This document discusses antepartum haemorrhage (APH), defined as vaginal bleeding after 20 weeks of gestation. It covers causes of APH such as placenta praevia and placental abruption. It describes the initial management, assessment, and monitoring of patients with APH. Based on the severity and cause of bleeding as well as gestational age, different approaches to delivery are outlined including conservative care, induction of labour, or caesarean section. Specific conditions like vasa praevia are also addressed.

1. May 31, 2023 APH 1
ANTEPARTUM HAEMORRHAGE

2. APH 2
May 31, 2023
Antepartum Haemorrhage
 vaginal blood loss >15 mL after 20 weeks’
gestation
 5% of all pregnancies
 Accounts for 20 -25% of perinatal mortality

3. APH 3
May 31, 2023
Causes
 Placenta praevia 20%
 Placental abruption 30%
 Others/ unknown 45%
 Vasa praevia
 Marginal sinus bleeding
 Rupture uterus
 Local causes 5%

4. APH 4
May 31, 2023
Local causes of APH
 Only 5% of APH
 Causes include:
 Cervicitis
 Cervical erosion, polyp
 Cervical cancer
 Vaginal/ vulval varicocities
 Vaginal infections
 Foreign bodies
 Genital lacerations
 Bloody show
 Degenerating fibroids
 non-genital tract bleeding

5. APH 5
May 31, 2023
Severity of bleeding
 Mild (<15% circulatory volume)
 No change in vital signs
 No postural hypotension
 Normal urine output
 Moderate (15 - 30%)
 Postural changes in BP or pulse
 Symptoms (thirst, dypsnoea etc.)
 Severe (>30%)
 Shock
 Fetal distress
 Oliguria

6. APH 6
May 31, 2023
Initial management of APH
 Admit
 History
 Examination
 Observation
 NO PV Exam
 IV access/ resuscitate
 Clotting screen
 Cross match
 Kleihauer test
 CTG
 Placental localization
 Speculum examination
when placenta praevia
excluded, bleeding
settled
 Anti-D if Rh-negative

7. APH 7
May 31, 2023
Placental abruption
 Separation of placenta before delivery
 Starts with bleeding into decidua basalis
 Impairs placental function
 About 1.5% of pregnancies
 Perinatal mortality 10%

8. APH 8
May 31, 2023
Complications
 DIC
 Fetal death
 Hypovolaemic shock
 Fetomaternal hemorrage

9. APH 9
May 31, 2023
Predisposing factors of abruption
 Hypertension
 External trauma - MVA, ECV
 Acute decompression of polyhydramnios
 PROM
 Substance abuse -tobacco, cocaine,
amphetamines
 Past history of abruption
 Antiphospholipid syndrome
 Multiple pregnancy

10. APH 10
May 31, 2023
Classification of abruption
 Mild
 Blood loss < 200 mL
 No uterine tenderness or rigidity
 Normal CTG
 Moderate
 Blood loss > 200 mL OR
 Uterus tense and tender OR
 Abnormal CTG
 Severe
 Fetal death - DIC in 30%

11. APH 11
May 31, 2023
Clinical features
 Vaginal bleeding in 80% (Revealed)
 Abruption is ‘Concealed in 20%
 Initial bleeding
 Pain, uterine tenderness, rigidity
 Sudden increase in fundal height
 Fetal distress or death
 DIC

12. APH 12
May 31, 2023
Diagnosis
 Clinical diagnosis, confirmed retrospectively by
examination of placenta
 Clinical features important in concealed
abruption
 Ultrasound unreliable
 Only shows 25% of abruptions

13. APH 13
May 31, 2023
Management
 Admit
 History, examination
 Assess blood loss
 Nearly always more than revealed
 IV access, X match, DIC screen
 Assess fetal well-being
 Placental localization

14. APH 14
May 31, 2023
Clinical flow chart
Is the fetus
alive?
No
Yes
Severe
abruption
(10% of
cases)
Resuscitate
Induction of labour
Vaginal delivery
CTG
Abnormal
?DIC
Yes
No
Correct
Caesarean section
Normal
Uterus tense
IOL
CTG
Abnormal CTG
Normal CTG
Vag del
Uterus soft
> 38/52
< 38/52
Conservative
management

