Antepartum hemorrhage

1. ANTEPARTUM
HEMORRHAGE
DR. HAFSA RAZZAQ

2. Table of contents
01
03
02
DEFINITION OF APH CAUSES & RISK FACTORS
COMPLICATIONS OF APH MANAGEMENT OF APH
04

3. DEFINITION:
● Antepartum hemorrhage is described as bleeding from genital tract in pregnancy before onset of labour
at gestation form 20 to 24 weeks
● Between 20 to 24 weeks management will be broadly same except delivery will be expedited.
● It affects approximately 4% of all pregnancies.

4. Classification of hemorrhage
Minor
Hemorrhage
Major
hemorrhage
Blood loss less than 50ml
that has been settled
50-1000 ml blood loss with
no signs of clinical shock
Blood loss of greater than
1000ml and/or with signs
of clinical shock
Massive
hemorrhage
50-1000 ml blood loss with
no signs of clinical shock
Spotting

5. AETIOLOGY
1
3
2
4
Placenta praevia
Placental
abruption
Local causes
Other causes
Cervical ectropion/ trauma
Local infection of cervix/vagina
Genital tract tumors
varicosities
Placenta partially or wholly situated in
the lower uterine segment
Marginal placental bleeding & Show
Vasa praevia
(occurs when fetal vessels cross or run
with the membranes between the
amnion & chorion close to cervical oss
and are thus at risk of rupture during
labour either as a result of shearing at
membranes rupture or from
compression from fetal head)
Bleeding following premature seperation
of normally sited placenta

6. Can APH be predicted?
APH has a heterogeneous pathophysiology and cannot reliably be predicted

7. Grades of placenta praevia:
MINOR PLACENTA PRAEVIA MAJOR PLACENTA PRAEVIA
GRADE I GRADE II GRADE III GRADE IV
The placental edge is
in the lower segment
but does not reach the
internal os
The placental edge
reaches but does not
cover the internal os
The placenta covers
the os and is
asymetrically situated
The placenta covers
the internal os and is
centrally situated

9. OCCURRENCE
RATE
50%

10. AETIOLOGY OF PLACENTA PRAEVIA
1
3
2
4
Uterine surgery Maternal age & parity
Assisted conception
Smoking
Risk is significantly higher in assisted
conception pregnancies with an odd
ratio of 5.9
• Caeserian section
• Two or more previous abortions
• Curettage
• Submucous myomectomy
Women older than 40yrs have 9
fold increase risk than 20yrs of
age

11. ASSOSIATIONS
01
03
02
FETAL
ABNORMALITY IUGR
CO EXISTANT
ABRUPTION
10 % of women with bleeding
placenta praevia will have
coexistant abruption
Rate of fetal abnormality is
approximately doubled in
placenta praevia
It is common in women with
multiple bleeds. The overall
rate is 15%

12. DIAGNOSIS OF PLACENTA PRAEVIA
● Placenta praevia usually presents with painless bleeding.
● It is difficult to diagnose a placenta praevia until the lower segment begins to
form at about 28 weeks, however low lying placenta can cause bleeding from
second trimester.
● 5% of women have ultrasound evidence of low lying placenta at 16-18 weeks
but only 0.5% have placenta praevia at delivery.
● TVS: should be performed at routine anomaly scan at 18-21 weeks.
● MRI: expensive & not superior to TVS

13. The following factors in second trimester ultrasound are assosiated
with persistence of placenta praevia in third trimester:
● Placenta covers internal os with an overlap of more than 1.5cm
● The leading edge of placenta is thick
● The placenta is posterior
● There is a uterine scar

14. MORBIDLY ADHERENT PLACENTA
Major Risk factors
1. Uterine scarring 2. Increasing C-section
rates
3. Prior mannual
removal
4. Submucous
myomectomy
5. Uterine
curettage 6. Short caesarean
section to conception
interval

15. Three degrees of adherence
The placenta attaches itself
too deeply and too firmly into
the uterus.
The placenta attaches itself even
more deeply into the muscle wall
of the uterus.
The placenta attaches itself &
grows through the uterus,
sometimes extending to
nearby organs, such as the
bladder.
Placenta accreta Placenta increta Placenta percreta

16. Grades of placental abruption:
GRADE 0 GRADE I GRADE II GRADE III
An asymptomatic clot
seen after placental
delivery
A symptomatic
retroplacental clot
seen after delivery.
Symptoms: vaginal
bleeding & uterine
tenderness
Retroplacental clot
seen after delivery.
Revealed bleeding
may or may not be
present but placental
seperation is
significant enough to
produce evidence of
fetal compromise.
Revealed bleeding
may or may not be
seen but there are
significant maternal
signs (uterine tetany,
hypovolemia,
abdominal pain) with
late stage fetal
compromise or fetal
death.
30% of these women
will develop DIC

