Antepartum Hemorrhage During Pregnancy

1. Antepartum Haemorrage
(APH)
Dr. Massam,
MD

2. Learning Objectives
 Define the terms: Antepartum
haemorrhage, vasa praevia, placenta
praevia, abruptio placentae
 Describe causes of antepartum
haemorrhage
 Describe clinical features of abruptio
placentae
 Describe complications of abruptio
placentae
 Describe management of abruptio
placentae

3. Definition of the terms
Antepartum Haemorrhage: Vaginal
bleeding that occurs after 28 weeks
of pregnancy up to the end of second
stage of labour.
Abruptio Placentae: Early separation
of the normally implanted placenta
after 28 weeks and before the end of
the second stage of labour.

4. Placenta Praevia: Implantation of
the placenta to the lower segment of
the uterus partially or completely
covering the cervix.
Vasa Praevia: Aberrant feto-placenta
vessels running in the placental
membranes.

5. • In Vasa praevia the foetal vessels
cross the cervix and they may
rupture by spontaneous rupture of
membranes or be damaged by
artificial rupture of membranes
leading to life threatening
haemorrhage (foetal blood).

6. Look at the normal placenta, no
retroplacenta blood/hematoma

7. Abruptio placenta – look at the blood
collection/hematoma behind the placenta

8. Placenta praevia – look at the
abnormally implanted placenta, at the
lower uterus blocking the cervical
opening

9. Vasa Previa – aberrant feto-placental
blood vessels running in placental
membranes

10. Causes of Antepartum Haemorrhage
 Antepartum haemorrhage affects 2-5%
of pregnancies.
 Causes include:
 Abruptio placentae
 Placenta praevia
 Vasa praevia
 Other unclassified causes, local
causes

11. During the 3rd trimester, these
conditions occur in the following
proportions:
 Abruptio placentae (22%)
 Placenta praevia (31%)
 Vasa praevia (rare)
 Other unclassified causes, local
causes (47%)

12. Abruptio Placentae/Placenta abruption

13. • Recall the definition of Abruptio
placenta

14. Abruptio Placentae: Risk factors
 Hypertensive disease in pregnancy
 Multiple pregnancy
 Direct trauma to abdomen
 Premature rupture of membranes

15. Risk factors con’t…
 Polyhydramnios with rupture of
membranes, caused by sudden decrease
of intrauterine pressure
 Uterine leiomyoma/fibroid,
especially if located behind the
placental implantation site
 Previous history of abruptio
placenta

16. Features of Abruptio Placenta
 Vaginal bleeding
- Sometimes the amount of blood
loss may not correspond with the
clinical presentation (concealed
haemorrhage) (remember another type
of abruptio placenta – revealed
hemorrhage type)
 Difficult to palpate foetal parts

17. Features con’t…
 Abdominal Pain, initially localized
then becomes generalized, tender and
tense abdomen
 Maternal distress
 Foetal distress or intrauterine
foetal death
 Hypotension

18. Complications of Abruptio Placentae
Shock
Acute renal failure
- This may result from seriously impaired
renal perfusion secondary to reduced cardiac
output and intrarenal vasospasms as in pre-
eclampsia

19.  Disseminated intravascular
coagulopathy
- Consumptive coagulopathy
secondary to hypofibrinogenemia along
with elevated levels of fibrin
degradation products
 Postpartum haemorrhage (PPH)
 Couvelaire uterus
- This is caused by widespread
extravasation of blood into the
uterine musculature and beneath the
uterine serosa.

