CME presentation slides on Antepartum Haemorrhage Bleeding from or in to the genital tract, occurring from 24 weeks (>500g) of pregnancy and prior to the birth of the baby

1. ANTEPARTUM
HAEMORRHAGE
Austin Jauyo – MBChB
NYSCH CME
APH

2. Definition
Defined as:
■ Bleeding from or in to the genital tract, occurring from 24
weeks (>500g) of pregnancy and prior to the birth of the
baby.
■ Complicates 3–5% of pregnancies.
■ Leading cause of perinatal and maternal mortality
worldwide.
■ Up to one-fifth of very preterm babies are born in
association with APH
■ Most of the time unpredictable.
APH

3. Severity
Assessing severity:
■ No consistent definitions of the severity of APH.
■ Amount of blood lost is often underestimated.
■ Amount of blood coming from the introitus may not
represent the total blood lost ( e.g in a concealed placental
abruption).
■ It is important to assess for signs of clinical shock.
■ The presence of fetal compromise or fetal demise is an
important indicator of volume depletion.
APH

4. Severity cont’d
But maybe:
■ Spotting – staining, streaking or blood spotting noted on
underwear or sanitary protection.
■ Minor haemorrhage – blood loss less than 50 ml that
has settled.
■ Major haemorrhage – blood loss of 50–1000 ml, with
no signs of clinical shock.
■ Massive haemorrhage – blood loss greater than 1000
ml and/or signs of clinical shock.
■ Recurrent APH- > one episode.
PMTCT

5. Etiology
Placental causes
■ Placental abruption
■ Placenta previa
■ Vasa previa
Bleeding disorders
■ Congenital (von willebrand’s
disease)
■ Acquired ( DIC)
Causes in Genital Tract
■ Labour- Excessive show
■ Rupture of uterus
■ Trauma
■ Infection (cervicitis &
vulvovaginitis)
■ Tumours
■ Cervical ectropion, polyps
Unexplained APH
APH

6. A 34-year-old multigravida at 31 weeks’
gestation comes to the labor unit stating she
woke up in the middle of the night in a pool
of blood. She denies pain or uterine
contractions. Examination of the uterus
shows the fetus to be in transverse lie. Fetal
heart sounds are regular at 145 beats/min.
On inspection her perineum is grossly
bloody

7. Placenta Praevia (PP)
■ Implantation of placenta over or near the internal
os of cervix.
APH

9. Placenta Praevia (PP)
Placenta Praevia Triad
■ Late trimester bleeding (2nd & 3rd)
■ Lower segment placental implantation
■ No pain

10. What are the risk factors for placenta praevia?
Abruption is more likely to be related to
conditions occurring during pregnancy
and placenta praevia is more
likely to be related to conditions
existing prior to pregnancy.

11. Risk factors for placenta praevia?
■ Previous placenta praevia (4-8%)
■ Previous caesarean sections ( risk with numbers of c-section)
■ Previous termination of pregnancy
■ Multiparity
■ Advanced maternal age (>40 years)
■ Multiple pregnancy
■ Smoking
■ Deficient endometrium due to presence or history of:
● uterine scar
● endometritis
● manual removal of placenta
● curettage
● submucous fibroid APH

12. A 32-year-old multigravida at 31 weeks’
gestation is admitted to the labor
unit after a motor-vehicle accident. She
complains of sudden onset of moderate
vaginal bleeding for the past hour. She has
intense, constant uterine pain
and frequent contractions. Fetal heart
sounds are regular at 145 beats/min. On
inspection her perineum is grossly bloody.

13. Abruptio Placenta (AP)
■ Separation of normally located placenta after 22 weeks of
gestation ( > 500g) and prior to delivery of fetus.
PMTCT

14. ■ Revealed
■ Concealed
■ Mixed

15. What are the risk factors for Abruptio Placenta?
Abruption is more likely to be
related to conditions occurring
during pregnancy and placenta
praevia is more likely to be related to
conditions existing prior to pregnancy.

