Antepartum haemorrhage
antepartum haemorrhage (APH), also
prepartum hemorrhage, is bleeding from the
vagina during pregnancy from twenty four weeks
gestational age to term.
It should be considered a medical
emergency(regardless of whether there is pain) and
medical attention should be sought immediately, as if
it is left untreated it can lead to death of the mother
and/or fetus.
Differential diagnosis of APH
placental abruption 15%
placenta praevia 10%
rarely caused by vasa praevia
Other causes include:
incidental haemorrhage from a lesion of the
cervix or vagina - infection, carcinoma, polyp,
 show - expulsion of the mucus plug at the
onset of labour
 Other causes to consider include:
 rectal bleeding; bleeding diatheses; haematuria
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Abruptio placenta
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Abruptio placentae refers to separation
of the normally located placenta after the
20th week of gestation and prior to birth.
Pathophysiology
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Bleeding into the decidua basalis leads to
separation of the placenta. Hematoma
formation further separates the placenta
from the uterine wall, causing compression
of these structures and compromise of
blood supply to the fetus. The myometrium
in this area becomes weakened and may
rupture with increased intrauterine pressure
during contractions. A myometrium rupture
immediately leads to a life-threatening
obstetrical emergency
Severity of fetal distress correlates with the
degree of placental separation. In nearcomplete or complete abruption, fetal
death is inevitable unless an immediate
cesarian delivery is performed.
Frequency
Occurs in about 1% of all pregnancies
throughout the world.
Mortality/Morbidity
 Maternal and fetal death may occur
because of hemorrhage and coagulopathy.
The fetal perinatal mortality rate is
approximately 15%.
Causes:
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Maternal hypertension - Most common cause of abruption,
occurring in approximately 44% of all cases
Idiopathic (probable abnormalities of uterine blood vessels and
decidua)
Maternal trauma (eg, motor vehicle collision [MVC], assaults, falls) Causes 1.5-9.4% of all cases
Cigarette smoking
Alcohol consumption
Cocaine use
Short umbilical cord
Sudden decompression of the uterus (eg, premature rupture of
membranes, delivery of first twin)
Retroplacental fibromyoma
Retroplacental bleeding from needle puncture (ie,
postamniocentesis)
Advanced maternal age
Symptoms
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Patients usually present with the following
symptoms:
◦ Vaginal bleeding - 80%
◦ Abdominal or back pain and uterine
tenderness - 70%
◦ Fetal distress - 60%
◦ Abnormal uterine contractions (eg,
hypertonic, high frequency) - 35%
◦ Idiopathic premature labor - 25%
◦ Fetal death - 15%
classification
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Is based on extent of separation (ie, partial vs
complete) and location of separation (ie, marginal or
central). :
Class 0: asymptomatic. Diagnosis is made
retrospectively by finding an organized blood clot or
a depressed area on a delivered placenta.
 Class 1: mild and represents approximately 48% of all
cases. Characteristics include the following:
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No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress
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Class 2 :moderate and 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
◦ Hypofibrinogenemia (ie, 50-250 mg/dL)
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Class 3: severe and represents
approximately 24% of all cases.
Characteristics include the following:
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No vaginal bleeding to heavy vaginal bleeding
Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (ie, <150 mg/dL)
Coagulopathy
Fetal death
Workup
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Laboratory Studies
Hemoglobin
Hematocrit
Platelets
Prothrombin time/activated partial thromboplastin time
Fibrinogen
Fibrin/fibrinogen degradation products
D-dimer
Blood type
Imaging Studies
Ultrasonography helps determine the location of the placenta to
exclude placenta previa Ultrasonography is not very useful in
diagnosing placental abruption.
◦ Retroplacental hematoma may be recognized in 2-25% of all abruptions.
Manegement:
The management of this condition is
largely dependent on the severity of the
haemorrhage and the condition of the
mother and the fetus.
 DO NOT PERFORM A DIGITAL
EXAMINATION.
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all patients with suspected placental
abruption. This care includes the following:
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Continuous monitoring of vital signs
Continuous high-flow supplemental oxygen
One or 2 large-bore IV lines with normal
saline (NS) or lactated Ringer (LR) solution
Monitoring amount of vaginal bleeding
Monitoring of fetal heart
Treatment of hemorrhagic shock, if needed
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Mild abruption
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admit to hospital
bed rest
iv line in situ
blood: cross-match, FBC, clotting studies
localise placenta by ultrasound scan
inspection of cervix with a speculum
The patient may be discharged after 4-5 days if
the bleeding does not recur. The pregnancy
should be monitored using ultrasound
measurements of fetal growth and cardiac
monitoring, and fetal kick charts. Intercourse
should be avoided
Sever cases
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Closely observe the patient. inister supplemental oxygen.
Admtinuous fetal monitoring.
Administer IV fluids.
Perform aggressive fluid resuscitation to maintain adequate perfusion, if
needed.
Monitor vital signs and urine output.
Crossmatch 4 units of packed red blood cells. Transfuse, if necessary.
Perform amniotomy to decrease intrauterine pressure, extravasation of
blood into the myometrium, and entry of thromboplastic substances into
the circulation.
