This document provides an overview of antepartum hemorrhage (APH), specifically focusing on placenta previa, abruption placentae, and vasa previa. It defines each condition, discusses causes, risk factors, clinical presentation, diagnosis, and management. Placenta previa is defined as implantation of the placenta in the lower uterine segment and is a leading cause of APH. Abruptio placentae is premature separation of a normally implanted placenta. Vasa previa occurs when fetal blood vessels cross the cervical opening. All three conditions can result in life-threatening bleeding and require careful monitoring and management to optimize maternal and fetal outcomes.

1. Antepartum heamorrhage
Dr Bilkisu Isa
25th -04-2022

2. Introduction/definition
• Death from hemorrhage still remains a leading
cause of maternal mortality.
• APH is defined as bleeding from the genital tract
in pregnancy from the age of viability(24 week’s
gestation –WHO but 28wks in Nigeria) and the
onset of labour.
• It affects 4% of all pregnancies. It is a medical
emergency.
• It is associated with increased risks of fetal and
maternal morbidity and mortality.

3. causes
• Placenta preavia
• Abruptio placenta
• Vasa preavia
• Excessive show
• Local causes ( bleeding from cervix, vagina
and vulva )
• Inderterminate APH

4. PLACENTA PREVIA
• Is defined as the implantation of placenta
partially or wholly in the lower uterine segment.
• About one-third cases of antepartum
hemorrhage belong to placenta previa.
-The incidence of placenta previa ranges from
0.5–1% amongst hospital deliveries.
-In 80% cases, it is found in multiparous women.

5. placentation

6. Cont.

7. Degrees of placenta previa with
findings on ultrasound examination

8. Cont.

9. ETIOLOGY
-The exact cause of implantation of the placenta
in the lower segment is not known.
-The following risk factors are identified:
• Advancing maternal age
• Multiparity
• Multifetal /multiple gestations
• Prior caesarean delivery

10. Cont.
• Smoking
• Prior placenta previa
• Uterine structural anomaly
• Assisted conception

11. TYPES OR DEGREES
• Type—I (Low-lying): the placental edge is in
the lower uterine segment but does not reach
the internal os
• Type—II (Marginal): The placenta reaches the
margin of the internal os but does not cover it.
Divided into anterior and posterior.

12. Cont.
• Type—III (Incomplete or partial central): The
placenta covers the internal os partially
(covers the internal os when closed but does
not entirely do so when fully dilated).
• Type—IV (Central or total): The placenta
completely covers the internal os even after it
is fully dilated.

13. CAUSE OF BLEEDING
• Bleeding results from small disruptions in the
placental attachment during normal development
and thinning of the lower uterine segment
• As the placental growth slows down in later
months and the lower segment progressively
dilates, the inelastic placenta is sheared off the
wall of the lower segment.
• This leads to opening up of uteroplacental vessels
and leads to an episode of bleeding.

14. CLINICAL FEATURES
• Bleeding: usually mild but it could be severe;
recurrent, painless and causeless.
• Soft and non-tender uterus
• Normal fetal heart rate (unless there is severe
bleeding or associated abruption).
• High presenting part.

15. Cont.
• Fetal malpresentation
(breech/transverse/oblique).
• General condition and anemia are
proportionate to the visible blood loss

16. Abdominal examination
• The size of the uterus is proportionate to the
period of gestation
• The uterus feels relaxed, soft and elastic
without any localized area of tenderness.
• Persistence of malpresentation. There is also
increased frequency of twin pregnancy.
• The head is floating in contrast to the period
of gestation. The head cannot be pushed
down into the pelvis.

17. Cont.
• Fetal heart sound is usually present.
• Vulval inspection: the blood is bright red as
the bleeding occurs from the separated utero-
placental sinuses close to the cervical opening
and escapes out immediately
• Vaginal examination is contraindicated

18. DIAGNOSIS
• Painless and recurrent vaginal bleeding in the
second half of pregnancy should be taken as
placenta previa unless proved otherwise.
• Ultrasonography is the initial procedure either
to confirm or to rule out the diagnosis
• Localization of placenta

19. Cont.
• Sonography –– Transabdominal ultrasound
(TAS) –– Transvaginal ultrasound (TVS) ––
Transperineal ultrasound –– Color Doppler
flow study
• Magnetic resonance imaging (MRI)
• Clinical –– By internal examination (double set
up examination) –– Direct visualization during
caesarean section –– Examination of the
placenta following vaginal delivery

