Antepartum
Hemorrhage
Abdulah Al-Tayyem;MD;JBOG
Consultant Ob&Gyn
Urogynaecology
Zarka Govern. Hospital
Definition:
APH is bleeding from or within the genital
tract after 24 W of gestation.
Causes:
 Placenta previa
the most common causes
 Abruptio placentae
 Rupture uterus
 Local causes: trauma,infection,tumors.
 Vasa previa
Placenta previa
Is the implantation of the placenta in the lower
uterine segment with different grades of
encroachment on the cervix.
 Bleeding is: -painless
-causless
classification
6
APH
Per vaginam blood loss >15
ml after 20 weeks’ gestation
 5% of all pregnancies
 Accounts for 20 -25% of
perinatal mortality

7
Severity of bleeding
Volume
Estimate
500 ml or >
Percent of
Type
circularity
volume
10-15% compensated
1000-1500 ml
15-25%
mild
1500-2000 ml
25-35%
moderate
2000-3000 ml
35-50%
Severe
(shock)
8
Abruptio Placentae





Is premature separation of a
normally implanted placenta, may be
precipitated by a sudden increase in
blood pressure or trauma
Fetal parts are difficult to feel.
Feta heart sound may be absent
Sings of hypovolemia
Coagulopathies occur in 30% of
cases
Diagnosis
History:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Present obstetric history
Symptoms of hypovolemia
Symptoms of pre-eclampsia
Lower abdominal pain or colic
The presence or absence of fetal movements
History of ROM or labour pains
Previous uterine operations
History of sexual intercourse before onset of
bleeding
History of trauma or recent surgery
Physical examination




General examination:-tachycardia,hypotenstion
-sings of shock
-lower limb edema.
Abdominal examination: -abdominal tinderness,or rigidity
-fundable level
-FHS
-consistency of the uterus‫ز‬
Pelvic examination:
-Don not perform a digital vaginal examination at this
stage.
-Inspect the external genitalia and vagina for:
-amount of blood loss
-sings of trauma or infection.
Investigations

Laboratory investigations:
-ABO blood group and Rh type
-Crossmatch at 2 units of blood
-CBC
-Fibrinogen, PTT, PT,CT
-Serume creatinine or BUN
-Urine analysis for protein and RBCs

Perform a transvaginal ultrasound scan on all
women in whom a low-lying placenta is
suspected from their transabdominal anomaly
scan (at approximately 20–24 weeks) to reduce
the numbers of those for whom follow-up will
be needed.

Transvaginal ultrasound is safe in the presence
of placenta praevia and is more accurate than
transabdominal ultrasound in locating the
placenta.
Ultrasound




Confirm the fetal viability
Localize the site of placenta,and its relation to the
cervix
Estimating the gestational age
Detecting the presence of retroplacental
hematoma



In case of sever bleeding, do not wait for an US
examination .Begin first aid management and the
quickly start active management .
Even if the amount of bleeding is mild NEVER
perform PV examination until placenta previa has
been excluded by US
Diagnosis of Antepatrm Hemorrhage



Painless vaginal bleeding after 24w.?
Symptoms and sings:
-shock
-bleeding may be precipitated
by intercourse
-relaxed uterus
-normal fetal condition
-fetal presentation not in the pelvis/ lower
uterine pole feels empty.
Dg: Placenta previa
Vaginal bleeding after 24
w,intermitent,or constant abdominal
pain?
 Symptoms and sings:
-Shock
-tense/tender uterus
-decreased /absent fetal movements.
-fetal distress/absent fetal heart sound.
Dg: Abruptio placentae.
( R/O co-exciting PIH)

Bleeding(intra-abdominal and/or
vaginal)?
 Sever abdominal pain(may decreas
after rupture)?
 Previous uterine scar?
- shock
-abdominal distention/free fluid.
-abnormal uterine contour -tender
abdomin
-easily palpable fetal parts -rapid
maternal puls
-absent fetal movements and FHS

Dg: Ruptured uterus


Mild vaginal bleeding after 24
w(mild)?
Symptoms and sings:
-clinically stable
-fetal assessment showed fetal distress
that can not be explained by the mild
bleeding.
Dg : Vasa previa
Complications of placenta previa
-shock
-postpartum hemorrhage
- Women with placenta previa are at
high risk for PPH and placenta
accreta/increta;
a common finding is at the site of a
previous cesarean section
Complications of abruptio placentae






Maternal shock
Fetal death
Uterine atony
Amniotic fluid embolism
Caogulopathy( 30%)
Renal failure
The principal cause of maternal death is
renal failure due to prolonged hypotension
.
Don not underestimate the amount of the
hemorrhage
Management

General rules:
-call for help -keep women NPO
-remember that mother and the neonate
require evaluation and intervention if
needed
First aid management








Insert 2 wide bore cannulae
Blood for CBC,crossmatch
Immediately star iv crystalloid
solutions
Provide 100% oxygen via mask
Warm the women
Insert Foley catheter
Monitor blood pressure and pulse/ 5
min
Monitor urine output /hour
Indications of when to terminate
pregnancy





Women in labour
Bleeding is heavy(evidente or
hidden) manifested by shock
Gestational age equals or more 37 w
There is fetal distress
There is IUFD and /or fatal
congenital anomalies by US
When to use conservative management




Bleeding is light or has stopped AND
The fetus is alive AND
The fetus is premature.
Cases of abruptio placentae which
are diagnosed only on US
examination, with no clinical finding(
no bleeding, no shock, no tender or
tonically contracted uterus)
In abruptio placentae:



When the clinical diagnosis is clear
Or in the presence of acute fetal
distress:…. Do not waste your time
for US examination.
US is neither sensitive nor specific
diagnosis modality in abruptio
placentae
Monitoring during hospital say




Check pulse every 3o min/2h, then
hourly/6h, then every 4 h.
Perform gentle uterine massage/30 min
APH predispose for PPH
Check for vaginal bleeding
Check urine output/ 2h
Conditions that should be met before
discharge






No active bleeding
No fever
Open bowel
Stable general condition
Satisfactory urine output
No wound complications
Management of Placenta praevia in a
Pregnancy of viable gestational age
+
-
Fetal distress
+
Expectant
management
C/Section
+
Fetal lung maturity
- -
Sono assessment
q 3-4 weeks
Bleeding
+
Double set-up
Bleeding
-
Placental
migration
Trial of labor
+
Trial of labor
(low-lying only)
+
-
Complete
resolution
28
Comparison of presentation of
abruption v. praevia v. rupture
Abruptio
n
Abdomin
Yes
al pain
Vaginal
Old dark
bleeding
DIC
Common
Fetal
Common
Praevia
Rupture
No
variable
Fresh
Fresh
Rare
Rare
Rare
Common
29




Associated with velamentous
insertion of the umbilical cord (1%
of deliveries)
Bleeding occurs with rupture of the
amniotic
membranes (the
umbilical vessels are only
supported by amnion
Bleeding is FETAL (not maternal as
with
placenta praevia)
Fetal death may occur with trivial
symptoms
31
Comparison of presentation of
abruption v. praevia v. rupture
Rupture
Praevia
variable
No
Fresh
Fresh
Rare
Rare
Abruptio
n
Yes
Abdomin
al pain
Old dark Vaginal
bleeding
Common
DIC
Common
Rare
Common
Fetal
distress