APH IS IMPORTANT TOPIC IN GYNAECOLOGY

1. ANTEPARTUM
HAEMORRHAGE
(APH)
FAHAD ZAKWAN

2. INTRODUCTION
Antepartum haemorrhage (APH),
also called prepartum hemorrhage,
is bleeding from the genital tract
during pregnancy from 28 weeks
gestational age to term

3. CLASSIFICATION

4. (A) Placental site bleeding : (62%)
•Placenta praevia (22%): Bleeding from separation of a
placenta wholly or partially implanted in the lower
uterine segment.
•Abruptio placentae (30%): Premature separation of a
normally implanted placenta.
•Marginal separation (10%): Bleeding from the edge of
a normally implanted placenta.

5. (B) Non-placental site bleeding :
(28%)
•Vasa praevia : Bleeding from ruptured
foetal vessels.
•Rupture uterus: 3-Bloody show.
•Cervical ectopy , polyp or cancer.
•Vaginal varicosity.

6. It should be considered as an obstetric
emergency (regardless of whether there
is pain or not) and medical attention
should be sought immediately, because
if it is left untreated it can lead to death
of the mother and/or featus.

7. NOTE
Avoid doing vaginal examination in
patients with antepartum haemorrhage
until placenta praevia has been excluded
either clinically or by USS

8. EPIDEMIOLOGY
•It Affects 3-5% of all pregnancies.
•It is 3 times more common in
multiparous than primiparous
women

9. DIFFERENTIAL DIAGNOSIS OF APH
•Bloody show - most common benign cause of
APH
•Uterine rupture
•Bleeding from the lower genital tract
•Cervical bleeding - cervicitis, cervical neoplasm,
cervical polyp
•Bleeding from the vagina itself - trauma, neoplasm

10. PLACENTA PRAEVIA
•Abnormally implanted placenta in the lower
segment of the uterus
•Although almost all the blood loss from placental site
is maternal, some fetal loss is possible particularly if
the substance of the placenta is traumatized.
•Bleeding from the vasa praevia is the only cause of
pure fetal haemorrhage.

11. •Bleeding is thought to occur in association with the
development of the lower uterine segment in the
third trimester.
•Placental attachment is disrupted as this area
gradually thins in preparation for the onset of
labor.
•When this occurs, bleeding occurs at the
implantation site as the uterus is unable to contract
adequately and stop the flow of blood from the
open vessels.

12. RISK FACTORS
•Previous placenta praevia
•Multiple pregnancies
•Multiparity
•Previous c/s scar
•Advanced age
•History of threatened abortion in index
pregnancy

13. •Deficient endometrium due to pre-existent
•Uterine scar (previous CS)
•Endometritis
•Manual removal of placenta
•Curettage (especially for miscarriage or
termination of pregnancy)
•Submucous fibroid

14. Typically:
•First episode of bleeding occurs:
•After 36th week: in 60% of cases
•32-36th week: in 30% of cases
•Before 32nd week: in 10% of cases

15. CLINICAL PRESENTATION
Painless vaginal bleeding, usually bright red, but variable amount.
Soft non tender uterus.
Fetal malpresentation
unusually high and mobile presenting part
Fetal kicks are usually present.
Normal foetal heart tones – foetal distress if blood loss is severe

16. ABDOMINAL EXAMINATION
Uterus is soft and non-tender
The presenting part is usually high
Fetal malpresentation may be found.
Fetal heart heard
No contraction.

17. Vaginal examination should be avoided, if
done should, be in theatre under GA with
preparation for emergency c/s in case
profuse bleeding occurs. Explore the fornices
first then the head. Passing the finger
through the cx should be avoided.

18. GRADING PLACENTA PRAEVIA
Placenta praevia is
classified according to the
placement of
the placenta:

19. GRADE 1 – low lying
•Placenta
encroaches
lower segment
but does not
reach the
cervical os.

20. GRADE 2 - marginal
• Placent
a
reaches
cervical os
but does not
cover it

21. GRADE 3 - partial
•Placenta covers
part of the cervical
os.
•The placenta
covers the internal
os when it is
closed or partially
dilated but not
when it is fully
dilated

22. GRADE 4 - total
•Placenta completely
covers the os, even when
the cervix is dilated.
•The placenta covers the
internal os completely
whether the cervix is
partially or fully dilated.

23. LOCALIZATION OF THE PLACENTA
Ultrasound
i. Transabdominal
ii. Transvaginal.
iii. Transperineal done if instrumentation of
the vagina is likely to cause problems.

24. The transvaginal US is the most
accurate route to locate the
placenta but the probe should
not touch the cx or the placental
placental site.

25. Management
•Depends on
-Gestation age
-Severity of bleeding
-Viability of fetus.

26. IMMEDIATE MEASURES
⯈Call for help!!! Involve the senior staff on call
⯈put in 2 large bore (14 gauge) IV cannulas.
⯈Keep patient flat and worm.
⯈Send blood for group, cross matching diagnostic tests and ask
for at least 2 units of blood
⯈Infuse rapidly 2 litres of normal saline (crystalloids) to re-
expand the vascular bed.
⯈Give oxygen by mask 10 – 15L/min

27. ⯈Insert Foley catheter to empty the bladder
and monitor urine output.
⯈Monitor the following:
pulse
BP
RR
urine output (continuous cathetarization)
type and amount of fluid the patient received

28. The management includes
•Restore blood volume by giving IV fluids – normal
saline or ringers lactate
•Assess blood loss:
• If bleeding is heavy or continuous, arrange or do
caesarean section delivery irrespective of foetal maturity
within 6 – 8 hrs.
• If bleeding is light and stopped and the foetus alive and
premature consider expectant management until 37/38
wks.