20. MANAGEMENT
• PREVENTION:
• — Adequate antenatal care
• — Antenatal diagnosis at 20th week
• — Significance of “warning hemorrhage”
should not be ignored

21. TREATMENT ON ADMISSION
• IMMEDIATE ATTENTION: Overall assessment
of the case is quickly made as regards :
- Amount of the blood loss — by noting the
general condition, pallor, pulse rate and blood
pressure;
- Blood samples are taken for group, cross
matching and estimation of hemoglobin;

22. Cont.
• A large-bore IV cannula is sited and an
infusion of normal saline is started and
compatible cross matched blood transfusion
should be arranged;
• Gentle abdominal palpation to ascertain any
uterine tenderness and auscultation to note
the fetal heart rate
• Inspection of the vulva to note the presence
of any active bleeding

23. FORMULATION OF THE LINE OF
TREATMENT
The definitive treatment depends:
• upon the duration of pregnancy,
• fetal and maternal status
• and extent of the hemorrhage

24. Expectant management
• The aim is to continue pregnancy for fetal
maturity without compromising the maternal
health. Conduct of expectant treatment:
• Strict Bed rest;
• Investigations—like hemoglobin estimation,
blood grouping and urine for protein are done;
• Periodic inspection of the vulval pads and fetal
surveillance with USG at interval of 2–3 weeks;

25. Cont.
• Supplementary hematinics should be given
and the blood loss is replaced by adequate
cross matched blood transfusion, if the patient
is anemic;
• Steroid for lung maturation if gestational age
is less than 34 weeks

26. Cont.
• Use of tocolysis (magnesium sulfate) can be
done if vaginal bleeding is associated with
uterine contractions;
• Rh immunoglobin should be given to all Rh
negative (unsensitized) women.

27. Active Management
Delivery :
• 1. Bleeding occurs at or after 37 weeks of
pregnancy
• 2. Patient is in labor
• 3. Fetal distress
• 4. Torrential Bleeding
• 5. Congenital anomaly not compatible with
life

28. Cont.
• 6. Intrauterine fetal death
• Cesarean delivery is done for all women with
sonographic evidence of placenta previa
where placental edge is within 2 cm from the
internal os.
• It is especially indicated if it is posterior or
thick

29. Clinical classification
Minor : Deliver vaginally
• Type 1 (anterior/posterior)
• Type 2 anterior
Major: Caesarean section
• Type 2 posterior
• Type 3
• Type 4

30. Complications
• MATERNAL • During pregnancy: Antepartum
haemorrhage, Malpresentation, Preterm
labour.
• During labour: PROM, Cord prolapse,
Intrapartum hemorrhage, Increased incidence
of operative interference, Postpartum
hemorrhage, Retained placenta, Shock.
• Puerperium: Sepsis, Subinvolution, Embolism

31. FETAL
• Low birth weight,
• Asphyxia, Intrauterine fetal death,
• Birth injuries.

32. ABRUPTIO PLACENTAE

33. definition
• It is one form of antepartum hemorrhage
where the bleeding occurs due to premature
separation of normally situated placenta after
the age of viability.
• Occurs in 1-2% of all pregnancies
• Perinatal mortality rate associated with
placental abruption was 119 per 1000 births
compared with 8.2 per 1000 for all others.

34. Types of abruption placenta
• Revealed : Following separation of the
placenta, the blood comes out of the cervical
canal to be visible externally.
• Concealed : The blood collects behind the
separated placenta or collected in between
the membranes and decidua

35. Cont.
• Mixed : In this type, some part of the blood
collects inside (concealed) and a part is
expelled out (revealed).
• (A) Concealed;
• (B) Revealed;
• (C) Mixed type

36. Types of abruption-placenta

38. pathophysiology
--- Spasm of vessels in uteroplacental bed (decidual
spiral artery) → anoxic endothelial damage → rupture
of vessels
& hemorrhage in decidua basalis → decidua splits →
decidual hematoma (retroplacental) → separation,
compression, destruction of the adjacent placenta
adjacent placenta

39. CLINICAL CLASSIFICATION
• Grade—0: Clinical features may be absent.
The diagnosis is made after inspection of
placenta following delivery.
• Grade—1 (40%): (i) Vaginal bleeding is slight
(ii) Uterus: irritable, tenderness may be
minimal or absent (iii) Maternal BP and
fibrinogen levels unaffected (iv) FHS is good.

