Diagnosis

1. ANTEPARTUM
HAEMORRHAGE
BY
COL O NDOLA

2. 2
Definition of APH
 This is defined as bleeding from the
genital tract between the 28th week of
pregnancy and the onset of labour.

3. 3
Causes of APH
 Placenta praevia
 Placental abruption
 Local causes
 Undetermined origin
 Vasa praevia

4. 4
Placenta Praevia
 A placenta that is implanted entirely or
in part, in the lower uterine segment.

5. 5
Grades of Placenta
Praevia
 Type I- placenta encroaches on the
lower uterine segment but does not
reach the internal cervical os.
 Type II- placenta reaches the edge of
the cervix, but does not cover it.
 Type III-placenta covers the cervix but
not at full cervical dilatation.

6. 6
Grades of Placenta
Praevia
 Type IV- placenta is symmetrically
implanted in the lower uterine
segment and covers internal os at full
dilatation
 Types I & II are minor praevias - as
the lower segment develops, may
become normally situated.
 Types III & IV are major praevias

7. 7
Placenta Praevia
 Causes are frequently unclear and the
low site of implantation may merely
represent an accident of nature
 Associations include: older multiparous
women, multiple pregnancy and
previous uterine damage such as C/S

8. 8
Clinical presentation of
Placenta Praevia
 Two classical presentation are of APH
or as fetal malpresentation in late
pregnancy. Can be asymptomatic and
routinely picked up on U/S.
 Recurrent painless bleeding is the
typical history
 Patient is usually stable unless there
has been a major bleed

9. 9
Clinical presentation of
Placenta Praevia
 The uterus is soft and non tender
 High head on presentation or
malpresentation- breech, transverse or
oblique lie
 FHHR

10. 10
Diagnosis of Placenta
Praevia
 History
 Clinical examination
 U/S
 EIT-examination in theatre -full
preparation for C/S

11. 11
Management of Placenta
Praevia
 Depends on stage of pregnancy and
extent of haemorrhage
 Minor praevia with minimal or no
bleeding -conservative management.
Aim to deliver at 38 weeks gestation.
Mode of delivery will depend on EIT
findings. If minor, then vaginal
delivery can be attempted unless it’s a
posterior placenta praevia.

12. 12
Management of Placenta
Praevia
 Major placenta praevia, if
asymptomatic or minimal bleeding -
then aim to deliver at 38 weeks
gestation. EIT? Delivery is by C/S.
 Any type of praevia associated with
severe haemorrhage should be
delivered by the quickest mode - C/S-
regardless of gestation age.

13. 13
Placental Abruption
 The premature separation of a
normally situated placenta
 The basic cause is unknown
 Is a self extending process with the
accumulating blood clot causing more
separation and thus more
haemorrhage, until the edge of the
placenta is reached

14. 14
Placenta Abruption cont’d
 Blood then escapes through the
potential space between the chorion
and decidua until it reaches the cervix
 Blood can also reach the amniotic
cavity (by disrupting the placenta,
producing blood- stained liquor) and
the myometrium (causing a couvelaire
uterus)

15. 15
Complications of
Abruption
 Fetal hypoxia or death - because of
the extent of placental separation
 Haemorrhagic shock
 Renal damage - acute tubular or
cortical necrosis
 DIC
 PPH

16. 16
Associations of Abruption
 Hypertension-cause or consequence?
 Sick placenta-excessive fetomaternal
transfer of AFP in mid pregnancy &
diminished ‘adhesiveness”
 Previous history of abruption-risk of
recurrence ten fold
 Trauma-RTA, assault, ECV,
cordocentesis

17. 17
Associations of Abruption
cont’d
 Fibriods - where site of placental
attachment covers a fibroid, increased
risk of abruption
 PROM esp with sudden decompression
as with polyhydramnios
 Multiple pregnancy - cause is unclear

18. 18
Clinical presentation of
Abruption
 Bleeding may be concealed or
revealed
 Pain over the uterus with no
associated periodicity
 Uterus is extremely hard and tender &
it does not relax. The HOF is large for
dates in concealed haemorrhage

19. 19
Clinical presentation of
Abruption cont’d
 Fetal parts are difficult to palpate and
the FH may be inaudible
 Faintness & collapse may occur, as
may signs of shock

20. 20
Diagnosis of Abruption
 History
 Examination & demonstration after
delivery, of a retroplacental clot
indenting the placental surface
 U/S - has a minimal role in placental
abruption

21. 21
Management of Abruption
cont’d
Principles of management are:
« early delivery
« adequate blood transfusion
« adequate analgesia
« detailed monitoring of maternal & fetal
condition

22. 22
Management of Abruption
cont’d
 Early delivery is vital & if the baby is
alive and the gestation age favors
extra uterine survival, delivery should
be by C/S even if the fetus is not
hypoxic.
 If the fetus is dead, vaginal delivery is
preferred unless there is severe
haemorrhage and mother’s life is at
stake.

23. 23
Management of Abruption
cont’d
 X-match at least 4 units of whole
blood, FFP
 Clotting profile - bedside clotting
- fibrinogen levels
- platelets
 Active management of third stage

24. ACTIVE MANAGEMENT OF THE
THIRD STAGE OF LABOUR
This has three components:
1. Administration of Oxytocin – to
enhance uterine contractions
2. Clamping the cord early – usually
before, alongside, or immediately
after giving the Oxytocin
24

25. 3. Controlled cord traction is applied
with counter-pressureon the uterus in
order to deliver the placenta
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