Obgy

1. Antepartum
Haemorrhage
Reuben Kamoto Mbewe
Associate Professor
Consultant Obstetrician and Gyneacologist
Lusaka University

2. Outline of the presentation
• Definition
• Causes of antepartum haemorrhage
• Signs and symptoms of Antepartum haemorrhage
• Complications of antepartum haemorrhage
• Management of antepartum haemorrhage

3. Definition
• Bleeding from the genital tract after viability (28weeks) but
before the birth of the baby

4. Types of antepartum haemorrhage
There are two main types of antepartum haemorrhage:
• placenta previa and
• placental abruption
Placenta previa happens when the placenta partially or wholly covers
the cervix.
Placental abruption occurs when the placenta separates from the
uterine wall before the baby is born.
Both conditions can lead to significant bleeding during pregnancy and
require immediate medical attention.
Local causes of antepartum haemorrhage include lesions on the cervix
such as polyps, cervicitis, ectropion and cancer of the cervix

5. Signs and symptoms of antepartum
haemorrhage
The most common sign of antepartum haemorrhage is vaginal
bleeding, which may range from mild spotting to heavy bleeding.
Other associated symptoms may include
abdominal pain,
contractions,
decreased fetal movements,
and
signs of shock such as dizziness or lightheadedness.
It is crucial for pregnant women to be aware of these signs and
promptly report them to their healthcare provider.

6. Placenta praevia
• The placenta is implanted partially or completely over the
lower uterine segment ( over and adjacent to the internal
os)
• High risks of placenta praevia
• Multiparity
• Increased maternal age
• History of previous C/S or any scar such as myomectomy or
hysterotomy
• Placenta size
• Prior curettage

7. Placental praevia

9. Types of placenta praevia
• Type I: (low lying) the major part of the placenta is attached
to the upper segment and only the lower margin
encroaches onto the lower segment but not up to the os
• Type II: (Marginal) the placenta reaches the margin of the
internal os but does not cover it
• Type III: (incomplete or partial central) the placenta covers
the internal os partially (covers the internal os when closed
but not when fully dilated
• Type IV: (central or total) the placenta completely covers the
internal os even after it is fully dilated

10. Complications of placenta praevia
• Malpresention
• Premature labour
• During labour
• Cord prolapse
• Slow dilatation
• Intrapartum haemorrhage
• Increased incidence of operative interference
• Post partum haemorrhage due to imperfect retraction of the lower
segment
• Occasional morbidly adherent placenta (placenta accreta)

11. Fetal complications
• Low birthweight
• Asphyxia
• Intrauterine fetal death
• Birth injuries
• Congenital malformations

12. Symptoms and signs of placenta
praevia
Painless, sudden onset of bleeding without a specific cause
In about 5% the bleeding occurs for the first-time during labour
In about one third there is history of a warning haemorrhage and it is
usually slight.
The bleeding is unassociated with pain unless in labour
• Abdominal examination
• The size of the uterus is proportionate to the gestational age
• The uterus is relaxed soft with no tenderness
• There is malpresentation
• High presenting part – fetal head
• The fetal heart sounds are heard

13. Management
A patient who presents with APH should be admitted
Diagnosis is confirmed from history, examination and U/S
• Overall assessment is made to assess blood loss
• Pallor, pulse rate, blood pressure is assessed
• Blood samples taken for FBC, blood group/x-match
• IV line set up
The management is divided into expectant and active

14. Management
• Expectant management ( 28weeks to 37 weeks) with Hb 10g/dl
or more. Not actively bleeding and assured fetal wellbeing
• Admit the patient for long stay
• Keep x-matched with two units of blood readily available
• Monitor PV bleeding using pads
• Do serial scan every 2 weeks
• Administer steroids in pregnancy less than 34 weeks gestation
• No vaginal examinations
• No vigorous abdominal palpations
• Admin Rh immunoglobulin in Rh negative women
• Otherwise planned for delivery at 37 completed weeks

15. Management
• Active management: delivery
• If patient has had a significant bleed i.e. causing haemodynamic
instability, deliver after resuscitation and stabilization of patient
• Or bleeding is continuing and of moderate degree
• Bleeding after 37 weeks of pregnancy
• Patient in labour
• There’s IUFD or has congenital malformations

