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

APH
Per vaginam blood loss >15
ml after 20 weeks gestation
5% of all pregnancies
Accounts for 20 -25% of
perinatal mortality

Severity of bleeding
Volume
Estimate
<ml or 500
1000-1500
ml
1500-2000
ml
2000-3000

Percent of
circularity
volume

Type

10-15% compensated
mild
15-25%
25-35%

moderate

35-50%

Severe

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.
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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 uterus
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 lowlying placenta is suspected from
their transabdominal anomaly scan
(at approximately 2024 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