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ANTEPARTUM

HAEMORRHAGE

DEFINITION OF APH
Bleeding from the genital tract from 28
weeks gestation.
Complicates 3% of preg
Bleeding = fresh blood, clots and
soaking of a pad exclude show,
blood-stained vaginal discharge
ALWAYS = Obstetric Emergency

AETIOLOGY
Placental:
Abruptio Placentae
Placenta Praevia
Vasa Praevia
Non-Placental:
Ruptured Uterus
Decidual Bleeding
Ca Cervix
Other Local Lesions / Cervical Infection
APH of unknown origin

GENERAL MANAGEMENT
Complete history, examination and
depending on the status of the
patient, you would then resuscitate.
Never perform a digital vaginal
examination, until placenta
praevia has been excluded

Examining fingers may dislodge a part of the placenta from the


uterine decidua and cause life-threatening haemorrhage

Confirm placental location with


ultrasound
Obtain urgent obstetric
consultation

Both are a clinical diagnosis


Difference between PP and AP
- AP is painful pv bleeding and dark
pv clots
-PP is increased frequency and amt
of blood and painless haemorrhage

Assess the vitals BP, Pulse, RR, T


CAB
Fluid Resuscitation
Ringers Lactate - if patient is bleeding heavily, Insert 2
large-bore i.v lines

Preparations for immediate c/section may


be necessary depending on the clinical
state of the patient

A serious APH is almost always


caused by abruptio placentae or
placentae praevia. These 2 conditions
are treated differently and a correct
diagnosis must be made.

ABRUPTIO PLACENTAE
DEFINITION:

Premature separation of a normally


situated placenta from the uterine wall.
This separation causes haemorrhage
from the decidua basalis, with bleeding
between the placenta and uterine wall.
Occurs in about 1:80 pregnancies
Obstetric emergency!

RISK FACTORS
Pre-Eclampsia = most common cause!
Results in explosive haemorrhage & delivery
(precipitous labour)
Previous abruptio placenta

1 previous AP 10-15% risk of recurrence


2 previous AP 25% risk
Pre-labour ROM
Prolonged ROM
Conditions that predispose to vascular compromise

Diabetes mellitus, Chronic renal failure

RISK FACTORS
Multiple pregnancy
Blunt abdominal trauma to the mother
Advanced maternal age
Social factors: cigarette smoking, cocaine abuse

CLINICAL PRESENTATION
HISTORY: risk factors, prev admission for APH/ abruptio
EXAMINATION:
Concealed / Revealed
Concealed no external bleeding, retroplacental clot
between placenta & uterine wall
Revealed Vaginal bleeding (can be fresh bleeding
if marginal placental separation) & Retroplacental
haemorrhage Dark red clots

Abdominal Pain
Pain from contractions if labour has commenced
Severe shock- pale, hypotension, tachycardia
Proteinuria if pre-eclamptic

Uterus: tender, woody hard, irritable,


bigger than expected for dates (due to
clot)
Fetus: difficult to feel, decreased
movements, inaudible heart
On PV: bleeding- dark clots. If labour- cervix
dilated

Grades of Abruptio
BABY IS ALIVE!!!
Grade 1
Retrospective diagnosis
No Signs & Symptoms
Baby is born alive, placenta
comes out
Grade 2
Slight PV bleed + LAP
+ irritable uterus
Diagnose abruptio
placentae
before baby is born baby
alive

DEAD BABY = Grade


3
Grade 3A:
Bleeding with dark, red cloths
Shock, hard tender uterus
Dead Baby,
no coagulopathy

Grade 3B:
Same as 3A but
with Coagulopathy

INVESTIGATIONS:
Urine & Blood Investigations:
FBC
Hb or Haematocrit estimation (to determine if blood
transfusion is needed)

Platelet count and clotting profile (as markers of


severe coagulopathy).
U & E - Creatinine levels for renal function

Imaging Studies
U/S
May show blood between placenta & uterine wall
absence does not exclude AP
May confirm foetal death
Assess Viability of the Foetus

COMPLICATIONS
Maternal:
1.
2.
3.
4.

Severe Blood loss Anaemia


Associated pre-eclampsia
DIC & PPH
Acute Renal Failure

Foetal:
1. Foetal Hypoxia & Cerebral Palsy d/t
placental separation
2. Pre-Term delivery complications of
prematurity

MANAGEMENT OF ABRUPTIO
CALL FOR HELP!
RESUS - CAB:
cannulate, catheter, breathing & bloods

Correct Hypovolaemia

2 large bore IV lines (16G)


IV fluids: Crystalloids MRL
Take Blood: Cross-match, FBC, U/E and INR
Blood products: transfuse 2-4 units of blood

Correct Anaemia (transfuse packed cells)


Correct coagulopathy (severity based on INR, order
4 units Fresh dried plasma: 2 units emergency, 2
units on standby)
Insert Foleys catheter
Facemask oxygen
Observe patients general condition/vitals, ?CVP

KEEP UP WITH RESUS with IV fluids/blood:

monitor the patient and maintain


resuscitation because there is risk of
coagulopathy if stopped
COUNSEL PATIENT
Assess FOETAL VIABILITY:
Viable (>28 weeks) deliver
Deliver within 6-8 hrs
Only rupture the membranes once you have blood available!

