3.

7 Antepartum Haemorrhage

1. Classification
a. Threatened miscarriage
i. Vaginal bleeding a/w intrauterine pregnancy up to 24 weeks
gestation
b. Antepartum haemorrrhage
i. Vaginal bleeding from 24 weeks until onset of labour
c. Intrapartum haemorrhage
i. Vaginal bleeding deom onset of labour until end of 2 nd stage of
labour
d. Postpartum haemorrhage
i. Vaginal bleeding from 3rd stage of labour until end of puerperium
(6 weeks postpartum)
2. Causes of antepartum haemorrhage
a. Placenta praevia (30%)
b. Placental abruption (20%)
c. Local causes (5%)
d. Unclassified (45%)
3. Placenta praevia
a. Definition
i. Placenta partially or wholly situated in lower uterine segment
b. Incidence
i. 1 in 20 at 24 weeks; 1 in 200 at 40 weeks
ii. Increase amongst multiparous patient
c. Grading or Classification
i. Minor/major
ii. Grades 1-4
iii. Both classifications exclude the important information
Whether placenta praevia is anterior posterior?
1. Anterior is more likely to be accrete or percreta especially
if previous c-section!!!!

Type Grade Description

Minor I Leading edge of placenta is within 2cm of
internal cervical os (low lying placenta)

Minor II Reached internal os (marginal)

Major III Covers internal os but asymmetrically

situated

Major IV Covers internal os, centrally situated

d. Risk factors
i. Prior uterine surgery
1. C-section (10x risk after 3 C-section)
 ii. Increased parity
iii. Advanced maternal age (9x risk)
1. < 20 y/o
2. > 40 y/o
iv. Multiple pregnancy
v. Smoking
e. Symptoms
i. Vaginal bleeding
1. Painless;
2. Unprovoked or post coitus or following uterine
contractions
3. Often asymptomatic- incidental diagnosis during routine
obstetric ultrasound
f. Clinical signs
i. Abdominal examination
1. Uterus = soft; non tender
2. Presentation=high presenting part or malpresentation
(Head cannot descend into pelvis)
ii. Doppler
1. Fetal heart rate normal
iii. NEVER ATTEMPT VAGINAL EXAMINATION IN ANTEPARTUM
HAEMORRHAGE UNLESS PRIOR SCAN HAS EXCLUDED PLACENTA
PRAEVIA!!!--> REPEAT SCAN
g. Diagnostic methods
i. Clinical suspicion from history & exam findings
ii. Ultrasound of placental localisation
1. Measurement ofdistance of lowermost placental edge
from internal cervical os
2. Low lying placenta is within 2cm of internal os
3. Transvaginal ultrasound most precise!!!!!
4. Performed with empty bladder
h. Complications
i. MATERNAL
1. Haemorrhage
2. Co-existent abruption
3. Placenta accrete
4. Hysterectomy
5. Death
ii. FETAL
1. Preterm death
2. IUGR (common in women with multiple bleeds) (overall
rate 15% in praevia)
3. Death
i. Immediate management
i.
4. Placental abruption
a. Symptoms
b. Clinical signs
c. Investigation
 i. HT
ii. PE
iii. Sterile speculum examination
d. Complications
e. Immediate management
5. Local causes
a. Symptoms
b. Clinical signs
c. Investigation
i. HT
ii. PE
iii. Sterile speculum examination
d. Complications
e. Immediate management