15. APH 15
May 31, 2023
Placenta praevia
 Placenta implanted on lower uterine segment
 1% of all pregnancies
 Perinatal mortality rate ~ 3%
 Major problem is preterm delivery
 At 18 weeks, ~5% of placentas are ‘low lying’

16. APH 16
May 31, 2023
Classification
4 grades or degrees of placenta praevia:
1. Low-lying: edge not near internal os, but could
be palpated by finger through cervix.
2. Marginal: edge of placenta reaches but does
not cover os.
3. Partial: placenta partially covers internal os.
4. Total: placenta completely covers internal os.

17. APH 17
May 31, 2023
Aetiology/ associations
 Uterine surgery or instrumentation
 Previous CS, D&C, myomectomy
 1 previous CS + anterior placenta praevia
= 25% risk placenta accreta
 P H placenta praevia
 Increasing parity and age
 Multiple pregnancy

18. APH 18
May 31, 2023
Clinical presentation
 Painless Recurrent Vaginal bleeding
 1/3 < 30 weeks
 1/3 30-35 weeks
 1/3 > 36 weeks
 Usually first episode mild
 Earlier is worse
 Often gets worse
 Abnormal presentation or lie

19. APH 19
May 31, 2023
Diagnosis
 Placental localization is by ultrasound
examination
 Transvaginal ultrasound better
 Not always right
 PPV 93%, NPV 96%
 At 18 weeks, 5-10% of placentas low
lying.
 Repeat scan at 32 - 34 weeks

20. APH 20
May 31, 2023
Management
 Admit to hospital
 NO VAGINAL EXAMINATION
 IV access
 Placental localization
 Conservative treatment until fetal maturity if
possible

21. APH 21
May 31, 2023
Management
Severe
bleeding
Caesarean
section
Moderate
bleeding
Gestation
>34/52
<34/52
Resuscitate
Steroids Unstable
Stable
Resuscitate
Mild bleeding
Gestation
<36/52
Conservative care
>36/52

22. APH 22
May 31, 2023
Delivery
 Delivery is by Caesarean section
 Usually LSCS, go around placenta
 Beware morbidly adherent placenta
 Occasionally Caesarean hysterectomy
necessary

23. APH 23
May 31, 2023
Outpatient management
 Inpatient observation for 72 hours without
bleeding
 Stable haematocrit > 35%
 Reactive CTG
 Can call ambulance 24 hours/day
 Rest at home, no intercourse
 Patient understands complications
 Weekly follow-up until delivery

24. APH 24
May 31, 2023
Asymptomatic patients
 Placenta praevia now diagnosed
prior to bleeding
 If no bleeding, no need to admit
before 34 weeks
 Admit if bleeds
 Delivery still by CS at 37-38 weeks
 Uncertainty about admission
between 34 and 37 weeks - admit
grades 3 and 4

25. APH 25
May 31, 2023
Vasa Praevia
 Vellamentous insertion of cord, bipartite or
succenturriate placenta
 Fetal vessels in membranes over cervix
 May rupture at or before ROM
 Suspect in small APH with abnormal CTG
 Confirm with Apt test

26. APH 26
May 31, 2023
How to do an Apt test
 Place 5 mL water in each of 2 test tubes
 To 1 test tube add 5 drops of vaginal blood
 To other add 5 drops of maternal (adult) blood
 Add 6 drops 10% NaOH to each tube
 Observe for 2 minutes
 Maternal (adult) blood turns yellow-green-brown;
fetal blood stays pink.
 If fetal blood, deliver STAT.

27. APH 27
May 31, 2023
APH of uncertain origin
 2.5% of all deliveries
 PNM 2% (3x background rate)
 Initial management as for all APH
 Monitor fetal well-being
 Marginal sinus bleeding
 Retrospective diagnosis
 Increased incidences of PROM, preterm labour