For MBBS and Post graduate students

1. Antepartum Haemorrhage
(APH)
PROF. IRAM CHAUDHRY
FCPS(Obs&gynae) MHPE.
BAHAWALPUR.

2. Contents
 Definition
 Importance
 Causes
 Management of APH

3. Bleeding
In
Pregnanc
y
Bleeding
in early
Pregnancy
Antepartum
haemorrhag
e
(APH
)
Post partum
Haemorrhage
(PPH)

4. Antepartum Haemorrhage
• bleeding from vagina during pregnancy from
24 weeks of gestation till delivery of the fetus.
• Epidemiology
 3-5% of all pregnancies
 3 times more common in
multiparous

5. Importance
 Obstetric emergency
 Attention should be sought immediately
 If left untreated can lead to death of the
mother and/or foetus
 Can leads to DVT
 Management reduces the risk of premature
delivery and maternal/perinatal morbidity and
mortality

6. CAUSES
Placental bleeding
(70%)
unexplained
(25%)
extraplacental
(5%)
Placenta
praevia
(35%)
abruptio
placenta
(35%)
Local
cervicovaginal
lesions
-cervical polyp
-carcinoma
cervix
-varicose vein
-local trauma

7. Causes
• 1: Placental causes:
• A. Placental abruption
• B. Placenta previa
• C. Vasa previa

8. • 2: Causes in genital tract:
• A. Labor
• B: rupture of uterus
• C. Trauma
• D. Infection (cervicitis &
vulvovaginitis)
• E. Tumours

9. • 3: Bleeding disorders
• A. Congenital (von willebrand’s
disease)
• B. Acquired ( DIC)

10. Placenta praevia
• Definition
Insertion of the placenta, partially or fully, in
the lower segment of the uterus

12. Etiology
• No definitive cause
• Endometrial factors:
– A scarred endometrium
– Curettage for several times
– Abnormal uterus
• Placental factors
– Large plcenta
– Abnormal formation of the placenta

13. ETIOLOGY
• Dropping down theory-due to poor decidual
reaction in the upper uterine segment
fertilized ovum drops down & gets implanted
in the lower segment.
• Persistence of chorionic activity in the decidua
capsularis.
• Defective decidua results in spreading of the
chorionic villi
• Big surface area of the placenta as in twins

14. Risk factors for Placenta praevia
• Multiparity
• Advanced maternal age
• Prior LSCS or other uterine surgery
• Prior placenta praevia
• Uterine structural anomaly

15. Predisposing factors

16. Degrees of Placenta praevia

17. Classification of Placenta praevia
• Four grades:
– Type I ( Low lying): encroaches lower
segment but does not reach the internal os
– Type II (Marginal placenta previa): Reaches
internal os but does not cover it
– Type III (Partial Placenta previa): Covers part of
the internal os
– Type IV (Complete): Completely covers the
os.

18. CAUSE OF BLEEDING
Bleeding
Inelastic placenta sheared off the wall of lower segment
Opening up of uteroplacental vessels
Placental growth slows down in later months
Lower segment progressively dilates

19. SPONTANEOUS CONTROL OF
BLEEDING
⚫Thrombosis of the open sinuses.
⚫Mechanical pressure by the presenting part
⚫Placental infarction.

20. Clinical Features
•
•
•
Recurrent painless vaginal bleeding
Abdominal findings
Uterus is soft, relaxed non tender
Contraction may be palpated
Presenting part: usually high with
abnormal presentations
Maternal cardiovascular compromise
Vaginal examination ×
•

21. Investigation
• 1: For Localization of placenta:
• Ultrasound:
• Abdominal ultrasound
• Transvaginal ultrasound
• 2: Haematological Investigations:
• A. Complete blood picture.
• B. Blood grouping.
• C:Renal profile

22. Placenta praevia-Complications
Maternal
• Major hemorrhage, shock, and death
• Renal tubular necrosis and acute renal failure
• Post partum haemorrhage
• Morbid adherence of Placenta :
placenta accreta approximately 10% of placenta
praevia cases
• Anaemia
• Disseminated intravascular coagulopathy (DIC)

23. Placental abruption
• Definition
Premature separation of a normally
situated placenta
• Placental abruption should be considered
in any pregnant woman with abdominal
pain with or without PV bleeding, as mild
cases may not be clinically obvious

