OF MOTHER
 FETAL WELL BEING

11. EXAMINATION
 ABDOMINAL PALPATION :
TENDERNESS OR ACUTE ABDOMEN
TENSE OR WOODY FEEL TO THE UTERUS INDICATES SIGNIFICANT ABRUPTION
SOFT NON TENDER UTERUS SUGGEST A LOWER GENITAL TRACT CAUSE OR VASA PREVIA
 DIGITAL VAGINAL EXAMINATION SHOULD NOT BE PERFORMED UNTIL ULTRASOUND HAS EXCLUDED
PLACENTA PREVIA .

12. INVESTIGATIONS
 MATERNAL :
PLACENTAL ABRUPTION IS A CLINICAL DIAGNOSIS AND NO SENSITIVE OR RELIABLE DIAGNOSTIC TEST
AVAILABLE
ULTRASOUND HAS LIMITED SENSITIVITY IN IDENTIFICATION OF RETROPLACENTAL HAEMORRAGHE.
 FETAL :
CARDIOTOCOGRAPH
ULTRASOUND IF FETAL HEART PULSATION CANT BE ACESSED WITH FETOSCOPE

13. LABOUR AND DELIVERY
 IF FETAL DEATH IS DIAGNOSED , VAGINAL BIRTH IS THE RECOMMENED MODE OF DELIVERY( PROVIDED
MATERNAL CONDITION IS SATISFACTORY) ELSE PROCEED TO C- SECTION (GUIDELINE NO 55)
 IF THE FETUS IS COMPROMISED, A C-SECTION IS THE APPROPRIATE METHOD OF DELIVERY WITH
ONGOING RESUSITATION OF MOTHER.
 WOMEN WITH APH AND ASSOCIATED MATERNAL AND FETAL COMPROMISE ARE REQUIRED TO BE
DELIVERED IMMEDIATELY.

14. LABOUR AND DELIVERY (CONT.)
 IN WOMEN WITH PRETERM LABOUR AND MAJOR APH OR RECURRENT MINOR APH : CONTINOUS
FETAL MONITORING IS RECOMMENDED
 WOMEN WITH 1 EPISODE OF MINOR APH WITH NO SUBSEQUENT CONCERNS : INTERMITTENT
AUSCULTATION IS APPROPRIATE
 WOMEN WITH MINOR APH WITH EVIDENCE OF PLACENTAL INSUFFICIENCY (FETAL GROWTH
RESTRICTION, OLIGOYDROMINOS ) : CONTINOUS MINITORING IS REQUIRED
 WOMEN WITH APH IN 3RD STAGE OF LABOUR : PPH MANAGEMENT SHOULD BE GIVEN

15. MASSIVE HAEMORRAGHE PRORTOCOL

16. COMPLICATION
 DISSEMINATED INTRAVASCULAR COAGULATION ( DIC)
 CLOTTING FACTORS , THROMBOCYTOPENIA
 UPTO 4 UNITS OF FFP AND 10 CRYOPRECIPITATE MAY BE GIVEN UNTIL RESULTS OF COAGULATION
STUDIES