Antepartum hemorrhage

1. Antepartum HemorrhageAntepartum Hemorrhage

2. DefinitionDefinition::
APH is bleeding from or within the genitalAPH is bleeding from or within the genital
tract after 24 W of gestationtract after 24 W of gestation..
CausesCauses::
 Placenta previaPlacenta previa the most common causesthe most common causes
 Abruptio placentaeAbruptio placentae
 Rupture uterusRupture uterus
 Local causes: trauma,infection,tumors.Local causes: trauma,infection,tumors.
 Vasa previaVasa previa

3. Placenta previaPlacenta previa
Is the implantation of the placenta in the lowerIs the implantation of the placenta in the lower
uterine segment with different grades ofuterine segment with different grades of
encroachment on the cervix.encroachment on the cervix.
 Bleeding is: -painlessBleeding is: -painless
-causless-causless

5. classificationclassification

6. 6

7. 7
APHAPH
 Per vagina blood loss afterPer vagina blood loss after
24 weeks24 weeks’’ gestationgestation
 5% of all pregnancies5% of all pregnancies
 Accounts for 20 -25% ofAccounts for 20 -25% of
perinatal mortalityperinatal mortality

8. 8
Severity of bleedingSeverity of bleeding
VolumeVolume
EstimateEstimate
Percent ofPercent of
circularitycircularity
volumevolume
TypeType
500500ml orml or<< 10-15%10-15% compensatedcompensated
1000-15001000-1500
mlml
15-25%15-25% mildmild
1500-20001500-2000
mlml
25-35%25-35% moderatemoderate
2000-30002000-3000 35-50%35-50% SevereSevere

9. Abruptio PlacentaeAbruptio Placentae
 Is premature separation of aIs premature separation of a
normally implanted placenta, may benormally implanted placenta, may be
precipitated by a sudden increase inprecipitated by a sudden increase in
blood pressure or traumablood pressure or trauma
 Fetal parts are difficult to feel.Fetal parts are difficult to feel.
 Feta heart sound may be absentFeta heart sound may be absent
 Hypovolemic shock.Hypovolemic shock.
 Coagulopathies occur in 30% ofCoagulopathies occur in 30% of
casescases

10. DiagnosisDiagnosis
History:History:
1.1. Present obstetric historyPresent obstetric history
2.2. Symptoms of hypovolemiaSymptoms of hypovolemia
3.3. Symptoms of pre-eclampsiaSymptoms of pre-eclampsia
4.4. Lower abdominal pain or colicLower abdominal pain or colic
5.5. The presence or absence of fetal movementsThe presence or absence of fetal movements
6.6. History of ROM or labour painsHistory of ROM or labour pains
7.7. Previous uterine surgeryPrevious uterine surgery
8.8. History of sexual intercourse before onset ofHistory of sexual intercourse before onset of
bleedingbleeding
9.9. History of trauma or recent surgeryHistory of trauma or recent surgery

11. Physical examinationPhysical examination
 General examination:-tachycardia,hypotenstionGeneral examination:-tachycardia,hypotenstion
-signs of shock-signs of shock
-lower limb edema.-lower limb edema.
 Abdominal examination: -abdominal tenderness,or rigidityAbdominal examination: -abdominal tenderness,or rigidity
-fundal height-fundal height
-FHS-FHS
-consistency of the uterus-consistency of the uterus
 Pelvic examination:Pelvic examination:
-Do not perform a digital vaginal examination at this-Do not perform a digital vaginal examination at this
stage.stage.
 -Inspect the external genitalia and vagina for:-Inspect the external genitalia and vagina for:
-amount of blood loss-amount of blood loss
-signs of trauma or infection.-signs of trauma or infection.

12. InvestigationsInvestigations
 Laboratory investigations:Laboratory investigations:
--ABOABO blood group and Rh typeblood group and Rh type
-Crossmatch-Crossmatch 2 units of blood2 units of blood
-CBC-CBC
-Fibrinogen, aPTT, PT,CT-Fibrinogen, aPTT, PT,CT
-Serum creatinine or BUN-Serum creatinine or BUN
-Urine analysis for protein and RBCs-Urine analysis for protein and RBCs

13.  Perform a transvaginal ultrasound scan on allPerform a transvaginal ultrasound scan on all
women in whom a low-lying placenta iswomen in whom a low-lying placenta is
suspected from their transabdominal anomalysuspected from their transabdominal anomaly
scan (at approximately 20–24 weeks) to reducescan (at approximately 20–24 weeks) to reduce
the numbers of those for whom follow-up willthe numbers of those for whom follow-up will
be needed.be needed.
 Transvaginal ultrasound is safe in the presenceTransvaginal ultrasound is safe in the presence
of placenta praevia and is more accurate thanof placenta praevia and is more accurate than
transabdominal ultrasound in locating thetransabdominal ultrasound in locating the
placenta.placenta.