Not viable (< 28 weeks) dont deliver

Monitor for and treat COMPLICATIONS


Hypovolaemia, Anaemia, Coagulopathy

TIMING & MODE OF DELIVERY


NVD dead fetus, severe fetal distress,
premature/under 1 kg, imminent delivery,
absence of contraindications to NVD
Immediate C/S Indications:

1. Baby alive & viable, good


condition (CTG)
2. Previous C/S
3. Failed to keep up with resus
4. Recurring coagulopathy
5. Multisystem organ failure
6. Any obstetric indication
Multiple Pregnancy &
Malpresentation

POST DELIVERY MANAGEMENT


Administer a drip with oxytocin 20units in 1
liter of Ringers lactate to prevent
postpartum haemorrhage Monitor Urine
output, BP, HR, CVP
Postnatal bloods: Hb and haematocrit
,platelet count, serum urea and creatinine on
the day after delivery
If dead fetus -grief counselling
breastfeeding/ suppression
Contraception
future fertility

Placenta Praevia
DEFINITION
Implantation of the placenta in the lower
segment of the uterus, or the placenta is in
front of the presenting part.
Lower segment definition:
On ultrasound internal os
Physiological isthmus (between histological and
physiological os)
On pv what u feel in the cervix

Major placenta praevia covers internal os


Minor placenta praevia does not cover os

Major placenta praevia


Partial = Grade 3 placenta preavia
Complete = Grade 4 placenta praevia

Minor placenta praevia


Marginal implantation, the lower edge of the placenta does
not reach the internal os = Grade 1 placenta praevia
Implantation on the lower segment without covering the
internal os = Grade 2 placenta praevia

Classification
Grade Description
Grade 1 Placenta is in lower segment, but
the lower edge does not reach the
internal os.
Grade 2 Lower edge of placenta reaches
the internal os but does not cover
it.
Grade 3 Placenta covers internal os
partially
Grade 4 Placenta covers the internal os

Risk factors for Placenta


Praevia

1. Previous placenta praevia


2. Previous c/section
3. Multiple pregnancy
4. Myomectomy
5. Alcohol/smoking during
pregnancy
6. Teenagers and AMA (> 35 y/o)

Clinical Presentation

Painless PV bleeding in the third trimester.


d/t expansion & stretching of the lower uterine segment which
leads to separation of the low-lying placenta.
During labour, a large separation may occur life threatening
haem.

Bright red blood no pain/clots, haem with each episode


over days/weeks

Mother signs of shock (cool, clammy, confused, pale,etc)

Abdominal exam:
If previous c/section - scar
fetal movements present, FH, fetal parts easily felt
soft, non-tender uterus,
Malpresentation/(4 %) abnormal lie
high presenting part/failure to engage
EIT (exam in theatre): pv para cervically and push the head into
the cervix and if u palpate sponginess then its the placenta

Diagnosis
Clinical Diagnosis
Investigations:
MUST LOCALIZE THE PLACENTA ON U/S
o Trans abdominal ultrasound: Anterior placentas
o Trans-vaginal ultrasound:
safe in the presence of placenta praevia
is more accurate than trans-abdominal
Locates posterior placentas
MRI:
especially posterior placentas
also where trans-abdominal ultrasound images have
been unsatisfactory.

Antenatal
Women with major placenta praevia who have previously
bled should be admitted and managed as inpatients from
34 weeks of gestation.
Women who are at risk should visit a nearby hospital
immediately if she experiences any bleeding, contractions
or pain (including vague supra-pubic pain)
Prior to delivery, all women with placenta praevia
should have had antenatal discussions regarding:
1. delivery,
2. risk of haemorrhage,
3. possible blood transfusion and major surgical
interventions such as a hysterectomy
4. any objections or queries dealt with effectively

Before 37 weeks + PVB not severe


Admit for observation of further PVB bed
rest, IV line access (crystalloid)
check Hb - correct anaemia, assess for shock,
FBC, U&E, cross-match
Do not perform digital exam, except if in
theatre, prepped for emergency caesar
After
the
37th week
(startable
of 38
week)
Do not
discharge
unless
tothreturn

If the placenta
does
not cover
the cervix, or
immediately
should
bleeding
recur
Delivery
cannot by
be c/section
felt, can rupture
membranes
and
if bleeding
recurs and
induce
labour
fetus
viable.