40. Cont.
• Grade—2 (45%): (i) Vaginal bleeding mild to
moderate (ii) Uterine tenderness is always
present (iii) Maternal pulse ↑, BP is
maintained (iv) Fibrinogen level may be
decreased (v) Shock is absent (vi) Fetal distress
or even fetal death occurs.

41. Cont.
• Grade—3 (15%): (i) Bleeding is moderate to
severe or may be concealed (ii) Uterine
tenderness is marked (iii) Shock is pronounced
(iv) Fetal death is the rule (v) Associated
coagulation defect or anuria may complicate

42. Risk factors
• The primary cause of placental abruption is
unknown, but there are several associated
conditions.
• Increased age and parity
• Preeclampsia, Chronic hypertension
• Preterm ruptured membranes

43. Cont.
• Multifetal gestation, Hydramnios
• Cigarette smoking, Folic acid deficiency
• Thrombophilias
• Cocaine use
• Prior abruption
• Uterine leiomyoma
• External trauma

44. Clinical Presentation
• Bleeding: revealed/concealed, so clinical
picture is important.
• Pain on the uterus and this increases in
severity.
• Signs of shock (hypovolaemia): fainting and
collapse.
• Woody hard tender uterus ( uterine tetany)
• Couvelaire uterus (Bluish uterus).

45. Cont.
• Difficult to palpate the fetal parts and to hear
the fetal heart.
• Normal fetal lie and presentation
• Ultrasonography: is done to confirm fetal
viability, assess fetal growth & normality,
measure liquor

46. MANAGEMENT
• Treatment for placental abruption varies
depending on gestational age and the status
of the mother and fetus.
• Admit patient, take History & examination
• Assess blood loss, Nearly always more than
revealed
• IV access, X match, DIC screen, Assess fetal
well-being
• Placental localization

47. Principle of management
• Early delivery (50% of abruption present in
labour).
• Adequate blood transfusion.
• Adequate analgesia.
• Detailed maternal and fetal monitoring.
• Coagulation profile (30% develop DIC).

48. Cont.
indication for caesarean section:
• Fetal distess, severe bleeding,
• alive baby and not in advanced labour.
• Perinatal mortality rate is 15-20%.
Vaginal delivery:
• very low gestation
• dead baby

49. Cont.
Conservative management
• small abruption,
• well mother and fetus,
• if the gestational age < 34, give steroids

50. COMPLICATIONS
MATERNAL
• Shock, Blood coagulation disorders,
• Oliguria and anuria, Postpartum
haemorrhage,
• Puerperal sepsis,
• Acute renal failure: acute tubular or cortical
necrosis.

51. Fetal complications
• Intrauterine growth restriction
• Anaemia
• Premature delivery
• Fetal distress and death

52. VASA PRAEVIA

53. introduction
• Rarely reported condition in which the fetal
vessels from the placenta cross the entrance
to the birth canal.
• Incidence varies occurrence in 1:3000
pregnancies.
• Associated with a high fetal mortality rate (50-
95%) which can be attributed to rapid fetal
exsanguination resulting from the vessels
tearing during labor

54. vasapreavia

55. Causes
• There are three causes typically noted for vasa
praevia:
• Bi-lobed placenta
• Velamentous insertion of the umbilical cord
• Succenturiate (Accessory) lobe

56. Risk factors
• Bilobed and succenturiate placentas
• Velamentous insertion of the cord
• Low-lying placenta
• Multiple gestation
• Pregnancies resulting from in vitro fertilization
• Palpable vessel on vaginal exam

57. Symptoms
• Usually asymptomatic
• Sudden onset of painless bleeding in second
or third trimester or at rupture of membranes
• No sign or symptom of placenta praevia or
abruption
• IUGR , Congenital malformation
• Abnormal fetal heart rate.

58. MANAGEMENT
• Detection of nucleated red blood cells
(Singer’s alkali denaturation test) or fetal
hemoglobin is diagnostic.
• Management depends on fetal gestational
age, severity, persistence or recurrence of
bleeding, and the presumed cause of bleeding

59. Cont.
• Pregnancy > 37 weeks and bleeding recurrent
— delivery is recommended.
• The mode of delivery depends on the state of
the fetus,
• and other associated factors (cervix).

60. Cont,
• Expectant management can be done in
selected cases for fetal maturity similar to
placenta previa.
• Fetal monitoring must be carefully done.
Intrapartum diagnosis of vasa previa, needs
expeditious delivery.
• Neonatal blood transfusion may be needed.

61. THANK YOU
THANK YOU