Immediately deliver the fetus by cesarean delivery if the mother or fetus
becomes unstable.
Treatment of coagulopathy or disseminated intravascular coagulation (DIC)
may be necessary. Some degree of coagulopathy occurs in about 30% of
severe cases of placental abruption. The best treatment for DIC as a
complication of placental abruption is immediate delivery.
prognosis
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The recurrence rate of fetal abruption is
as high as 1 in 10. Therefore, subsequent
pregnancies have a risk of separation at
any time and must be treated as high risk.
Placenta previa
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Placenta previa is generally defined as the
implantation of the placenta over or near
the internal os of the cervix.
Classification
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Total placenta previa occurs when the internal
cervical os is completely covered by the placenta.
Partial placenta previa occurs when the internal os
is partially covered by the placenta.
Marginal placenta previa occurs when the placenta
is at the margin of the internal os.
Low-lying placenta previa occurs when the placenta
is implanted in the lower uterine segment. In this
variation, the edge of the placenta is near the internal os
but does not reach it
Pathophysiology
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The exact etiology of placenta previa is
unknown. The condition may be multifactorial
and is postulated to be related to multiparity,
multiple gestations, advanced maternal age,
previous cesarean delivery, previous abortion,
and possibly, smoking.
Frequency
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Placenta previa complicates approximately
5 of 1,000 deliveries and has a mortality
rate of 0.03%.
Causes
Prior uterine insult or injury
 Risk factors
◦ Prior placenta previa (4-8%)
◦ First subsequent pregnancy following a
cesarean delivery
◦ Multiparity (5% in grand multiparous patients)
◦ Advanced maternal age
◦ Multiple gestations
◦ Prior induced abortion
◦ Smoking
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Symptoms
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Vaginal bleeding
◦ It is apt to occur suddenly during the third trimester.
◦ Bleeding is usually bright red and painless. Some
degree of uterine irritability is present in about 20%
of the cases.
◦ Initial bleeding is not usually profuse enough to cause
death; it spontaneously ceases, only to recur later.
◦ The first bleed occurs (on average) at 27-32 weeks'
gestation.
◦ Contractions may or may not occur simultaneously
with the bleeding.
Physical
Profuse hemorrhage
 Hypotension
 Tachycardia
 Soft and nontender uterus
 Normal fetal heart tones (usually)
 Vaginal and rectal examinations
◦ Do not perform these examinations in the ED
because they may provoke uncontrollable bleeding.
◦ Perform examinations in the operating room under
double set-up conditions (ie, ready for emergent
cesarean delivery)
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Workup
Laboratory Studies
 Beta-human chorionic gonadotropin (beta-hCG) subunit
 Rh compatibility
 Fibrin split products (FSP) and fibrinogen levels
 Prothrombin time (PT)/activated partial thromboplastin
time (aPTT)
 CBC-bld Group and cross matching
 Apt test to determine fetal origin of blood (as in the
case of vasa previa)
 Wright stain applied to a slide smear of vaginal blood,
looking for nucleated red blood cells (RBCs), not adult
blood
 Lecithin/sphingomyelin (L/S) ratio for fetal maturity, if
needed
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Imaging study
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Transabdominal ultrasonography
◦ A simple, precise, and safe method to visualize the
placenta, this ultrasonography has an accuracy of 9398%.
Transvaginal ultrasonography
◦ Recent studies have shown that the transvaginal
method is safer and more accurate than the
transabdominal . And also considered more accurate
than transabdominal ultrasonography. In one study,
26% of placental localization diagnosed by
transabdominal ultrasonography was later changed
using transvaginal ultrasonography.
Procedures
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If the location of the placenta is unknown
and sonography is not available, a double
set-up bimanual examination under
anesthesia (EUA) may be performed in
the operating room.
Manegement
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The principle objective of management is to
prolong the pregnancy until the fetus is mature.
Optimally, this is a gestational age of 37 weeks:
the neonatal mortality rate is not improved by
further intrauterine development
Immediate steps include:
 admission to hospital that is equipped to
deal with this condition
 bed rest
 cross matching of blood
 transfusion if severe haemorrhage: use O
Rh-ve blood
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If there is a diagnosis of a major placenta
praevia then a caesarian section should be
undertaken without vaginal examination.
 If the diagnosis is in doubt or there is minor
placenta praevia then there should be vaginal
examination under anaesthesia; this should be
carried out when the fetus is as mature as
possible and only in the setting of the operating
theatre with preparations for caesarian section.
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Rarely, placenta praevia haemorrhage may
be so severe as to necessitate evacuation
of the uterus despite fetal immaturity
Vasa Previa
Definition: bleeding from umbilical vessels.
 Diagnosis: Apt test (hemoglobin alkaline
denaturation test.
 Complications: bleeding is fetal in origin
(mortality is >75%).
 Treatment: Emergent CS if fetus is viable.
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Apt Test
Addition of 2-3 drops of alkaline solution
to 1 ml of blood.
Fetal erythrocyte are resistant to rupture
and the mixture will remain red.
If the blood is maternal, erythrocytes will
rupture and the mixture will turn
browne.
Thanx