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Review

Antepartum Haemorrhage

Rosalba Giordano1 arises from haemorrhage into the deciduas basalis of the
Alessandra Cacciatore1 placenta, which results in the formation of haematoma
Pietro Cignini2 and an increase in hydrostatic pressure leading to sepa-
Roberto Vigna2 ration of the adjacent placenta. The resultant haema-
Mattea Romano1 toma may be small and self-limited or may continue to
dissect through the decidual layers. However, the
bleeding may be in whole or in part concealed, if the
1
Department of Obstetrics and Gynecology, Policlinico-
haematoma does not reach the margin of the placenta
Vittorio Emanuele. University of Catania, Italy.
and cervix for the blood loss to be revealed. Therefore
2
Fetal-Maternal Mediacl Centre Artemisia, Depart-
the amount of revealed haemorrhage poorly reflects
ment of Prenatal Diagnosis, Rome. Italy
the degree of blood loss. The bleeding may infiltrate
the myometrium resulting in so-called Couvelaire
uterus.
Corresponding Author:
A causal relationship between hypertension and abrup-
Roberto Vigna
tion is controversial. Most explanations implicate vas-
Artemisia fetal Maternal Medical Center
cular or placental abnormalities, including increased
Viale Liegi, 45 - Roma
fragility of vessels, vascular malformations, or abnor-
vigna.roberto@libero.it
malities in placentation. The absence of transformation
from muscular arterioles to low-resistance, dilated ves-
Summary sels as in normal pregnancy and the lack of tro-
phoblastic invasion of uterine vessels is thought to re-
Objective: Antepartum haemorrhage (APH) defined as sult in decreased placental blood flow and dysfunction-
bleeding from the genital tract in the second half of al endothelial responses to vasoactive substances.
pregnancy, remains a major cause of perinatal mortali- These abnormal placental vessels may predispose to
ty and maternal morbidity in the developed world. ischaemia and rupture of involved vessels, thus caus-
Results: In approximately half of all women presenting ing placental abruption. Placental abruption is seen
with APH, a diagnosis of placental abruption or placen- more often in gestational hypertensive disease, ad-
ta praevia will be made; no firm diagnosis will be made vanced maternal age, increasing parity, the presence
in the other half even after investigations.
of multiple gestations, polyhydramnios, chorioamnioni-
Conclusion: In cases presenting with APH, the evalua-
tis, prolonged rupture of membranes, trauma, and pos-
tion consists of history, clinical signs and symptoms
sibly thrombophilias. Potential preventable risk factors
and once the mother is stabilized, a speculum examina-
tion and an ultrasound scan. include maternal cocaine and tobacco use. Unex-
A revision of the literature was mode only larger pro- plained elevated maternal serum alpha-fetoprotein
spective tials or case-control study were taken into ac- (MSAFP) levels in the second trimester is associated
count. with pregnancy complications such as placental abrup-
tion.
Key Words: hemorrage, post-partum complications, pregnancy Placenta praevia is defined as a placenta that lies
wholly or partly within the lower uterine segment. The
prevalence of clinically evident placenta praevia at
Introduction term is estimated to be approximately 4 or 5 per 1000
pregnancies (2).
Usually the placenta is situated in the upper uterine seg- Classification of placenta praevia is important in mak-
ment. Placental abruption is the premature separation ing management decisions because the incidence of
of a normally situated placenta from the uterine wall, morbidity and mortality in the fetus and mother increas-
resulting in haemorrhage before the delivery of the fe- es as the grade increases.
tus. It occurs in around one in 80 deliveries and re- Classically, placenta praevia is divided in four types or
mains a significant source of perinatal mortality and grades (Table 1). Types I and II are regarded as minor,
morbidity. and types III and IV as major degrees of placenta prae-
Recent large epidemiological studies report an inci- via. Care must be taken not to confuse these grades
dence ranging from 5.9 to 6.5 per 1000 singleton births with grades of placental maturity.
and 12.2 per 1000 twin births. Perinatal mortality is re- The classification is difficult to use in practice, because
ported to be 119 per 1000 births complicated by abrup- the definition of lower uterine segment is more concep-
tion. The risk of abruption recurring in a subsequent tual than anatomical. In any case, with the availability
pregnancy is increased as much as 10-fold (1). of ultrasound, this classification has become obsolete.