Elective
preferred method
Before
34 c/section
weeks
however
cause massive
haemorrhage
IV beta-2can
stimulants
can be used,
provided

Manageme
nt
1 -PP
Typical
presentation
-small bleed
-stops spontaneously

Depends on
1. clinical
2.
severity of bleeding
presentation
3. degree of praevia
4. gestational
age associated

-Admit pt
-Bed rest, ( of
left
lateral packed cells
-correction
anaemia
position
) discussions regarding
--antenatal
delivery, the risk of haemorrhage,
possible blood transfusion and major
surgical interventions such as a
hysterectomy and any objections or

Manageme
nt PP

Resuscitate ( IF
NECESSARY)
- ABC - oxygen via face
mask
- 2 wide bore (16 G) IV line
- Transfuse 2-4 units of
blood
- Fluid Ringers Lactate
-Coagulopathy 4 Fresh Dried

Management
Con..
- Bloo
FBC - haemoglobin or haematocrit
ds
estimation, platelet count
-U+E - urea and creatinine levels for renal
function
-INR - clotting profile (as markers of severe
coagulopathy)
-Crossmatch
oMonitor Patient
-Insert a Folly Catheter
- + CVP ( measure hourly)
-observe general condition
-monitor BP, HR, Pad checks

Assess
-Look for causes of Preterm
Labour
-vaginal swabs
-Fetal kick count
-Decide on timing of
delivery Elective C/S once
fetus is viable(37
completed wks ideally)

Between 28(viability) - 34
weeks
steroids should be givenBetamethasone 12mg IM / 12
hourly (FLM)
If contraction occur before 34
weeks they may be suppressed
Tocolyse B2 Stimulant
C\S should be performed
when the pregnancy

>37 weeks
-If on ultrasound scan the placenta covers
the cervix or the placenta perform
c/section.
-If the placenta does not cover the cervix,
or cannot be felt, u can rupture
membranes and induce labour
-c/section can however cause massive
haemorrhage and should be performed
by an experienced doctor or consultant
obstetrician.
-Transfer to a level 2 or 3 hospital
for elective c/section.

Management Con
Post Delivery Management
-Administer a drip with oxytocin
20units in 1 liter of Ringers lactate to
prevent postpartum haemorrhage (PPH)
-Monitor Urine output, BP, H.R, CVP
-Postnatal blood tests for Hb and
haematocrit
,platelet count, serum urea and
creatinine on the day after delivery
-if dead fetus -Mum should be provided
with grief counseling

PP is assoc with morbidly adherent placenta (placenta


accreta), esp in previous C/S or previous uterine
surgery
Ultrasound, and MRI (if available), should be
performed to exclude morbidly adherent placenta.

Morbid adherence - Take


consent for TAH
Place
nta
accre
ta

Place
nta
incre
ta
Place
nta
percr
eta

portion, or the whole


maternal placental surface,
is abnormally adhered to
the uterine surface. The
decidua basalis is partially
or totally absent, resulting in
choronic villi attaching
directly to the myometrium
penetration of the villi into,
but not through the
myometrium
penetration through the
myometrium up to the
serosal surface of the
uterus

C/section in placenta praevia


Lower segment retract the bladder
incision with low placental implantation- may encounter
blood vessels, causing severe hemorrhage before delivery.
An anterior placenta may need to be incised or pushed
aside to deliver the baby
Placenta rarely delivered before the baby
Umbilical cord must be clamped quickly to prevent fetal
blood loss
After c/section careful obs for PVB + IV oxytocin infusion
of 20 units in 1litre MRL, run for a least 8 hours

Complications
Maternal

Fetal

APH
Mal-presentation
Abnormal
placentation
PPH

IUGR( 15%
incidence)
Premature
delivery
Death

d risk of
puerperal
sepsis

NON-PLACENTAL CAUSES
RUPTURED UTERUS
Uncommon cause of APH
Risk factors:
-Previous myomectomy or classical C/S
-Excessive oxytocin
-Multi-parity
Presentation: Painful vaginal bleeding with
loss of station, absent fetal heart sounds
and movements
Management: resuscitation, emergency

LOCAL LESIONS-Benign
Warts, polyps, ulcers, trauma during coitus
or iatrogenic lacerations
Cervicitis: cervical swab and antibiotics
LOCAL LESIONS-Malignant
Ca Cervix: rare cause of APH. After you
have excluded the placental causes do a
SSE and examine the cervix and vagina
thoroughly (primary vaginal carcinoma or
choriocarcinoma)

APH of unknown origin (APHUO)


Majority of cases of mild APH
Diagnosis of exclusion
Only complaint is painless PVB with normal fetal
movements
Most likely cause: minor separation of the placenta
Chorioamnionitis may also be responsible
Management:
Admit
26-36 weeks: daily CTG for at least 2 days, d/c if no PVB
> 37 weeks: IOL

Abruptio vs Placenta
Praevia

Abruptio
(Pt
Hypertension,
Placenta

Placenta Praevia

(SYMP) Pain(generalized),
FMF/ abs
EXA
M
Shock

EXA
M
(GEN) shock

prev abruptio,
blunt abd
trauma, ROM

(GEN
Hard tender irritable
)
uterus, HOF increased
(ABD for GA, difficult to
)
asses fetus, absent
(PV)- FHR (sometimes)
(U/S) Dark imminent bleeding
with clots Normal placental
site,

(Pt Prev C/S or uterine


)surgery (SYMP)Painless

(ABD) Soft, non-tender


uterus
malpresentation or
high presenting
part
(PV) Bright red flow
(U/S) Placenta implanted on
lower segment