16. Risk factors for Abruptio Placenta ?
■ Previous history of AP
■ Maternal hypertension
■ Advanced maternal age
■ Trauma ( domestic violence, accident, fall)
■ Polyhydramnios
■ Intrauterine infections
■ Non-vertex presentations
■ Short umbilical cord
■ Sudden decompression of uterus (PROM/delivery of 1st twins)
■ Retroplacental fibroids
■ Fetal growth restriction
APH

17. Risk factors for Abruptio Placenta ?
■ Smoking/alcohol/cocaine/amphetamines
■ Low body mass index (BMI)
■ Idiopathic
■ First trimester bleeding increases the risk of abruption later in
the pregnancy
■ When an intrauterine haematoma is identified on ultrasound
scan in the first trimester, the risk of subsequent placental
abruption is increased
APH

18. Abruptio Placenta
■ Diagnosed CLINICALLY
● Painful vaginal bleeding -80%
● Tense/woody hard, and tender abdomen/back pain
(70%) increase in fundal height
● Fetal distress ( 60%)
● Abnormal uterine contractions (hypertonic and high
frequency)
● Preterm labour ( 25%)
● Fetal death ( 15%)
● Ultrasound is NOT USEFUL to diagnose AP;
retroplacental clots (hyperechoic) easily missed

19. Vasa Praevia (VP)
● Present when fetal
vessels traverse
the fetal
membranes over
the internal
cervical os.
PMTCT

20. Vasa Praevia (VP)
■ Antenatal diagnosis – reduced perinatal mortality and morbidity.
■ Painless vaginal bleeding at the time of spontaneous rupture of
membrane or post amniotomy
■ Fetal bradycardia;
■ Fetal shock or death can occur rapidly at the time of diagnosis
due to mainly fetal blood loss; blood volume in fetus ( 3kg
fetus~300ml)
■ ALWAYS check the FHR after rupture of membrane or
amniotomy.
■ Definitive diagnosis by inspecting the placenta and fetal
membrane after delivery.

21. Reminder!!
A 27-yo G2 P1 woman comes to the maternity unit for
evaluation for regular uterine contractions at 34 weeks’
gestation. Her previous delivery was an emergency CS at
32 weeks because of hemorrhage from placenta previa. A
classical uterine incision was used because of lower uterine
segment varicosities. Pelvic exam shows the cervix to be
closed and long. As she is being evaluated, she experiences
sudden abdominal pain, profuse vaginal bleeding, and fetal
bradycardia. Uterine contractions cannot be detected. The
fetal head, which was at –1 station, now is floating.

23. Complications of APH

24. Clinical assessment in APH
Initial: Primary Survey~~~ ABCD
● First and foremost: Mother and fetal well being (mother is the
priority)
● Establish whether urgent intervention is required to manage
maternal or fetal compromise.
● Assess the extent of vaginal bleeding, cardiovascular condition of
the mother
● Assess fetal wellbeing
APH

25. Full History
Taken after the mother is stable:
■ Associated pain with the bleeding?
● Continuous pain: Placental abruption.
● Intermittent pain: Labour.
■ Risk factors for abruption and placenta praevia should be
identified.
■ Reduced fetal movements?
■ If APH is associated with spontaneous or AROM: ruptured vasa
praevia
■ Previous cervical smear history; possibility of Ca cervix.
Symptomatic pregnant women present with APH (mostly
postcoital) or vaginal discharge.

26. Examination
■ General: PULSE & BP (a MUST!)
■ Abdomen:
● The tense, tender or ‘woody’ feel to the uterus
indicates a significant abruption.
● Uterine contractions– mild, moderate, strong
● Abnormal uterine contractions (hypertonic
and high frequency)
● Progressive increase in fundal height?–
concealed, major abruption?