The precise cause of abruption is unknown. Abruption Currently, the condition is most commonly diagnosed

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Antepartum Haemorrhage

on ultrasound examination. Ultrasound remains the placental abruption have been excluded, a cause may
method of choice because it is relatively cheap and still be found. They include show, cervicitis, trauma,
readily available. vulval varicosities, genital tumours, haematuria, genital
Placenta praevia is caused by implantation of the blas- infections and vasa previa. Many of these conditions
tocyst low in the uterine cavity. Factors associated with are evident on the initial speculum examination.
the development of placenta praevia include increas- Vasa praevia is the presence of unsupported fetal ves-
ing maternal parity, advancing maternal age, increas- sels below the fetal presenting part, where the cord in-
ing placental size (multiple pregnancy), endometrial sertion is velamentous. It is rare, but consequences
damage (previous dilatation and curettage), previous are disastrous, if not prenatally diagnosed. Vasa prae-
Caesarean section, uterine scars and pathology (previ- via has an incidence of approximately one per 6000
ous myomectomy or endometritis), placental pathology deliveries. Classically, vaginal bleeding follows am-
(marginal cord insertions and succenturiate lobes), niotomy with subsequent fetal bradycardia suggests
previous placental praevia, and curiously, cigarette vasa praevia. The diagnosis of this condition before
smoking (1). these events is difficult but the experienced observer
Although placenta accreta is very rare (0.004%) in may be able to feel vessels on digital examination be-
women with a normally situated placenta, it occurred in low the presenting part. A speculum examination may
9.3% of women with placenta praevia according to da- also reveal the vessels on inspection. An Apt test on
ta from Southern California. Ultrasound features of pla- the blood can be performed to demonstrate the pres-
centa accrete in second and third trimesters include vi- ence of fetal blood.
sualization of irregular vascular sinuses with turbulent Immediate Caesarean delivery is needed if fetal blood
flow, abnormalities of the bladder wall on ultrasound in- is confirmed to be present in the vaginal bleeding.
spection and possibly myometrial thickness of less Oyelese et al. demonstrated the importance of prena-
than 1 mm. Absence of the sono-luscent space be- tal diagnosis. In the group where prenatal diagnosis
tween myometrium and the placenta is not a reliable had been made, 97% infants survived, as opposed to
sign. Colour Doppler and magnetic resonance imaging only 44% where the diagnosis had not been made be-
are not yet completely sensitive and specific tests for fore birth. Echogenic parallel or circular lines near the
the diagnosis of placenta accreta (3, 4). cervix representing the umbilical cord, seen by grey-
When a probability of placenta accreta is raised, multi- scale ultrasound, should raise the possibility of vasa
disciplinary input involving the patient and the family, praevia. The diagnosis of vasa praevia can be con-
the anaesthetist, obstetrician and the sonographer firmed by Doppler and endovaginal ultrasound studies
should be arranged. Advance planning should be if aberrant vessels over the internal cervical os are
made for management of delivery. The options are suspected. Several reports have linked vasa praevia to
subsequent hysterectomy after delivery or leaving the invitro fertilization. The diagnosis should be kept in
placenta in-situ in order to reduce surgical complica- mind in cases of in-vitro fertilization pregnancies with
tions and blood loss. Of the four maternal deaths due low placenta, and cases where the placenta had been
to placenta praevia in the triennium 20002002, all had low-lying at the midtrimester scan, but has receded
at least on previous Caesarean, and three had a histo- from the internal os on repeat assessment. Delivery by
ry of placenta accreta. elective Caesarean section after fetal pulmonary matu-
The exact cause of bleeding in late pregnancy is un- rity is established and prior to the onset of labour
known in about half of cases. The woman typically should be recommended unless obstetric complica-
presents with painless vaginal bleeding without ultra- tions supervene (6).
