Antepartum Haemorrhage (APH)

Contents
• Definition
• Importance
• Causes
• Management of APH
• Prognosis
 Bleeding in pregnancy

Bleeding
in early APH PPH
pregnancy
 Antepartum Haemorrhage
[APH, prepartum haemorrhage ]

• Antepartum haemorrhage is :
- bleeding from the vagina after 24 weeks of pregnancy
but before the birth of the fetus .

• Epidemiology :

• Affects 3-5% of all pregnancies

3 times more common in multiparous than primigravidae .

 APH : severity
• Spotting – staining, streaking or blood
•

• Minor haemorrhage – blood loss less than 50 ml that has settled

• Major haemorrhage – blood loss of 50–1000 ml,

WITHOUT signs of clinical shock

• Massive haemorrhage – blood loss >1000 ml and/or SIGNS OF CLINICAL

SHOCK
 APH : severity

Important indicators of volume depletion ----

• signs of shock and

• presence of fetal compromise or fetal demise.

• Amount of blood lost is often under estimated

• Bleeding coming from introitus may not represent the total

blood lost [eg. Concealed haemorrhage.]
 Causes of APH
Utero- Lower genital Inherited Unexplained or
Placental tract bleeding bleeding indeterminate
disorders
bleeding

Abruptio Cervicitis Very rare 40% of APH

placenta 1/100 1in 10000 women

Placenta praevia Cervical polyp

1/200

Vasa praevia Ca cervix

1/2000 -3000

Ruptured uterus Vulval varices

[< 1% in scarred Local trauma
uterus.]

 ? Blood Vaginitis
stained show Vaginal ca
Placenta praevia & abruptio placenta

• Placenta praevia and placenta praevia acreta and

abruptio placenta : ↑↑↑ Maternal and fetal morbidity
and mortality

• rising incidence of caesarean sections + increasing

maternal age ↑↑ number of cases of placenta
praevia and its complications, including placenta
acreta

• (RCOG 2014)
Placenta Praevia
 Placenta Praevia
• Definition
Insertion of the placenta, partially or fully, on the lower segment of
the uterus

Incidence 0.5% to 1% of all pregnancies

 Classification of degrees of Placenta praevia

• Four types:
M
I – Type I: Placenta encroaches lower segment but does not
N
O reach cervical os
R
– Type II: Reaches cervical os but does not cover it

– Type III: Covers part of the cervical os

M
AJ
O
R
– Type IV: Completely covers the os, even when the cervix is
dilated
Type ll B = major PP
Note: In all types
“A”-When Placenta is anteriorly located
“B”-When Placenta is posteriorly located
 Placenta praevia : types

Type I Type ii
[minor] [minor]

lateral marginall
Type III Type IV
[major] [major]

central central
 USG GRADING

• Placental edge less than 1 cm from the internal os

most likely placenta praevia.

• Placental edge greater than 2 cm from the internal os

not praevia.

• Patients with the edge between 1 to 2 cm of the internal os,

however, remain in the gray zone.
 USG GRADING

• If at 36 weeks placenta is less

than 2cm from internal os , prefer
LSCS (RCOG)
 Risk factors
 Multiparity
 Advanced maternal age (> 40 yrs)
 Multiple pregnancy

 Prior placenta praevia

 Prior LSCS
 Previous termination of pregnancy
 Submucous fibroid

 Deficient endometrium eg endometritis, manual removal of

placenta, uterine scar, curettage
 ART
 Smoking
 Clinical Features :

• Recurrent PAINLESS vaginal bleeding / provoked bleeding

• Abdominal findings : Uterus is soft, relaxed and NON TENDER

intermittent contractions may be palpated [labour]
Presenting part is usually high
Abnormal presentation[transverse/breech ]or
cephalic

• Maternal cardiovascular compromise

• Foetal condition satisfactory until severe maternal compromise

• *VAGINAL EXAMINATION- SHOULD NOT BE DONE

 Diagnosis by TVS
Diagnosis of placenta praevia should be made after 34 weeks
of pregnancy

[ as lower segment forms from 26 till 34 weeks apparent

migration of placenta from low lying to normal placenta )