16. Abruptio placenta
• Definition
• This is where the bleeding occurs due to premature separation
of normally situated placenta
• Varieties
• Revealed: following separation, the blood insinuates downwards
between the membranes and the decidua. The blood comes out of the
cervical os to be visible externally
• Concealed: the blood collects behind the separated placenta or
collected in between the membranes and decidua
• Bleeding is almost always maternal. But placental tear may
cause fetal bleeding

17. Concealed and revealed abruptio
placenta

18. Risk factors of placental abruptio
• Hypertension is the most important predisposing factor
• High birth order
• Advancing age
• Poor social economic status
• Malnutrition
• Smoking
• Trauma
• Sudden uterine decompression

19. Signs and symptoms
• Depends on the degree of separation of placenta, the speed
at which the separation occurs and the amount of concealed
blood
• Diagnosis is mainly clinical although U/S may help in the
diagnosis

20. Signs and symptoms ( Revealed
abruptio)
• Abdominal pain with vaginal bleeding
• Continuous dark colour
• General condition of patient is proportionate to visible pv
loss
• Pallor is equivalent to visible blood loss
• on examination, uterine size equivalent to the gestational
age
• Some localized tenderness will be elicited and fetal parts
may be felt easily and fetal heart sounds may be present

21. Signs and symptoms (concealed
features prominent)
• Intense abdominal pain may be continuous
• Slight dark blood or no bleeding
• Shock may be pronounced which is not proportionate to
visible blood loss
• Pallor usually severe and not proportionate to visible blood
loss
• On examination, uterus may be enlarged (larger than
dates), fetal parts may be difficult to feel
• Fetal heart sound will be absent in most cases

22. Complications of placenta abruptio
Maternal
• In revealed type, maternal risk is proportionate to blood loss and
maternal death is are
• In concealed type,
• Shock
• Blood coagulation disorder - DIC
• Oliguria and anuria
• Postpartum haemorrhage
Fetal
• Fetal death due to prematurity or anoxia due placenta separation

23. Management of placenta abruption
Prevention
• Elimination of all known factors likely to produce placental
separation
• early detection and treatment of PE and other hypertensive
disorders
• Avoid sudden decompression of the uterus
• Correction of anaemia during pregnancy so that the patient
can withstand haemorrhage
• Prompt detection and treatment to lessen complications

24. Management of placenta abruptio
• Assessment of the patient
• Amount of blood loss
• Whether the patient is in labour or not
• Presence of any complications
• Type of placenta abruptio
• Emergency measures
• FBC, blood for coagulation profile
• ABO and Rhesus grouping
• Urinalysis for detection of protein
• Canulate with wide bore canula – start crystalloids as you await blood
for transfusion

25. Management of abruptio placenta
• Patient should be delivered immediately
• If patient in labour, accelerate labour by ARM and augment with
oxytocin if needed
• Aim for vaginal delivery
• In abruptio with dead fetus
• Limited placental abruption where electronic continuous fetal monitoring
is available
• If patient not in labour deliver by
• Induction
• C/S in severe abruptio with live fetus,
• Pts with other indications for C/S i.e. with big baby or previous C/S

26. Bleeding due to unknown cause
• When placenta praevia and placenta abruptio have been ruled out, a
speculum is done to look for local causes of antepartum haemorrhage
• However, the cause of bleeding is not known in some of the cases of
APH
• The diagnosis of bleeding due to unknown cause is made after
exclusion of placenta praevia, placenta abruptio and local causes
• Pregnancy of 37 weeks and above with unknown bleeding should be
delivered. Mode of delivery depends on state of the fetus and other
associated factors such as bishop score
• Expectant management is done in selected cases for maturity as in
placenta praevia

27. Prognosis
• The prognosis for antepartum haemorrhage can vary
depending on the specific circumstances.
• With prompt medical intervention and proper management,
many cases can result in healthy pregnancies and deliveries.
• However, the prognosis may be less favorable in cases
where severe bleeding or complications have occurred.
• Close follow-up care and ongoing monitoring are essential
for ensuring the well-being of both mother and baby.