sound evidence of placenta praevia. Placenta praevia
can be excluded by an ultrasound scan, but the diag-
nosis of placental abruption is based on clinical signs Material and methods
and symptoms, and is difficult to confirm in mild cases
(5) The diagnosis of placenta abruption is made clinically
. Approximately 15% of women with unexplained APH and then confirmed by evaluation of the placenta after
will go into spontaneous labour within 2 weeks of the delivery. It presents classically with vaginal bleeding,
initial haemorrhage. In the majority of cases, the bleed- abdominal pain, uterine contractions and tenderness.
ing is mild and settles spontaneously. Further manage- On clinical examination, the uterus is irritable, with in-
ment will either be expectant or delivery will be expe- creased baseline tone. There may be evidence of fetal
dited. If pregnancy is beyond 37 weeks gestation and distress. In severe cases, the mother may show car-
the bleeding is recurrent or associated with fetal diovascular decompensation with evidence of hypovo-
growth retardation, labour induction is the manage- laemia. The fetal heart may be absent, and there is a
ment of choice. If episodes of bleeding are recurrent serious risk of development of coagulopathy in the
and significant, there may be a need for immediate de- mother due to consumption of clotting factors. The clin-
livery even if the gestation is below 37 weeks. If a pol- ical signs of blood loss are out of proportion to the
icy of expectant management is adopted, fetal well-be- amount of vaginal bleeding. Ultrasound is an insensi-
ing should be monitored. Once the bleeding has set- tive and unreliable tool for detecting or excluding pla-
tled and the woman has been observed as an inpatient cental abruption, as negative sonographic findings are
for 2448 h, it may be considered safe to allow her to common with clinically significant abruptions. The di-
be managed as an outpatient. If the gestational age is agnosis may be confirmed postpartum on gross exam-
below 3436 weeks, antenatal steroids should be ad- ination of the placenta, which reveals a clot and/or de-
ministered in view of the risk of preterm delivery. In a pression in the maternal surface, known as a delle. In
small proportion of cases where placenta praevia and

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R. Giordano et al.

less severe cases, the diagnosis of placental abruption manual placental removal, and a higher prevalence of
may not be obvious, particularly if the haemorrhage is placenta accreta.
largely concealed and it may be misdiagnosed as idio-
pathic preterm labour. The majority of fetal morbidity is Table 1 Classification of placenta praevia.
thought to be due to prematurity, with low birth weight, Type I The placenta encroaches into the lower uter-
fetal growth restriction, anaemia, and hyperbilirubi- ine segment and lies within 5 cm of the internal cer-
naemia significantly more common. Placental abrup- vical os
tion cannot be eliminated as a potential diagnosis in Type II The placenta reaches the cervical os but
the absence of vaginal bleeding, as haemorrhage may does not cover it
be retroplacental and concealed. Placental abruption Type III The placenta covers the cervical os but the
is concealed in 2035% and revealed in 6580% of placental site asymmetric with most of the placenta
cases (3). being on one side of the cervical os
In severe abruption, complications include haemor- Type IV The placenta is centrally located over the
rhage requiring transfusion, disseminated intravascu- cervical os
lar coagulopathy (DIC), infection and rarely, maternal
death. Couvelaire uterus may occur and occasionally
Results
may require hysterectomy. The incidence of stillbirth is
related to the size of the abruption. Separation exceed-
Once placental abruption has been suspected, action
ing 50% of the placenta causes a marked elevation in
should be swift and decisive because the prognosis for
stillbirth rate. mother and fetus is worsened by delay. Treatment con-
Most women in the UK will have a routine scan at sists of initial resuscitation and stabilization of the
2123 weeks (anomaly scan). The placenta will be mother, treatment of the abruption, and recognition
low-lying in some, necessitating a repeat scan later in and management of complications. It is individualized
pregnancy, typically at 3436 weeks. Women classi- based on the extent of the abruption, maternal and fe-
cally present with minor degrees of painless vaginal tal reaction to this insult, and gestational age of the fe-
bleeding in the absence of labour pains. The bleeds tus. Maternal resuscitation and treatment of hypo-
tend to occur due to the formation of the lower uterine volaemic shock are a subject of a review in its own
segment. Fetal malpresentation or unstable lie is found right, and will not be discussed further. For the purpose
in one-third of cases and many cases of placenta prae- of management or abruption, Sher and Statland divid-
via do not bleed until the onset of labour. The diagno- ed placental abruption into three degrees of severity
sis of placental praevia is most commonly made on ul- (3).