24. Etiology
Risk factors
1.Increased age and parity
2.Vascular diseases: preeclampsia, maternal
hypertension, renal disease,SLE
3.Mechanical factors: Trauma, intercourse
Polyhydroamnios Multiple pregnancy
4.Smoking, cocaine use, 5.Premature
rupture of membranes

25. Pathology
• Main changes
Hemorrhage into the decidua basalis →
decidua
splits →hematoma → separation, compression,
destruction of the adjacent placenta
• Types of abruption
1. Revealed abruption
2. Concealed abruption
3. Mixed type

26. Revealed abruption Concealed abruption

27. Diagnosis-Clinical Features
• Vaginal bleeding associated with
 Persistent abdominal pain
 Tenderness on the uterus
 “Woody” hard uterus
 Features of hypovolemic shock
 Fetal heart rate abnormalities

28. Complication of Placental abruption
Maternal
 Disseminated intravascular coagulopathy
 Hypovolemic shock
 Amnionic fluid embolism
 Renal tubular necrosis and acute renal failure
 Post partum haemorrhage
 Maternal death

29. Complication of Placental abruption
Feotal
• Premature labour
• IUGR in chronic abruption
• Hypoxic ischemic encepalopathy
Cerebral palsy
• Fetal death

30. Investigations
•
•
1: Ultrasonography
To exclude placenta praevia
Retroplacental hematoma, Fetal viability
• 2: Laboratory investigations
1. CBC
2.Grouping& Rh factor
3.Consumptive coagulopathy – Platelet
count/BT/CT/PT/INR & APTT
4.Liver and Renal function tests

31. Vasa praevia
 Fetal blood vessels from placenta or
umbilical cord cross the internal os beneath
the presenting part
 Rupture of membranes leads to damage of
the fetal vesseles leading to exsanguination
and death
 High fetal mortality (50-75%)

32. Vasa praevia

33. Management of APH

34. Management of APH
 Admit, assess and manage
 Resuscitation if in shock or severe bleeding
 Airway, breathing and circulation
 Senior staff –Consultant obstetrician
Consultant anesthetist,
Neonatologist
 Two wide bore canula
 Take blood for Grouping, FBC , coagulation
profile, Liver & Renal function

35. Management of APH
• Volume replacement by
• Crystalloid /colloid until blood is
available
• Severe bleeding or fetal distress:
Urgent delivery irrespective of
gestational age

36. Management of APH cont…
History
• Obtain a history including:
•
•
•
•
•
Colour and consistency of bleeding
Quantity and rate of blood loss
Precipitating factors i.e
trauma
Degree of pain, site and type
ultrasound report, placental localization
• Ascertain fetal heart rate and movements

37. Management of APH cont…
Examination
GPE
• Assess maternal and foetal well-being
• Perform abdominal examination
Note areas of tenderness and hypertonicity
Determine gestational age of foetus,
presentation and position, auscultate foetal
heart
• No vaginal examination, until placenta praevia is
excluded
• Do speculum examination first

38. Management of APH cont…
Investigations
• Ultrasound scan
• Foetal monitoring
Continuos electronic foetal monitoring
Laboratory investigations
1.Investigation for Consumption coagulopathy
– Platelet count/BT/CT/PT/INR & APTT
2.Liver and Renal function tests

39. Further management of APH
• Further management will depend on
Cause of the APH
Extent of bleeding
Presence of feotal distress
Gestational age and feotal maturity

40. Placenta praevia -
Management
•
1.Near term / Term
Delivery is considered
Types I and II - May be able to deliver
vaginally
Types III and IV - Will require caesarean
section by senior obstetrician

41. Placenta praevia – Management
2. Early in pregnancy
• Continuation of pregnancy
Educate regarding condition and risk
bed rest
3 pint of crossed matched blood available till
delivery
Fetal well being and growth monitoring
Medications to prevent premature labour
•

42. Placental abruption
Management…. Conti…
• Small abruption
Conservative management
depending on gestational age
Careful monitoring of feotal condition

43. Placental abruption - management
• Moderate or severe placental abruption:
• Restore blood loss
• Ideally measure central venous pressure (CVP) and
adjust transfusion accordingly
• Prevent coagulopathy
• Monitor urinary output
• Delivery
1.Caesarean section
2.Vaginal
If coagulopathy present
If fetus is not compromised If
fetus is dead

44. Vasa Previa management
• Urgent delivery, may need urgent LSCS
• Neonatologist involvement & aggressive
resuscitation of the baby
• Perinatal mortality more than 50 per
1000 even with tertiary care facilities
• High rates of maternal mortality

45. THANK YOU