20.  Sheehan syndrome
- Acute pituitary necrosis to
massive haemorrhage

21. Treatment of Abruptio Placentae
Management depends on:
 Degree of severity
 Viability of the foetus/foetal
distress
Treatment modalities
 Induction/augmentation of labour
 Caesarean section (C – section)

22. • Note: This condition is best managed
at the hospital by a doctor, but at a
dispensary or health centre level the
following general measures should be
taken:
1. Resuscitation of the mother
- Infuse her with IV fluids
preferably ringers lactate or normal
saline (two large bore IV lines,
oxygen)

23. 2. Take vital signs
- Blood pressure, pulse rate and
respiratory rate
3. Catheterization
- Monitor urine output
4. Obtain blood for Hb level, grouping
and cross matching
5. Urgently refer the patient to the
hospital under escort of a nurse
and potential blood donors

24. Management at Hospital
1. Continue with above general
measures
2. Deliver the foetus
- Perform Artificial Rupture of
Membranes (ARM)
NB – ARM done only if placenta
praevia has been ruled out
- Induce/augment labour by
Oxytocin infusion if labour has not
started or speed-up labour

25. Management at hospital con’t…
3. Do bedside clotting time
- If does not clot within seven
minutes suggests coagulopathy.
- Then should be monitored every
two hours
4. Ensure availability of fresh blood
- The patient might need blood
transfusion

26. Management at hospital con’t…
Caesarean Section can be done if
vaginal delivery is contraindicated
Indications for Caesarean Section
 Salvageable baby
 Ongoing haemorrhage
 Poor progress as in case of
transverse lie, inadequate pelvis

27. Management at hospital cont…
Post delivery -observe for PPH

28. Placenta Praevia

29. • Recall the definition of placenta
praevia

30. Classification of Placenta
Praevia
i. Total/complete Placenta Praevia:
Covers the cervical os.
ii.Partial Placenta Praevia: Covers
part of the os.
iii.Marginal Placenta Praevia: Lies
close to, but does not cover, the
os.

31. Picture: Types of placenta
praevia

32. Risk Factors for Placenta
Praevia
i. Multiparity/Multiple pregnancy
ii.Advanced maternal age
iii.Prior C/S or other uterine
surgery
iv.Prior placenta praevia

33. Features of Placenta Praevia
i. Average Gestation Age (GA) 32.5 weeks
ii. Up to 10% may have simultaneous abruption
iii.First episode usually moderate
iv. Painless vaginal bleeding in 2nd/3rd
trimester
v. Bright red blood
vi. Placenta praevia is confirmed by
ultrasound
NB – Do not perform digital vaginal
examination in patient with Placenta
praevia as it may provoke bleeding

34. Complications of Placenta
Praevia
• Similar to those mentioned above for
abruptio placenta.
• Can you recall atleast five (5)
complications?

35. Treatment of Placenta Praevia
• Management depends on degree of
severity, gestation age (viability)
• Refer the patient to the hospital as
soon as possible when you make the
diagnosis of placenta praevia.
• General measures are similar to
those mentioned above for abruptio
placenta

36. Treatment of Placenta praevia
cont..
• Initial resuscitation
• Identify potential blood donors
• Refer the patient to the hospital
with facilities for blood
transfusion, caesarean delivery

37. Conservative Management
i. Patients with minimal PV bleeding
and far from term
ii.If possible, delay delivery until
foetus is mature
iii.Give steroids (eg. dexamethasone
to accelerate fetal lung maturity)

38. Indications for Immediate
Delivery
I. Active labour
II.≥ 37 weeks gestational age
III.Excessive bleeding
IV.Development of another obstetric
complication mandating delivery

39. Mode of Delivery
Often caesarean section is preffered
- Note that there is a higher
rate of accreta, increta, and
percreta with placenta praevia
Vaginal delivery may be indicated in
patients with the low lying placenta
and presenting with minimal PV
bleeding

40. What do you understand by the
following
• Placenta accreta
• Placenta increta
• Placenta percreta

42. Summary
• Antepartum hemorrhage is one of the
obstetric emergencies needing timely
and proper diagnosis and management.
• The most common causes of antepartum
hmorrhage are placenta praevia and
abruptio placenta.
• Clinician must be able to diagnose
appropriately and provide timely
management.

43. References
• Facilitator guide Obstetrics and
Gynaecology I - Ministry of health
and social welfare 2010
• Textbook of Obstetrics by Dutta