trasound examination. These are mild (grade 1): not recognized clinically be-
Up to 26% of placentas are found to be low lying on ul- fore delivery and usually diagnosed by the presence of
trasound examination in the early second trimester. a retroplacental clot; moderate (grade 2): intermediate,
Several studies have demonstrated that unless the the classical signs of abruption are present but the fe-
placental edge is at least reaching the internal cervical tus is still alive; and severe (grade 3): the fetus is dead
os at midpregnancy, placenta praevia at term will not and coagulopathy may be present.
be encountered. There are three practical options for management:
Transvaginal ultrasound is safe in the presence of pla- Expectant: in the hope that the pregnancy will con-
centa praevia, and is more accurate than transabdom- tinue
inal ultrasound in locating the placental edge. Ultra- Immediate caesarean section
sound has been used to observe and document the Rupture the membranes and aim at vaginal delivery
phenomenon of placental migration from the lower In mild placental abruption, the bleeding may stop and
uterine segment. It is thought that this process is not a the symptoms gradually resolve with satisfactory fetal
true migration of placental tissue but, rather, a degen- monitoring and the patient can often be managed as
an outpatient. The management of moderate or severe
eration of the peripheral placental tissue that receives
placental abruption is resuscitation, delivery of the fe-
a suboptimal vascular supply and has slow placental
tus and observation for and correction of any coagula-
growth in better perfused uterine areas at the same
tion defect that arises. This requires management in
time, so-called placental trophotropism.
the labour ward with intensive monitoring of both moth-
None of the cases presented with placenta praevia at er and fetus. A trial of labour and vaginal delivery is
term, unless the placental edge overlapped the internal recommended whenever tolerated by the maternalfe-
os at least by 1 cm at the mid-trimester scan. There tal pair. Labour is usually rapid and progress should be
was a minimal placental migration rate of 0.1 mm/week monitored with continuous fetal heart rate assessment.
in this group. In contrast, cases where the placenta If fetal distress is present then delivery should be ex-
eventually migrated away from the internal os showed pedited in the form of Caesarean section. Major abrup-
a mean rate of migration of 4.1 mm/week. Placental tion should be regarded as an emergency, requiring
edge overlapping the internal os at the mid-trimester multidisciplinary input from the obstetrician, anaes-
scan, and a thick placental edge (where the angle be- thetist and haematologist. A fulminant maternal DIC
tween the placental edge and the uterine wall is o1351) can ensue within hours of a complete abruption and de-
are known to be associated with reduced likelihood of livery should be effected, as it is the only means with
placental migration. In addition, those cases, where which to halt the DIC. Replacement of blood and its com-
the placentas failed to migrate were associated with in- ponents should begin before surgery. Abruption also
creased rates of interventional Caesarean delivery and places the patient at risk of severe postpartum haemor-

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Antepartum Haemorrhage

rhage. This is as a result of a combination of uterine ommended. In contrast, if the placental edge to inter-
atony and coagulation failure. Invasive monitoring with nal cervical os distance was 23.5 cm at the last ultra-
arterial lines and central venous access may be neces- sound scan within 2 weeks of delivery, the likelihood of
sary, and patients are best treated in the high-dependen- achieving a vaginal delivery was at least 60%. It is rec-
cy unit. Urine output should be closely monitored, as re- ommended that these cases be still referred to as low-
nal failure is a potential complication. Multiple studies lying placenta, because the risk of postpartum haemor-
have shown expectant management with or without to- rhage remains high in this group. An attempt at vaginal
colytics to be safe and effective in a select population of delivery is appropriate. RCOG guidelines recommend-
patients with preterm placental abruption. In some obser- ed that any women going to the operation theatre with
vational studies, tocolysis allowed a median delay of de- known major placenta praevia should be attended by
livery of several days without increasing neonatal or ma- an experienced obstetrician and anaesthetist, with
ternal morbidity, including the need for transfusion or de- consultant presence available, especially if these
livery by Caesarean section. However, in the absence of women have previous uterine scars, an anterior pla-
randomized controlled trials, the benefits of tocolysis re- centa or are suspected to be associated with placenta
main uncertain (7). accreta. Four units of cross-matched blood should be
The management of placenta praevia depends upon kept ready, even if the mother has never experienced
clinical presentation, severity of bleeding and degree of vaginal bleeding. Delivery of women with placenta
praevia. Currently, the diagnosis of placenta praevia is praevia should not be planned in units where blood
made using ultrasound. Most cases presenting with transfusion facilities are unavailable. The choice of
APH would already be known to have a low-lying pla- anaesthetic technique for Caesarean sections is usual-
centa. Those cases, in which the placenta was low-lying ly made by the anaesthetist conducting the procedure.