• If at 36 weeks placenta is less than 2cm from internal

os , prefer LSCS (RCOG)
 Placenta Praevia

• Low-lying placenta seen in 12% of ultrasound scans at

16-20 weeks

• At 32 weeks:
– Of those covering os -- 40% persisted as placenta praevia
– Of those not covering the internal os, praevia did not persist

Placentae that lie close to the internal os—but not over it—
during the second trimester or early third trimester are
unlikely to persist as a praevia by term
Transvaginal sonogram in the second trimester demonstrating
form of placenta praevia. In this case, the inferior placental edge is
shown to encroach upon the posterior cervix but not reach or cover
the internal cervical os (arrow).
 Complications
MATERNAL FETAL

 Haemorrhage and Maternal shock IUGR

 Placental abruption Prematurity iatrogenic/spontaneous

 PPH Fetal hypoxia

 Morbid adherence of placenta [placenta IUFD

accreta complicates 10%-35% of PP with
prior C- section]

 Sensitization of mother for fetal blood in Rh

–ve patients
 Malpresentations
 Anemia
 Problems with Placenta praevia

• 1)Haemorrhage [Mild or massive] : causing foetal

distress or death / maternal shock or death

• 2) Preterm labour

• 3) High association with placenta accreta [ 5% ]

 Higher risk of accreta if prior caesarian delivery .

Praevia + one caesarian --- 10 -25 %
Praevia + two or more caesarian > 50%
 Antenatal Management of Placenta Praevia

A. Prevention and treatment of anaemia during the antenatal

period is recommended

B. Women with placenta praevia in the third trimester should be

counseled about the risks of preterm delivery and obstetric
haemorrhage

C. Those with major praevia who have previously bled should be

admitted from approximately 34 weeks of gestation.

D. Those with minor praevia or those who are asymptomatic

outpatient care can be considered .

•
 Home-based care

• Home-based care requires :

• close proximity to the hospital,
• constant presence of a companion
• full informed consent by the woman.

• She should attend hospital immediately if she

experiences any bleeding, contractions or pain (including
vague suprapubic period-like aches).

Note : strictly no digital vaginal examination

 Management of Placenta Praevia
***
Mild to moderate bleeding [<37 weeks ]
Expectant management : In hospital [Mcafee ]

Aim : to continue pregnancy for fetal maturity without compromising

maternal health

Suitable cases :
 pregnancy < 37 weeks,
 good maternal status ,
 no active vaginal bleeding,
 fetal wellbeing assured .
 Expectant Management ***

If preterm give steroids to mother (Dexamethasone

IM)
(better not to use tocolytics to supress labour in a
bleeding patient)

Foetus : CTG to r/o foetal distress

Keep the patient in hospital till 38 weeks for vaginal

delivery / LSCS
 Mcafee regime
• < 37 weeks
• Maternal condition stable
• No active bleeding
• Fetus not compromised
• ADMIT :
• Rest
• Pad chart
• Monitor vital signs
• Cross match 4 units of blood
• Steroids ( if < 34 weeks GA )
• Daily FM count
• Daily CTG
• USG
• Plan for delivery at GA > 37 weeks
 Expectant management

Prematue termination may have to be done if :

• Recurrence of brisk haemorrhage and which is continuing
• Fetus is dead
• Fetus found to be congenitally malformed
 Management of severe bleeding
ADMIT
Initiate red alert (obstetrician , anaesthetist, sister on call & blood
bank
Do ABCDE & Transfuse blood if necessary

A: maintain airway with mask or nasal tubes

B: oxygen at 5-8 L/min

C: maintain circulation with 2 IV drips 14-16 G cannula (start

crystalloids like Hartmann's or normal saline or colloids like
heamaccel or plasma)
cross match 2 to 4 units of blood

D: insert Foley’s catheter to ensure urine drainage , monitor I/O

chart

E elevate legs

Emergency LSCS
 Management of Placenta Praevia --***
severe bleeding
assess patient :
amount of blood loss
pallor
BP /pulse : ½ hourly

Monitor vaginal bleeding /pad chart

Continuous CTG

Cross match 4 units of blood

Maternal steroids if < 34 weeks

Mode of delivery : LSCS

If fetal death …. Consider vaginal delivery

 Management of placenta praevia

• Active interference is done if :