18. OCCURRENCE
Majority of these are small
and only visible on
placental examination after
delivery
5%

19. AETIOLOGY & ASSOSIATION:
• The aetiology of placental abruption is unclear but there are number of recognized assosiations

20. RISK FACTORS
4. Rapid uterine
decompression
5.
Chorioamnionitis/
PROM
10. Underlying
thrombophilia
11. Women with low
BMI
1. Previous abruption &
family hx of abruption
2. Fetal
abnormality
3. Smoking/drug (cocaine &
amphetamines)
6. Abnormal placentation
(circumvellate placenta)
12. Women who are heterozygous
for factor V leiden or prothrombin
gene
7.Pre eclampsia 8.1st trimester
bleeding
9.Multiparity & increased age

21. DIAGNOSIS OF PLACENTAL ABRUPTION
● The diagnosis of placental abruption is primarily a clinical one.
● There may or may not be revealed bleeding.
● The women may have pain preceeding or during the bleed and irritable uterus or
alternatively hard and tender uterus during large abruption.
● In grades II and III clinical picture is usually clear but grades 0 and I may be much
more difficult to diagnose.

22. ● Ultrasonography is not a good method of diagnosing placental abruption. Small
areas are difficult to visualize. In acute phase and in large abruptions images can
be isoechoic and look like placenta.
● Ultrasound should be used to:
● Confirm fetal viability
● Assess fetal growth
● Measure liqour volume
● Perform umbilical artery doppler velocities
● Confirm fetal normality as far as possible
● Exclude placenta praevia

23. Can APH be prevented?
Women should be advised, encouraged and helped to change modifiable risk factors
(such as smoking and drug misuse)

24. Complications of APH
• Fetal hypoxia
• Small for gestational age and
fetal growth restriction
• Prematurity
• Fetal death
• Anemia
• Infection
• Maternal shock
• Renal tubular necrosis
• Consumptive coagulopathy
• Postpartum hemorrhage
• Prolonged hospital stay
• Psychological sequelae
• Complications of blood transfusion
Maternal complications Fetal complications

25. Is APH associated with any specific pregnancy
complications and outcomes?
• Health professionals should be aware that domestic violence
in pregnancy may result in APH.
• Women with repeated presentations that may include APH
should be asked about this.

26. MANAGEMENT OF APH

27. Management at initial presentation
● Rapid assessment of condition of both mother & fetus is a vital
first step

28. History
Dates by
previous
scan
Amount of
bleeding &
abdominal
pain
Assosiated
or initiating
factors
Hx of coitus
or trauma
Fetal
movements
Previous
uterine
surgery
Previous
episodes of
bleeding
Leakage of
fluid

29. History
Smoking &
Use of
illegal drugs
such as
coccaine
Position of
placenta if
known from
previous
scan
Previous
induced
abortions &
surgically
managed
miscarriage
s
Blood group

30. EXAMINATION
o Pressence or absence of fetal heart (make
sure its fetal not maternal)
o Fetal heart monitoring if GA >26 wks
o Pulse
o Blood pressure
o Per-abdomen: Uterine palpation for size, tenderness
& presenting part
o Per-vaginal: Should not be performed until placenta
praevia has been excluded
Maternal assessment Fetal assessment

31. Following this initial assessment women
will fall into one of two categories
The bleeding is heavy and
continuing and the mother or
fetus is or soon will be
compromised
The bleedind is minor or settling
and neither the mother nor fetus
is compromised

32. This is the most common group:
 Once it is clear that placenta is not low lying.
 PV examination should be done to access:
 Degree of bleeding
 Cervical changes– labor
 Local cause of bleeding(trauma,polyps,lesion)
 To take bacteriological samples if infection is suspected
Investigations:
 CBC
 Kleihauer testing (in women with
Rh –ive BG/unknown BG
 Grouping & cross matching
 Clotting screen (abruption or heavy bleeding)
 USG: fetal size, AFI,location of placenta, biophysical
profile, umbilical artery doppler
 CTG
 When any pregnant women complains of episodes of
vaginal bleeding, cervical cancer should be excluded.
Surveillance after a limited APH:
 Once APH has occurred the pregnancy becomes high
risk, and management plan for ongoing fetal
surveillance must be formulated and discussed with
the mother.
 Women must be advised to watch for warning signs
such as:
 Decrease in fetal movements
 Further bleeding or pain
 Repeat assessment if any of these occurs
Plan for rest of pregnancy:
 If bleeding settles and the mother is discharged, a
clear plan for the remainder of pregnancy should be
made.
 Extra fetal surveillance is needed
 If all remains well,induction of labour at term is not
needed
 But degree of surveillance may need to be increased
after due date
Bleeding is minor or settling and neither the mother nor fetus is compromised

