2. Intro
• Antepartum haemorrhage (APH) is defined as any bleeding from the
genital tract from 20 weeks of pregnancy up to delivery of the baby.
CAUSES
• Placental - abruptio placentae, placenta praevia, vasa praevia.
• Non-placental - vaginal and cervical lesions including cancer, cervical
infections, trauma; and uterine rupture
• Unknown - APH of unknown origin.
• NB: do not ignore bleeding if postcoital, it still can signify pathology
3. EMERGENCY MANAGEMENT
At a clinic or community health centre
• Start an intravenous infusion of Ringer-Lactate solution.
• If the mother is in shock, resuscitate with one to two litres of Ringer-
Lactate.
• Do not do a digital vaginal examination unless placenta praevia has
been excluded by a previous ultrasound scan.
• Transfer urgently from a clinic or community health centre to a
specialist facility where 24 hour Caesarean delivery (CD) services and
adequate blood supply is available.
• Use NASG (Non-Pneumatic Anti-Shock Garment) if patient is in shock
for transfer to the specialist unit (Do not apply the abdominal panel).
4. EMERGENCY MANAGEMENT
At the hospital
• Re-evaluate the patient, If bleeding is mild
• Take blood for Full Blood Count and cross match and perform point of care Haemoglobin.
• Do an ultrasound scan to help with the diagnosis.
• If placenta praevia is found, manage accordingly.
• If no placenta praevia, exclude an abruptio placentae by doing a full clinical examination
and CTG.
• Frequent uterine contractions (>5/10 minutes), an irritable uterus and an audible but
abnormal fetal heart suggest minor abruptio placentae
• A tender hard uterus and absent fetal heart suggest a major abruptio placenta (NB:
distinguish CTG tracing from maternal pulse, and if in doubt confirm fetal viability with
ultrasound scan)
• Do a speculum examination to exclude a local cause.
• Further management depends on the cause
5.
6. MANAGEMENT OF PLACENTA PRAEVIA
Continue resuscitation.
• Check Hb level and cross match.
• If less than 10 g/dL, commence blood transfusion and transfer urgently to a specialist hospital.
• Patient must be accompanied by a doctor or life support personnel if transfusion in progress.
At the Specialist hospital
• Distinguish Major praevia from Minor, by USS.
• Obtain consent for caesarean delivery and hysterectomy.
• Blood must be available for surgery.
• If the bleeding is significant, perform a caesarean delivery supervised or done by an experienced
doctor or Specialist, and with an Anaesthetist who is skilled in general anaesthesia as well as
regional.
• Note that PPH may occur.
• If less than 36 weeks, and bleeding subsides, manage conservatively.
• Keep in hospital, administer steroids if less than 34 weeks, and observe vital signs.
• Deliver electively after 36 weeks by CD.
7. MANAGEMENT OF ABRUPTIO PLACENTAE
• Abruptio placentae is strongly associated with pre-eclampsia: the blood pressure
may be low due to the presence of clinical shock and there will be tachycardia,
• But hypertension may manifest as soon as the patient is resuscitated.
• Proteinuria may be an indicator of underlying pre-eclampsia with abruptio
placentae.
If the foetus is alive and viable:
• If the foetal heart rate >100/minute as recorded on CTG, resuscitate the patient
and perform emergency caesarean delivery, unless delivery is imminent (cervix
≥9 cm dilated).
• NB: Be sure that the patient is haemodynamically stable, and that the fetus really
is alive on USS before surgery.
• For a non-viable baby, rupture the membranes and plan vaginal delivery.
Occasionally, augmentation of labour with oxytocin may be necessary.
• Monitor blood loss carefully.
8. MANAGEMENT OF ABRUPTIO PLACENTAE
If the foetus is dead
• A dead foetus with abruptio placentae signifies massive blood loss and early onset of coagulopathy.
• Resuscitate with iv fluids and blood and fresh frozen or dried plasma and transfer urgently.
On arrival at specialist hospital, manage as follows:
• Aim to deliver vaginally within eight hours. Rupture membranes as soon as possible, even if the cervix is
unfavourable
• Take blood for cross-match, FBC, INR, PTT, and urea and creatinine. Can also do whole blood clotting time in
glass tube; it should be less than 7 minutes.
• Blood transfusion (two to four units) is usually necessary, with two units of fresh frozen plasma or Fresh
Dried Plasma (FDP)
• Give oxygen via face mask and keep patient warm.
• Consider a central venous pressure (CVP) line through a cubital vein, if feasible
• Insert an indwelling urinary catheter and monitor hourly urine output.
• Give fluids to maintain the systolic BP ≥100 mmHg, or a CVP of six cm H20.
• If there is no progress of labour within one to two hours after membrane rupture, augment with oxytocin if
not contraindicated.
• Give analgesia using morphine 5 mg IM four hourly if necessary
9. MANAGEMENT OF ABRUPTIO PLACENTAE
Caesarean delivery is indicated if:
• There is lack of progress despite oxytocin augmentation, life-
threatening haemorrhage, ongoing DIC, or severe oliguria
• The patient is not near delivery after eight hours
• There is doubt about the diagnosis and there could be uterine
rupture (especially if previous CS)
• This is a high-risk procedure and must preferably be done in a
specialist institution.
10. MANAGEMENT OF ABRUPTIO PLACENTAE
• Following delivery, there is a significant risk of complications (Massive PPH,
Coagulopathy and Acute Kidney Injury)
• Active management of the third stage is mandatory.
• In addition, add oxytocin 20 U in one L Ringer-Lactate immediately after
delivery and observe for bleeding.
• Do not remove the IV line for at least 12 hours.
• Monitor vital signs hourly, fluid balance and observe for postpartum
haemorrhage for at least twelve hours.
• Manage associated pre-eclampsia
• Check Hb, platelet count, urea and creatinine on the day after delivery.
• Provide psychological support and advice about contraception
11. MANAGEMENT OF ABRUPTIO PLACENTAE
District hospital, transfer to a Specialist Facility if:
• The woman also has severe pre-eclampsia or eclampsia.
• There is evidence of coagulopathy; spontaneous bleeding from the
mouth or puncture sites, or prolonged clotting time
• Urine output is less than 30 mL/hour for more than four hours.
• There is pulmonary oedema.
• There is evidence of acute renal failure - increasing urea and
creatinine levels.
• There is severe thrombocytopenia (<50,000/mm3).
12. ANTEPARTUM HAEMORRHAGE OF
UNKNOWN ORIGIN
This is a common problem in obstetrics, where APH occurs with no evidence
of abruptio placentae, placenta praevia, or cervical or vaginal (local) causes.
• Admit the mother to hospital to exclude an abruptio that may not initially
be clinically apparent
• Do six hourly CTG until the bleeding stops; then daily CTG
• Give steroids if less than 34 weeks
• Discharge from hospital 24-48 hours after bleeding has stopped
• Assess the cervix before discharge to excluded imminent preterm labour
• Continue antenatal care visits at hospital, with attention to foetal growth
and foetal movements; consider delivery at 38 weeks
Note: All patients presenting with APH must be regarded as obstetric emergencies until properly assessed. Transfer urgently to hospital.
If bleeding is severe
Take blood for FBC and cross match and resuscitate with IV fluids and blood. Make a clinical diagnosis of whether abruptio placentae or placenta praevia and manage according to the cause.
If patient is Rhesus negative and expectant management followed, give anti-D immune globulin to protect against RhD alloimmunization
A CTG occasionally picks up a maternal heart rate when the fetus has already died