• Bleeding occurs at or after 37 week s of pregnancy
• Patient is in labour
• Maternal condition is compromised at the time of admission [heavy
bleeding emergency LSCS
• Bleeding is continuing emergency LSCS
• Baby is dead / congenitally malformed

• Grades I and IIa - May be able to deliver vaginally

Grades IIb,III and IV - Will require caesarean section
 At what gestation should elective
delivery occur?
• Elective delivery by caesarean section in asymptomatic
women is not recommended before 38 weeks of
gestation for placenta praevia, or

• before 36–37 weeks of gestation for suspected placenta

accreta.

• while in those with uncomplicated placenta praevia

delivery can be delayed until 38–39 completed weeks of
gestation.
Problems during placenta praevia at LSCS

High risk of Post partum haemorrhage leading to

DIVC
 Placenta acreta—what is it ?

• A morbidly adherent placenta or a placenta that has

grown into the basal layer of decidua myometrium
perimetrium
• and includes : placenta acreta, increta and percreta .

• for ease of description the term P acreta is used as a general term

for all of these conditions.
 Placenta Acreta
• Diagnosis is by US Doppler

• Rx : Classical CS / LSCS and deliver the foetus

& followed by Hysterectomy [uterus with placenta
attached}
 Placental Abruption
• Definition :

Premature separation of a normally situated placenta , from the

uterine wall .

• Placental abruption should be considered in any pregnant

woman with :
*abdominal pain
with or without PV bleeding,
as mild cases may not be clinically obvious

• Incidence is 0.5% to 1.0%.

Placental Abruption : pathology

• Main changes

Hemorrhage into the decidua basalis

decidua splits

decidual hematoma

separation, compression, destruction of the placenta

adjacent to it
 Types of abruption
1. Revealed abruption
2. Concealed abruption
3. Mixed type

• Revealed abruption Concealed abruption

Placental abruption
Retro placental blood clot
PLACENTAL ABRUPTION ------- RISK FACTORS

 Abruption in previous pregnancy

[3-16% ][with 2 previous abruptions – 50% rec. ] IUGR
 Increased age and parity
Multiple pregnancy
 Vascular diseases eg.
pre eclampsia Hydramnios
maternal hypertension
renal disease Cigarette smoking
SLE
APS Cocaine /amphetamine use

Uterine leiomyomas
 Mechanical factors eg.
trauma Thrombophilias
intercourse
sudden decompression of uterus
[multiple preg. , poly hydramnios ]
 Premature rupture of membranes
 Intra uterine infection
 Low BMI
 Placental Abruption

• Clinical features

• **Painful vaginal bleeding

Pain is usually continuous
1.Mild type
Abruption---- ≤ 1/3
• Vaginal bleeding may be present or absent

2.Severe type -----

• Abruption > 1/3 [Large retro placental haematoma]
•
• *Vaginal bleeding associated with persistent abdominal
• pain
• OR

– abdominal pain or backache with no bleeding

(concealed)

– Amount of bleeding seen may not reflect the clinical signs

of patient and baby
 Placental abruption : clinical features

• Features of hypovolemic shock

• Tachycardia & hypotension may be out of proportion
compared to amount of vaginal bleeding

• Abdominal exam : Uterus tense / tender

• “Woody” hard uterus

• Difficult to palpate fetal parts

•
• Change of fetal heart rate – CTG changes

• Vaginal & speculum examination : [after ruling out

placenta praevia]
to see cervical dilatation and where the bleeding is from
.
 Placental abruption
Investigations

• Ultrasonography
Mainly to exclude placenta praevia
Location of placenta
Retroplacental hematoma
Fetal viability
Most of the time findings will be negative
* Negative findings do not exclude placental abruption

• CTG – Sinusoidal pattern, Fetal tachycardia or bradycardia

• Laboratory investigations
1. Investigation for Consumptive coagulopathy – Platelet
count/BT/CT/PT/INR & aPTT
2. Liver and Renal function tests
 Diagnosis of abruption
 Diagnosis is done on clinical grounds mainly based on
History and Examination

 U/S is sometimes helpful as it can show retroplacental clot

(>300ml )
and more importantly to rule out placenta praevia
U/S : if no placenta praevia , suspect abruption
 Abruptio placenta – grades [clinical]
• Grade 0 --- clinical features may be absent .
• Diagnosis is made after inspection of the placenta
following delivery..