33. Delivery must be expedited if mother is compromised & if
fetus is compromised, the decision to deliver will be based on
gestational age.
Method of delivery:
 The method of delivery will be determined by the cause &
severity of bleeding, the fetal gestation & status
 If fetus is already dead, vaginal delivery after stabilization
of mother is safest option
 If bleeding continues & mothers condition cannot be
stabilized delivery should be achieved by CS
Antepartum blood loss:
 It can be difficult to measure antepartum blood loss accurately
as loss may be concealed or diluted by amniotic fluid.
 Major hemorrhage can be defined by blood loss & vital signs
 Blood loss >1000ml
 Disturbance of conscious state
 Systolic pressure <100mmHg
 Pulse >120bpm
 Reduced peripheral perfusion
Resuscitation should aim to keep:
 Hb >8g/dl
 Pulse <100bpm
 Systolic BP >100mmHg
 4 units crossmatch blood
 Platelet count >75
 PT&APTT <1.5 + mean control
 Fibrinogen >1g/L
When major hemorrhage is identified:
i. Call for help
ii. Start oxygen 10-15L/min
iii. Insert two IV cannulae
iv. Take 30ml blood for (fbc,clotting screen,rft,lft,s/e,crosmatch)
v. Commence following infusion (0.9% saline/hartman soltn upto 2L, colloid
upto 1.5L, un-crossmatched rh-ive blood/ group specific)
vi. Foleys catheter to monitor urine output & aim to keep output above 30ml/hr
vii. One member of staff should be assigned to record following
(BP,pulse,CVP,fundal height, any drug administration, measure blood loss
viii. Senior obstetrician should coordinate and manage clinical situation to
prevent & treat DIC
Severe ongoing bleeding, compromised mother and / or fetus

35. Should women with APH be hospitalised, and if
so, for how long?
• Women presenting with spotting, who are no longer bleeding &
where placenta praevia has been excluded can go home after a
reassuring initial clinical assessment.
• All women with APH heavier than spotting and women with
ongoing bleeding should remain in hospital at least until the
bleeding has stopped.

36. Should corticosteroids be administered to
women who present with APH before term?
• Single course of antenatal corticosteroids should be offer
to women between 24+0 and 34+6 weeks of gestation at
risk of preterm birth

37. Should tocolytic therapy be used in women
presenting with APH who have uterine
activity?
• Tocolysis should not be used to delay delivery in a woman
presenting with:
major APH
haemodynamically unstable
evidence of fetal compromise

38. What is the optimal mode of anasthesia for
women who have experienced APH?
• Regional anesthesia is recommended for operative
delivery unless there is a specific contraindication.
• In a case of APH where maternal or fetal condition is
compromised and caesarean section required, a general
anesthesia should be considered

39. What is the appropriate management of the
third stage of labour in women with APH
• Postpartum haemorrhage (PPH) should be anticipated in
women who have experienced APH.
• Women with APH resulting from placental abruption or placenta
praevia should be strongly recommended to receive active
management of the third stage of labour.
• Ergometrine-oxytocin should be to used to manage the third
stage of labour.

40. Should women presenting with APH who are
RhD-negative be given anti-D ?
• Anti-D Ig should be given to all non-sensitised RhD-negative
women after any presentation with APH, independent of
whether routine antenatal prophylactic anti-D has been
administered.
• In the RhD-negative woman in the event of recurrent vaginal
bleeding after 20+0 weeks of gestation, anti-D should be given
at a minimum of 6-weekly intervals

41. In women whose pregnancy is complicated
by APH, how should the neonate be managed
and by whom?
• Major or massive APH may result in fetal anaemia and fetal
compromise.
• Abruption: The principal concern in these circumstances is neonatal
anaemia and therefore these babies should be managed by an
experienced paediatrician/neonatologist. Neonatal staff should be
present at the time of delivery and be informed of the likely diagnosis
and extent of the blood loss so that arrangements for early neonatal
blood transfusion can be made if necessary.
• Vasa praevia: In cases of vasa praevia, the umbilical cord is clamped
as soon as possible after delivery, leaving the longer part attached to
the neonate so that umbilical artery catheterisation is facilitated if
required.
• Placenta praevia: Anterior placenta praevia that necessitates incising
the placenta at the time of caesarean section is an indication for
attendance by an experienced paediatrician/neonatologist.

42. What are the postnatal issues that need to be
addressed in women whose pregnancies are
complicated by APH?
• The postnatal management of pregnancies complicated
by major or massive APH should include
thromboprophylaxis, debriefing and clinical incident
reporting

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