27. Examination cont’d
■ Abdomen:
● Painless bleeding, high fetal presenting part –
Placenta praevia
● Soft, non-tender uterus may suggest a lower
genital tract cause or bleeding from placenta or
vasa praevia

28. Examination cont’d
■ Speculum :
● Identify cervical dilatation or visualize a lower
genital tract cause.
■ Digital vaginal examination
● Should NOT be done until Placenta Praevia
has been excluded by USG if suspicious for PP
● Can provide information on cervical dilatation
if APH is associated with pain or uterine
activity

29. Investigations
■ FBC (HB, Platelets) UEC, LFT, Coagulation profile,
■ GXM 4 units,
■ Ultrasound- r/o PP & IFUD ***does not exclude abruption***
■ D-dimer : AP
■ Colour doppler TVS – VP
■ In all women who are RhD-negative, a Kleihauer test should be
performed to quantify FMH to gauge the dose of anti-D Ig
required.
■ Fetal monitoring: FHR, CTG monitoring

30. Management
The four pillars of management:
■ communication between all members of the
multidisciplinary team
■ resuscitation
■ monitoring and investigation
■ arrest bleeding by arranging delivery of the
fetus

31. Management cont’d
WHEN to admit?
■ Based on individual assessment
■ Discharge after reassurance and counselling danger signs
● Presenting with spotting, no longer bleeding and
placenta praevia has been excluded.
● However, spotting + previous IUFD due to placenta
abruption, an admission would be appropriate.
■ All women with APH heavier than spotting and women
with ongoing bleeding should remain in hospital at least
until the bleeding has stopped.

32. Management cont’d
■ If preterm delivery is anticipated, a single course of
antenatal corticosteroids (dexamethasone 12mg 12
hourly, 2 doses) to women between 24 and 34 weeks 6
days of gestation.
■ Tocolytics - not to be used to delay delivery in major
APH, or haemodynamically unstable, or if there is
evidence of fetal compromise.
■ For very preterm (24-26 weeks),
● Conservative management if mother is stable .
● Delivery of fetus – life threatening
● Experienced neonatologists should be involved

33. Management cont’d
For Placenta Praevia
■ Conservative:
● Premature < 37 weeks; mother haemodynamically
stable, no active bleeding, fetus stable
● Advise bed rest, keep pad chart, vital signs
monitoring , Ultrasound, steroids, GSH, Daily
● CTG and biophysical profile, fetal movement count.
■ Plan for CS delivery
● >37 weeks. Crossmatch 4 units of blood.

34. Management cont’d
For Abruptio placenta, (obs emergency!!)
■ ABC, high flow O2, aggressive fluid resuscitation
■ Continuous vital signs monitoring and urine output
■ Monitor vaginal bleeding – strict pad chart
■ Continuous CTG for fetal heart rate
■ Crossmatch 4 units of blood
■ FFP – coagulopathy
■ Dexamethasone – preterm
■ ** ICU admission: Close monitoring and resuscitation!

35. Management cont’d
For Abruptio placenta, (obs emergency!!)
■ Decide Mode of delivery
● Vaginal delivery – when fetal death,
hemodynamically stable
● Caesarean section
● If maternal/ fetal health compromised
● Indicated when early DIC sets in
● Consent should be taken for hysterectomy in
case bleeding could not be controlled.
Err on the side of caution!!!

36. 1. Should the antenatal care of a woman be altered following
APH?
2. Is it blood-stained show or APH?
3. Any concerns for third stage of labour in women with
APH?
4. Who should be included in the management and
resuscitation team?
5. Any concerns with the APH newborn?
6. Any postnatal issues to be addressed with the woman
&family?
7.

37. NI HAYO TU!
ASANTE

38. APPENDIX

39. Appendix 1

40. Appendix 2

41. Appendix 3

42. Appendix 4

43. Appendix 5:
visual
estimation of
blood loss
Measure blood
loss accurately,
and remember it
is safer to
overestimate
than
underestimate