Gynecology Department

 Dr. Faiz Alwaely 

L1: Antepartum hemorrhage (APH)
Is defined as vaginal bleeding, occurring from 24 weeks of gestation until
birth.
*It complicates between 2 and 5% of all pregnancies.

Causes of APH:
Placental
1- Placenta praevia
2- Placenta abruption
Maternal
1- Cervical erosion, Ca CX.
2- Local infection of the CX and vagina.
3- Show
4- Trauma
Foetal
- Vasa praevia
Placenta Praevia
Is the placenta that is partially or wholly implanted into the lower uterine
segment.

Incidence:
 5% in early pregnancy and called low lying placenta.
 0.5% in late pregnancy and called P.P.
This mean that more than 90% of low lying placenta return to
normal position this is to what is called placental migration due to
grow of lower uterine segment.
Predisposing Factors
1- Any injury or scar in the uterus like caesarian section or
vigorous curettage.
2- Multiparty
3- Increase maternal age
4- Multiple pregnancy
5- Previous placenta Previa, 10%.
6- Anemia
7- Congenital malformation
8- Malpresentaion like breech or transverse lie.

Types of P.P:
Complications
Maternal
1- Hypovolemic shock
2- Renal tubular necrosis and acute renal failure
3- Postpartum hemorrhage
4- Placenta accreta complicates approximately 10% of placenta
previa cases.
5- Anemia
6- Disseminated intravascular coagulopathy (DIC)
7- Death

Fetal
1- IUD
2- Hypoxic ischemic encephalopathy
3- Cerebral palsy
4- Prematurity

Clinical features
 Typical presentation causeless, painless and recurrent bright-red
vaginal bleeding.
 In majority it occurred without cause, however sometimes precipitated
by sexual intercourse or by vaginal examination.
 Although it is painless but sometimes associated with pain like if the
patient developed labor pain or associated with premature uterine
contraction & or placenta abruption at the same time.
 The fetal movement are still present after the bleeding.
 Symptoms of blood loss: palpitation, dizziness, syncope.
Symptoms
Causeless, painless and recurrent bright-red vaginal bleeding.

 It is causeless, but may follow sexual intercourse or vaginal

examination.
 It is painless, but may be associated with labor pain
 It is recurrent, but may occur once in slight placenta Previa lateralis.
 Fortunately, the first attack usually not severe.

Examination
Signs:
General Examination:
 The general condition of the patient depends upon the amount of
blood loss. Shock develops if there’s acute severe blood loss and
Anemia develops if there is recurrent slight blood loss.

Abdominal Examination:
 The Uterus is corresponding to the period of amenorrhea, relaxed and
not tender.
 The fetal parts and heart sound (FHS) can be easily detected.
 Malpresentations, particularly transverse and oblique non-engagement
of the head.
Signs of Placenta Previa
 If the mother is bleeding, she may be in shock, and the shock is
usually proportional to the amount of blood lost vaginally.
 The presenting part is usually high and there may be a non-cephalic
presentation.
 The uterus is usually soft and non-tender but there may be evidence of
early labor with contractions and relaxation in between contractions.
 Digital vaginal examination is contraindicated but a speculum
examination is useful if there is only slight bleeding (to exclude local
cause).

Vaginal Examination is absolutely contraindicated

1- In operating room
2- Under general anesthesia
3- Cross matched blood is in hand
4- Operating theatre is ready for immediate cesarean section.

Investigations
 Ultrasound scans
 Hematological examination
 MRI may be considered in cases of suspected accreta when the
ultrasound is inconclusive.
Management
Management depend on
1- Severity of bleeding
2- Gestational age
Evaluate the severity of bleeding and resuscitation:

 Mild < 15% blood loss

 Moderate 15-30% blood loss
 Severe 30-40% loss

1-Resuscitation
1- Call for help
2- 2 IV line
3- Draw blood for blood group and cross match 2-4 pint of blood +
coagulation screen..
4- Start IV fluid ringer lactate
5- Rh negative blood in life saving condition
6- Foley catheter for assessment of renal function
7- CVP
8- Monitoring an definitive management

2-Definitive Management
 Severe bleeding: Delivery by C.S regardless of gestational age
 Moderate bleeding: 1- Ig GA 37 weeks so delivery
2-If less than 36-37 weeks, observation if remain moderate or become
severe so do S.C, but if become mild so expectant management
 Mild bleeding: >37 weeks delivery , <37 weeks expectant management
Expectant Management
 Admission to hospital for bed rest
 Correction of anemia by blood transfusion
 Prevention of preterm labor and Rx of PUC by : Mg sulphate drug of
choice, Ca channel blockers.
 Acceleration of fetal lung maturity by steroids, dexamethasone or
betamethasone 28-34 weeks
 Repeat ultrasound exam every 2 weeks
 Delivery at term if no complication

Route of Delivery
 For grade I,II anterior can have vaginal delivery
 Grade II posterior, G III, G IV should be by C.S
 Every patient with APH liable for PPH so active management of third
stage of labor.

Best Regards