at the time of routine anomaly scan should receive a re-
peat ultrasound scan at 36 weeks to check placental lo-
cation. Some of these cases will present with antepar- Discussion
tum bleeding. Initial haemorrhages, referred to as
warning haemorrhages are often small and tend to The cause of APH remains undetermined in about half
stop spontaneously. Delivery may be needed for se- of the cases.
vere, intractable or recurrent bleeding. Fetal morbidity Diagnosis of placental abruption is clinical, whereas that
is associated with iatrogenic prematurity. In the report of placenta praevia, based on an ultrasound scan.
of confidential enquiries into maternal mortality over In cases of abruption presenting with intrauterine death,
20002002 in the UK (Why mothers die 20002002), at least a 2 unit blood transfusion should begin because
there were 17 maternal deaths due to haemorrhage. average blood loss is about 1 l.
Four out of these 17 deaths were due to placenta prae- Unless the placental edge overlaps the internal os by at
via. Controversy surrounds the antepartum manage- least 1.0 cm at 2123 weeks scan, placenta praevia at
ment of those cases found to have a low-placenta at the term will not be encountered. A repeat scan at 3436
anomaly scan, particularly the ones who have never weeks should be organized.
had antepartum bleeding. Moreover, many women will Caesarean section for placenta praevia should involve
be admitted with vaginal bleeding due to known low-ly- the most senior available staff in the anaesthetic and ob-
ing placenta, but the bleeding would stop spontaneous- stetric service. At least 4 units of blood should be cross-
ly, and not recur for several days. Current guidelines by matched.
the Royal College of Obstetricians and Gynaecologists The possibility of placenta accreta should be kept in
(RCOG) recommend that such women be kept admit- mind in cases of placenta praevia. Absence of an echo-
ted to the hospital. This advice is based on a small ran- luscent line behind the placenta is not a reliable sign.
domized trial that showed no difference between inpa- Sonographic visualization of irregular sinuses with tur-
tient and outpatient management of cases of placenta bulent flow in the placenta is the most reliable sign.
praevia. However, the authors of the RCOG guideline Antepartum identification of vasa praevia leads to signif-
felt that uncommon, but potentially serious, maternal icant improvement in perinatal mortality.
complications are unlikely to come to light with a trial A multi-disciplinary massive obstetric haemorrhage pro-
with small numbers. The recommendation for inhospital tocol should be available in all units. It should be regu-
management is not based on the presence of evidence larly updated and rehearsed in conjunction with the
of benefit of hospitalization, but due to absence of large blood bank.
good quality trials.
Traditionally, Caesarean section has been the recom-
mended mode of delivery for major placenta praevia References
(type III and IV), whereas for minor praevia (type I and
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a Caesarean delivery due to bleeding. We proposed January 2000.
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of less than 2 cm be referred to as major placenta tal abruption and adverse perinatal outcomes. JA-
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