APH

1. ANTEPARTUM HAEMORRHAGE

2. GOALS
1. To identify and recognize causes of APH
2. To be able to resuscitate properly
3. To be able to manage appropriately

3. ANTEPARTUM HAEMORRHAGE
 PV bleeding after 22 weeks till birth of baby
 Incidence: 3 – 5%
 Before 22 weeks – miscarriage/abortion
 E.g. threatened miscarriage
 Have to differentiate from “show”
 blood-stained mucoid discharge

4. CAUSES
 Indeterminate 45%
 Abruptio Placenta 30%
 Placenta Praevia 20%
 Local causes 5%
(e.g. vaginitis, cervical polyp, ectropion,
carcinoma)

5. HISTORY
 Colour, quantity of bleeding
 Precipitating factors e.g. trauma, intercourse
 Contractions
 Leaking liquor
 Fetal movement
 Previous ultrasound

6. GENERAL MEASURES
 Call for help
 Resuscitation: A, B, C
 BP,PR
 2 IV access
 Blood ix
 FBC, coagulation profile
 Rhesus
 Cross match blood 4 units
 Ultrasound
 Identify Cause of bleeding
 NO VE until cause determined

7. PLACENTA PRAEVIA
 Placenta lying partly or wholly within the lower uterine
segment (> 28 weeks)
 < 28 weeks - Low-lying placenta
Upper segment
Lower segment

8. CLASSIFICATION
 PP I : Within lower segment (5cm)
 PP II : Reaches internal os
 PP III : Partially covers os
 PP IV: Completely covers os

9. INCIDENCE
 18 weeks: 26%
 32 weeks: 5%
 Term: 0.5%
 Only about 1 in 10 of low lying placenta persists as
clinically relevant placenta praevia towards term

10. RISK FACTORS
 Maternal
 Previous caesarean section (associated with placenta
accreta)
 Previous placenta praevia
 Grandmultip
 Elderly
 Smoking
 Fetal
 Twins

11. COMPLICATIONS
 Maternal
 PPH
 Placenta accreta
 Maternal death
 Fetal
 Prematurity
 IUGR
 Congenital malformations (2-fold increase
in PP and abruptio)

12. MANAGEMENT
 Diagnosis by U/S (ideally with transvaginal U/S)
 No V/E
 Active PV bleeding- immediate delivery
 Bleeding stop- hospitalized till delivery

13. MORBIDLY ADHERENT PLACENTA
 Placenta penetrates through the
myometrium of uterus
 Includes
- Placenta accreta
- Placenta increta
- Placenta percreta
 Risk factors
- Previous scar
- Previous D&C

14.  Women with previous caesarean section and at the
same time had placenta praevia at increase risk of
morbidly adherent placenta
 Increase in maternal morbidity and mortality

15. LINK BETWEEN NUMBER OF PREVIOUS CAESAREAN
SECTION AND RISK OF MORBIDLY ADHERENT PLACENTA
& HYSTERECTOMY
NUMBER OF
PREVIOUS C-
SECTION
NUMBER OF
WOMEN
NUMBER OF
WOMEN WITH
PLACENTA
ACCRETA
CHANCE OF
PLACENTA
ACCRETA IF
PRAEVIA
NUMBER OF
HYSTERECTOMIES
0 6201 15 (0.24%) 3% 40 (0.65%)
1 15808 49 (0.31%) 11% 67 (0.42%)
2 6324 36 (0.57%) 40% 57 (0.9%)
3 1452 31 (2.13%) 61 % 35 (2.4%)
4 258 6 (2.33%) 67 % 9 (3.49%)

16. PLACENTA ABRUPTIO
 Premature separation of the placenta prior to the 3rd
stage of labour
 Incidence: 1-2%

17.  Placental separation if severe enough, can cause
inadequate nutrition and oxygenation of the fetus –
fetal death

18.  Can be concealed, revealed or mixed (most common)

19. RISK FACTORS
 Maternal
 Previous abruptio
 Grandmultipara
 PIH
 Trauma, fall, massage
 ECV
 Substance abuse
 Smoking
 Fetal
 Twins
 Polyhydramnios (with sudden decompression on rupture of
membrane)

20. MANAGEMENT (FETUS ALIVE)
 Assess maternal and fetal stability
 ARM to augment labour and prevent amniotic fluid
embolism
 Continuos CTG monitoring
 LSCS for:
 Fetal distress
 Persistent bleeding
 Vaginal delivery not imminent
 If mother not stable (need to resuscitate first!)
 Paeds for neonatal resuscitation
 Watch for PPH

21. MANAGEMENT (FETUS DEAD)
 Assess maternal stability and coagulopathy
 Vigorous replacement of fluid and blood products
 Correct any coagulopathy
 Vaginal delivery unless severe haemorrhage
 Watch for PPH

22. MATERNAL COMPLICATIONS
 Couvelaire uterus
 Blood seeping into uterus (myometrium) causing
uterine atony
 Coagulopathy
 Due to profuse bleeding
 Due to thromboplastin release from decidua
 Hypovolaemic shock
 Renal cortical necrosis
 Amniotic fluid embolism
 Maternal death

23. FETAL COMPLICATIONS
 IUGR
 Birth asphyxia
 Perinatal death

24. PRAEVIA ABRUPTIO
Painless Painful
Revealed Can be concealed
Uterus soft Uterus tense/ tender
FH usually present FH may be absent
May have abnormal lie
or malpresentation
May be hard to feel
fetal parts
How to differentiate? Clinical presentation

25.  If there is no identifiable cause of APH
 Deliver by 40 weeks – due to possibility of minor
abruption (may lead to placental insufficiency)
 Refer if undelivered by 40 wks + 0 days
INDETERMINATE APH

26.  Bleeding with onset at rupture of
membranes
 Immediate delivery
 High perinatal mortality from fetal
exsanguination
VASA PRAEVIA

27. PRINCIPLES OF MANAGEMENT
 Assess maternal condition and stabilize if necessary.
 Then assess the fetal condition.
 Determine the cause of the bleeding
 Manage according to underlying cause.