29. •Keep the woman in hospital for bed rest
until delivery
•Correct anaemia
•Give iron/ folic acid, vit. B12
•Blood transfusion
•Packed cells
•Whole blood

30. NOTE
• Decide management after weighing benefits and risks
to the woman and fetus.
• PRIORITY IS SAVING THE MOTHER!!
•ALL GRADES OF PLACENTA PRAEVIA ARE DELIVERED
BY C/S EXCEPT GRADE IA WHERE THE PLACENTA JUST
DIPS IN THE LOWER SEGMENT AND ITS ANTERIORLY
LOCATED

31. Bloods Tests
• Complete blood picture and D-Dimer
• Group and cross match 4 units
• Consider need for Anti-D if Rh negative.
Ultrasound
• Confirm diagnosis.
Corticosteroids
• Consider corticosteroid prophylaxis if < 34 weeks

32. ABRUPTIO PLACENTA
• Refers to bleeding due to the premature
separation of a normally sited placenta from its
attachment to the uterus.
May be described as
•Concealed ( if no external bleeding is seen)
•Revealed (if there is obvious external bleeding)

33. RISK FACTORS
• Hypertension
• Maternal thrombophilias
• Increasing maternal age, parity
• Cigarette smoking
• Abdominal trauma e.g. motor vehicle accident
• Substance abuse (crack, cocaine, amphetamines)
• Sudden decrease in uterine volume (e.g. SROM in the presence of
polyhydramnios, or after delivery of a first twin)
• External cephalic version (ECV) or instrumental delivery.

34. CLASSIFICATION
•Classification of placental abruption is based on:
•extent of separation (ie, partial vs complete) and
•location of separation (ie, marginal vs central).
Clinical characteristics include the following:

35. Class 0 is asymptomatic.
Diagnosis is made
retrospectively by finding an
organized blood clot or a
depressed area on a delivered
placenta.

36. Class 1 is mild
•represents approximately 48% of all cases.
•Characteristics include the following:
• No vaginal bleeding to mild vaginal bleeding
• Slightly tender uterus
• Normal maternal BP and heart rate
• No coagulopathy
• No fetal distress

37. Class 2 is moderate
• represents approximately 27% of all cases.
• Characteristics include the following:
• No vaginal bleeding to moderate vaginal bleeding
• Moderate-to-severe uterine tenderness with possible
tetanic contractions
• Maternal tachycardia with orthostatic changes in BP and
heart rate
• Fetal distress
• Hypofibrinogenaemia (i.e. 50-250 mg/dL)

38. Class 3 is severe
•represents approximately 24% of all cases.
Characteristics include the following:
•No vaginal bleeding to heavy vaginal bleeding
•Very painful tetanic uterus
•Maternal shock
•Hypofibrinogenemia (ie, <150 mg/dL)
•Coagulopathy
•Fetal death

39. Clinical features
• Vaginal bleeding is usually associated with abdominal pain,
uterine contractions, tenderness and / or irritability
• May be faint and / or collapse
• Signs of haemorrhagic shock
• Consider concealed abruption if abdominal or back pain is
present
• Fetal moments are usually absent unless it is an early
abruption or partial

40. •Contractions/uterine tenderness
•Uterine contractions are a common
finding with placental abruption.
•Contractions progress as the abruption
expands, and uterine hypertonus may be
noted.
•Contractions are painful and palpable.

41. Principles of early management
• Intravenous (IV) access (2 large bore iv lines must be put in
place)
• Indwelling catheter
• Start intensive care list (fluid balance, blood pressure, pulse
rate etc)
• The cornerstone of appropriate management is adequate
resuscitation with intravenous fluids (plasma volume
expanders, blood)
• Consider need for early delivery dependent on maternal and
fetal condition

42. • Achieving adequate perfusion is essential to allow the
reticulo-endothelial system (Kupfer cells, spleen) to clear
fibrinogen / fibrin degradation products (FDPs). Acceptable
perfusion is signalled by urine output of > 30 mL per hour
• Cross match blood
• Urgent complete blood picture, D-dimer, thrombin time,
fibrinogen levels, creatinine
• Bed side clotting time (NORMAL – 7mins)
• Consider giving FFP if there is prolonged bed side clotting time
or abnormal bleeding indices.

43. Later on
•Monitor in-put and output
•Monitor maternal vital signs.
•Continuous CTG to assess for signs of fetal
compromise if the fetus was alive at the time of
diagnosis.
•Anti D prophylaxis for Rh negative women

44. Active management:
• Consultation with anaesthetist as indicated
• Consider central venous pressure monitoring
• Ensure adequate blood, blood products (6-8 packed cells to start with in
case of total abruption), and fresh frozen plasma (FFP) guided by fibrinogen
levels and mostly also 1 FFP unit required for each 4-6 units of blood
transfused. Specific replacement of coagulation factors is very rarely
required - only in consultation with laboratory / haematologist
• If fetal death is confirmed
• Aim for vaginal delivery with ARM and Syntocinon® if condition allow.

45. Delivery
• Consider vaginal delivery with continuous electronic fetal monitoring if
fetus is alive and rapid recourse to caesarean section depending on
fetal/maternal condition.
• Caesarean section if acute fetal compromise occurs (if it was alive at
diagnosis) or if other obstetric indications dictate so.
Following delivery:
• Recognize increased risk of PPH
After delivery do placental examination for:
• Completeness
• Any area of abruption
• Associated pathological features e.g. abnormal degree of calcification
• Send for histopathology