Antepartum hemorrhage

By: Sara Alaa

Bleeding in pregnancy

H
 DDX for APH
 Maternal
 Obstetrics : Placenta abruption / Placenta previa
uterine rupture

 Gynecology : Vaginal lesion like trauma and

infection / Cervical lesion like cervical ectropion;
cervical carcinoma; cervical polyp

 Systemic : Drugs ( anticoagulants ) / Diseases (

ITP )

 Fetal vasa previa

Placental causes of APH are the most worrying, as potentially

the mother’s and fetus’s life is in danger and often the
bleeding may be more severe than with other causes such
as cervical ectropion.
So I wil explain those causes with detailes
Obstetrics causes
• Placenta abruption (accidental hemorrage)
• Placenta previa
• vasa previa
Pathogenesis and types

• Separation of the placenta results in formation of a

retroplacental haematoma and its extension leads to more
separation of the adjacent placental tissue (concealed
haemorrhage).

• Ultimately the blood reaches the placental margin and tracks

between the membranes and uterine wall to escape from the
cervix (revealed haemorrhage).

• The presence of concealed and revealed haemorrhage together

called mixed variety. Thus the three varieties are actually
different presentations to one process.

• If separation of the membranes does not occur, there is

progressive disruption of the placental tissue and intravasation
of blood through the myometrium even up to the peritoneal coat
resulting in Couvelaire’s uterus.

• Thromboplastin-like substances are released from the damaged

placental site and passed to the maternal circulation initiating
the process of disseminated intravascular coagulopathy (DIC).
Pathogenesis and types

• If separation of the membranes does not occur, there is

progressive disruption of the placental tissue and intravasation
of blood through the myometrium even up to the peritoneal coat
resulting in Couvelaire’s uterus.

• Thromboplastin-like substances are released from the damaged

placental site and passed to the maternal circulation initiating
the process of disseminated intravascular coagulopathy (DIC).
Pathogenesis and types
• Progressive stretching of the
lower uterine segment
normally occurs during the
3rd trimester and labour, but
the inelastic placenta cannot
stretch with it. This leads to
inevitable separation of a
part of the placenta with
unavoidable bleeding. The
closer to term, the greater is
the amount of bleeding.
Degrees (types)
 First degree (Type I = P.P. lateralis = low-lying
placenta):-
The lower edge of the placenta reaches the lower
uterine segment but not the internal os.
 Second degree (Type II= P.P. marginalis):
The lower edge of the placenta reaches the margin of
the internal os but does not cover it.
 Third - degree (Type III= P.P. incomplete centralis):
The placenta partially covers the internal os
 Fourth - degree (Type IV = P.P. complete centralis)
Pathogenesis and types

Degrees (types)

 First degree (Type I = P.P. lateralis = low-lying

placenta):-

The lower edge of the placenta reaches the lower

uterine segment but not the internal os.

 Second degree (Type II= P.P. marginalis):

The lower edge of the placenta reaches the margin of

the internal os but does not cover it.

 Third - degree (Type III= P.P. incomplete centralis):

The placenta partially covers the internal os

 Fourth - degree (Type IV = P.P. complete centralis)
 Other risk factores

• smoking

• Cocaine cause vasoconstriction

• multiple pregnancy

• fetal growth restriction (FGR )

Diagnosis
History
 Acute constant severe abdominal pain
(present between contraction in labour)
which may be localised or diffuse.
 Dark vaginal bleeding results from
escape of blood from the retroplacental
haematoma.
 Cessation of foetal movement is
common
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 labour
pains .
It is recurrent, but may occur once in slight placenta
praevia lateralis. Fortunately, the first attack usually
not severe
Diagnosis
examination
 Acute constant severe abdominal pain
(present between contraction in labour)
which may be localised or diffuse.
 Dark vaginal bleeding results from
escape of blood from the retroplacental
haematoma.
 Cessation of foetal movement is
common
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 labour
pains .
It is recurrent, but may occur once in slight placenta
praevia lateralis. Fortunately, the first attack usually
not severe
 Investigations

US is the most simple, precise and safe method for

diagnosis of placental disorder

 Ultrasound: detects normally  . A partially full bladder is necessary to identify the lower
sited placenta with edge of the placenta. If it is less than 3 cm from the margin
retroplacental haematoma that of the internal os, it is diagnosed as placenta praevia.
may dissect the placental margin

 Tests for DIC (couvelaire uterus)
 In mid - pregnancy the placenta reaches the internal os in
up to 20% of pregnancies. With increasing gestational age
and the formation of the lower uterine segment, a gap
develops between the placental edge and the internal os "
placental migration". So it is recommended to repeat scan
when placenta praevia is diagnosed in mid - pregnancy.
Management of APH

Prior to admission
 Arrange for immediate transfer to the hospital.
 no vaginal examination and no vaginal pack, only a sterile vulval pad is applied.
 No oral intake as anaesthesia may be required.
 Antishock measures as pethidine IM, fluids and blood transfusion may be given in the way to the
hospital if bleeding is severe

At Hospital
 Assessment of the patient's condition (ABCD), general and abdominal examination and resuscitation
if needed.
 At least 2 unites of cross matched blood should be available.
 Ultrasonography for:
differentiation between abruptio placentae (retroplacental haematoma in a normally implanted
placenta), marginal bleeding (separation of the margin of a normally implanted placenta) and placenta
praevia (in the lower uterine segment),
 assessment of fetal viability age, position and presentation
Management of APH

 Regarding placenta Abruptio.  regarding placenta praevia.

 Maternal and fetal distress………emergent  Maternal and fetal distress………emergent CS

CS
 Term and stable mother(had Mild
bleeding)…….induction of VD (AROM and
oxytocin )
 Pre term and stable mother…….admit and
observe till maturity or labor
 Term stable fetus , mother vitally stable and edge
of PL >2cm from int. os ( type 1)……….induction
of VD
 Preterm ,mother and her fetus stable ………admit
and observe
 Term and stable and edge of PL <2cm from int. os
…………scheduled CS

Conservative management after

admission
• Reserve crossed matched blood
• Steroid for fetus lung
• Anti D if RH negative mother
• Continuous assessment of fetal
wellbeing till delivary
 velamentous cord insertion is
when a fetus' umbilical cord
abnormally inserts on the edge of
the placenta along the
chorioamniotic membranes,
causing fetal blood vessels to
travel unprotected from the
placenta until they come together
and reach the protection of the
umbilical cord.
succenturiate placenta is a
condition in which one or more
accessory lobes develop in the
membranes apart from the
main placental body to which
vessels of fetal origin usually
connect them