14. UltrasoundUltrasound
 Confirm the fetal viabilityConfirm the fetal viability
 Localize the site of placenta,and its relation to theLocalize the site of placenta,and its relation to the
cervixcervix
 Estimating the gestational ageEstimating the gestational age
 Detecting the presence of retroplacentalDetecting the presence of retroplacental
hematomahematoma

 In case of sever bleeding, do not wait for an USIn case of sever bleeding, do not wait for an US
examination .Begin first aid management and theexamination .Begin first aid management and the
quickly start active management .quickly start active management .
 Even if the amount of bleeding is mild NEVEREven if the amount of bleeding is mild NEVER
perform PV examination until placenta previa hasperform PV examination until placenta previa has
been excluded by USbeen excluded by US

15. Diagnosis of Antepatrm HemorrhageDiagnosis of Antepatrm Hemorrhage
 Painless vaginal bleedingPainless vaginal bleeding after 24w.?after 24w.?
 Symptoms and signs:Symptoms and signs:
-shock -bleeding may be precipitated-shock -bleeding may be precipitated
by intercourseby intercourse
-relaxed uterus -normal fetal condition-relaxed uterus -normal fetal condition
-fetal presentation not in the pelvis/ lower-fetal presentation not in the pelvis/ lower
uterine pole feels empty.uterine pole feels empty.
 Dg:Dg: Placenta previaPlacenta previa

16.  VaginalVaginal bleeding after 24bleeding after 24
w,intermitent,or constant abdominalw,intermitent,or constant abdominal
painpain??
 Symptoms and signs:Symptoms and signs:
-Shock -tense/tender uterus-Shock -tense/tender uterus
-decreased /absent fetal movements.-decreased /absent fetal movements.
-fetal distress/absent fetal heart sound.-fetal distress/absent fetal heart sound.
Dg: Abruptio placentaeDg: Abruptio placentae..
( H/O co-exciting PIH)( H/O co-exciting PIH)

17.  Bleeding(intra-abdominal and/orBleeding(intra-abdominal and/or
vaginal)?vaginal)?
 Sever abdominal pain(may decreaseSever abdominal pain(may decrease
after rupture)?after rupture)?
 Previous uterine scar?Previous uterine scar?
- shock -abdominal distention/free fluid.- shock -abdominal distention/free fluid.
-abnormal uterine contour -tender-abnormal uterine contour -tender
abdomenabdomen
-easily palpable fetal parts -rapid maternal-easily palpable fetal parts -rapid maternal
pulsepulse
-absent fetal movements and FHS-absent fetal movements and FHS
Dg: Ruptured uterusDg: Ruptured uterus

18.  Mild vaginal bleeding after 24Mild vaginal bleeding after 24
w(mild)?w(mild)?
 Symptoms and sings:Symptoms and sings:
-clinically stable-clinically stable
-fetal assessment showed fetal distress-fetal assessment showed fetal distress
that can not be explained by the mildthat can not be explained by the mild
bleeding.bleeding.
Dg : Vasa previaDg : Vasa previa

19. Complications of placenta previaComplications of placenta previa
-shock-shock
-postpartum hemorrhage-postpartum hemorrhage
- Women with placenta previa are atWomen with placenta previa are at
high risk for PPH and placentahigh risk for PPH and placenta
accreta/increta;accreta/increta;
a common finding is at the site of aa common finding is at the site of a
previous cesarean sectionprevious cesarean section

20. Complications of abruptio placentaeComplications of abruptio placentae
 Maternal shockMaternal shock
 Fetal deathFetal death
 Uterine atonyUterine atony
 Amniotic fluid embolismAmniotic fluid embolism
 Caogulopathy( 30%)Caogulopathy( 30%)
 Renal failureRenal failure
The principal cause of maternal death isThe principal cause of maternal death is
renal failure due to prolonged hypotensionrenal failure due to prolonged hypotension
..
Don not underestimate the amount of theDon not underestimate the amount of the
hemorrhagehemorrhage