• Grade 1--- external bleeding is ------slight.

• Uterus –irritable, tenderness may or may not be present
• Shock is ----absent
• FHS is good
•
• Grade 2--- External bleeding------ mild to moderate
• Uterine tenderness is always present
• Shock is----- absent
• Fetal distress or even fetal death occurs

Grade 3-- -bleeding is moderate to severe or may be concealed

uterine tenderness is ----marked
shock is pronounced
fetal death is the rule
associated coagulation defect or anuria may complicate
 Abruptio placenta –complications
MATERNAL FETAL

 Hypovolemic shock  Small for gestational age and

IUGR

 Renal tubular necrosis & ac. Renal  Prematurity [iatrogenic &

failure spontaneous]

 PPH  Fetal hypoxia

 Sensitization of Rh –ve mother  Fetal mortality

 DIC

 Amniotic fluid embolism

 Management of abruption
1)Admit & asses patient :
amount of blood loss

Pallor /BP (hypotension) /tachycardia , [ BP /pulse ½ hourly ]

Abdomen: tense , tender uterus > dates,

difficult to feel foetal parts,
head can be engaged
FHS
 Management of abruption
initiate red alert (obstetrician , anaesthetist, sister on call & blood
bank
Do ABCDE & Transfuse blood if necessary

A: maintain airway with mask or nasal tubes

B: oxygen at 5-8 L/min

C:maintain circulation with 2 IV drips Size 14-16 cannula

(start crystalloids like Hartmann's or normal saline or colloids like
heamacel or plasma) & cross match 2 to 4 pints blood& DIVC
regime

D: insert Foley’s catheter to ensure urine Drainage , monitor I/O

chart

E : elevate legs
 Delivery of foetus
Delivery based on maternal and foetal condition (distress )
<37 weeks
a) Slight bleeding with no effect on mother or foetus, sometimes can
leave alone till foetus mature(expectant management)

b) Maternal tachycardia , low BP , no foetal distress: induce &deliver

vaginally (majority of cases)

c) Maternal tachycardia, low BP, foetal distress : do LSCS

d) If foetal death , deliver vaginally

> 37weeks --- deliver [vaginal/LSCS]

 Problems of abruption after delivery

High risk of Post partum haemorrhage leading to

DIVC
 Distinguishing features of placenta praevia and
Clinical features abruptio placenta Abruptio placenta
Placenta praevia
Nature of bleeding Painless , apparently Painful and continuous,
causeless and Often attributed to pre
recurring eclampsia and trauma
Character of bleeding Always revealed Revealed ,concealed
Bright red Usually mixed
dark red
General condition and Usually proportionate Out of proportion to
anemia to visible blood loss visible blood loss in
case of concealed or
mixed variety
Features of preeclampsia Not relevant Present in 1/3rd of
cases
Pain Completely painless Sharp ,stabbing pain in
abdomen
Uterus Soft , unless uterine Hard board like
contraction is present abdomen
Pathology Abnormal implantation Sudden separation of
of placenta in the lower normally situated
uterine segment placenta
 Vasa praevia
• Vasa praevia is an obstetric complication in which
• fetal blood vessels traverse the fetal membranes over the
internal cervical os.
• These vessels are at risk of rupture when the supporting
membranes rupture, as they are unsupported by the umbilical cord
or placental tissue.

•
 Etiology/Pathophysiology

•These vessels may be from either a velametous insertion

of the umbilical cord or
•may be joining an accessory (succenturiate) placental lobe to
the main disk of the placenta.
•If these fetal vessels rupture the bleeding is from the feto
placental circulation, and fetal exsanguination will rapidly
occur, leading to fetal death.[high fetal mortality –50-70 % ]
Eccentric (velamentous) cord
insertion

Bilobate placenta
Succenturiate placenta

Bilobate placenta
 Diagnosis
Diagnosis rarely confirmed before delivery
The diagnosis is usually confirmed after delivery on examination of
placenta and membranes .