21. ManagementManagement
 General rulesGeneral rules::
-call for help -keep women NPO-call for help -keep women NPO
-remember that mother and the neonate-remember that mother and the neonate
require evaluation and intervention ifrequire evaluation and intervention if
neededneeded

22. First aid managementFirst aid management
 Insert 2 wide bore cannulaeInsert 2 wide bore cannulae
 Blood for CBC,crossmatchBlood for CBC,crossmatch
 Immediately start iv crystalloidImmediately start iv crystalloid
solutionssolutions
 Provide 100% oxygen via maskProvide 100% oxygen via mask
 Warm the womenWarm the women
 Insert Foley catheterInsert Foley catheter
 Monitor blood pressure and pulse/ 5Monitor blood pressure and pulse/ 5
minmin
 Monitor urine output /hour

23. Indications of when to terminateIndications of when to terminate
pregnancypregnancy
 Women in labourWomen in labour
 Bleeding is heavy(evident orBleeding is heavy(evident or
concealed) manifested by shockconcealed) manifested by shock
 Gestational ageGestational age equalsequals or more 37 wor more 37 w
 There is fetal distressThere is fetal distress
 There is IUFD and /or fetalThere is IUFD and /or fetal
congenital anomalies by UScongenital anomalies by US

24. When to use conservative managementWhen to use conservative management
 Bleeding is light or has stopped ANDBleeding is light or has stopped AND
 The fetus is alive ANDThe fetus is alive AND
 The fetus is premature.The fetus is premature.
 Cases of abruptio placentae whichCases of abruptio placentae which
are diagnosed only on USare diagnosed only on US
examination, with no clinicalexamination, with no clinical
finding( no bleeding, no shock, nofinding( no bleeding, no shock, no
tender or tonically contracted uterus)tender or tonically contracted uterus)

25. In abruptio placentae:In abruptio placentae:
 When the clinical diagnosis is clearWhen the clinical diagnosis is clear
 Or in the presence of acute fetalOr in the presence of acute fetal
distress:distress:……. Do not waste your time. Do not waste your time
for US examination.for US examination.
 US is neither sensitive nor specificUS is neither sensitive nor specific
diagnosis modality in abruptiodiagnosis modality in abruptio
placentaeplacentae

26. Monitoring during hospital stayMonitoring during hospital stay
 Check pulseCheck pulse every 3o min/2h, thenevery 3o min/2h, then
hourly/6h, then every 4 h.hourly/6h, then every 4 h.
 Perform gentle uterine massage/30 minPerform gentle uterine massage/30 min
APH predispose for PPHAPH predispose for PPH
 Check for vaginal bleedingCheck for vaginal bleeding
 Check urine output/ 2hCheck urine output/ 2h

27. Conditions that should be met beforeConditions that should be met before
dischargedischarge
 No active bleedingNo active bleeding
 No feverNo fever
 Open bowelOpen bowel
 Stable general conditionStable general condition
 Satisfactory urine outputSatisfactory urine output
 No wound complicationsNo wound complications

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Placental
migration
Bleeding
C/Section
Expectant
management
Management of Placenta praevia in a
Pregnancy of viable gestational age
Fetal distress
Bleeding
Fetal lung maturity
Sono assessment
q 3-4 weeks
Complete
resolution
Trial of labor
)low-lying only(
Double set-up
Trial of labor
+ -
-+
+
-
+
- -
+
+
-

29. 29
Comparison of presentation ofComparison of presentation of
abruption v. praevia v. ruptureabruption v. praevia v. rupture
AbruptionAbruption PraeviaPraevia RuptureRupture
AbdominAbdomin
al painal pain
YesYes NoNo variablevariable
VaginalVaginal
bleedingbleeding
Old darkOld dark FreshFresh FreshFresh
DICDIC CommonCommon RareRare RareRare
FetalFetal
distressdistress
CommonCommon RareRare CommonCommon

30.  Associated withAssociated with velamentousvelamentous
insertion of theinsertion of the umbilical cord (1%umbilical cord (1%
of deliveries)of deliveries)
 Bleeding occurs with rupture of theBleeding occurs with rupture of the
amnioticamniotic membranes (themembranes (the
umbilical vessels are onlyumbilical vessels are only
supported by amnionsupported by amnion
 Bleeding is FETAL (not maternal asBleeding is FETAL (not maternal as
withwith placenta praevia)placenta praevia)
 Fetal death may occur with trivialFetal death may occur with trivial
symptomssymptoms

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