1. The classic triad of the vasa praevia is:

• membrane rupture,
• painless vaginal bleeding and
• fetal bradycardia.
•
•2.Vessels may be palpable through dilated cervix
•3.Amnioscopy
•4.Vessels may be visible on ultrasound (Transvaginal colour Doppler
ultrasound)
 Vasa Previa management

• urgent LSCS

• Neonatologist involvement

• Aggressive resuscitation of the baby with blood transfusion

following delivery
 Rupture of Uterus

High Index of clinical suspicion

In all cases of antepartum and intra partum haemorrhage uterine

rupture must be excluded
 Risk factors

• Scarred uterus –Previous caesarian section & other uterine

surgeries

• Grand multipara

• Injudicious use of oxytocin & prostaglandins

• Shoulder dystocia

• Forceps delivery

• Trauma

• Uterine abnormalities
 Rupture of Uterus-
* clinical features

MATERNAL FETAL

 Pain between contractions

 Fetal distress-CTG changes
 Scar tenderness [earliest sign]

 Vaginal bleeding
 Loss of station
 Maternal tachycardia and
Hypotension  Absence of FHS
 Loss of uterine contractions
 Easily Palpable fetal parts
 Haematuria through maternal abdomen

 Postpartum haemorrhage may

be a sign
 Complications
MATERNAL
FETAL

– Hemorrhage – Hypoxia

– Bladder rupture – Acidemia

– PPH – Death

– DIC

– Maternal death
 Rupture of Uterus Management

EMERGENCY LAPAROTOMY

Deliver the baby

Uterine repair if possible specially in primi gravida

PPH haemostasis sequence

OR

Caesarian hysterectomy (may be

preferred in multigravida)
 Rupture of Uterus

• Uterine scar dehiscence: Uterine rupture:

 Separation limited to old scar,  Separation of scar 

extension,
 Peritoneum overlying is intact
 Rupture of overlying
 Fetal membranes remain intact, peritoneum

 Fetus is not extruded intra  Rupture of fetal

peritoneally . membranes with extrusion

 Usually no fetal distress /  Results in fetal distress /

maternal Hemorrhage maternal hemorrhage

 Maternal mortality

 Fetal mortality = 35%

 Comparison of Presentation of
Abruption v. Praevia v. Rupture

Abruption Praevia Rupture

Abd. pain present absent variable

Vag. blood old or fresh fresh fresh
DIC common rare rare
Acute fetal common rare common
distress
Thank You
 Antenatal management
• Prevention and treatment of anaemia during the
antenatal period is recommended.
• Where should women with placenta praevia be
cared for in the late third trimester?
• Women with placenta praevia in the third trimester
should be counselled about the risks of preterm delivery
and obstetric haemorrhage, and their care should be
tailored to their individual needs.
• Any home-based care requires close proximity to the
hospital, the constant presence of a companion and full
informed consent by the woman.
• those with major praevia who have previously bled should be
admitted from approximately 34 weeks of gestation, while outpatient
care can be considered for those with minor praevia or those who
are asymptomatic. International opinion is similar, with the Royal
Australian and New Zealand College of Obstetricians and
Gynaecologists recommending that all women at risk of major
antepartum haemorrhage should be encouraged to remain close to
the hospital of confinement for the duration of the third trimester of
pregnancy.
• Where possible, home-based care should be conducted within a
research context.
• If women are managed at home, they should be encouraged to
ensure they have safety precautions in place, including having
someone available to help them should the need arise and,
particularly, having ready access to the hospital.
• It should be made clear to any woman being managed at home that
she should attend immediately she experiences any bleeding,
contractions or pain (including vague suprapubic period-like aches).
 In what situations can vaginal delivery be
contemplated for women with a low-lying
placenta?
• The mode of delivery should be based on clinical judgement
supplemented by sonographic information.
• A woman with a placental edge less than 2 cm from the internal os
in the third trimester is likely to need delivery by caesarean section,
especially if the placenta is thick, but the evidence for this is poor
and further research in this area is needed.
• As the lower uterine segment continues to develop beyond 36
weeks of gestation, there is a place for TVS if the fetal head is
engaged prior to an othe
• Decisions regarding the mode of delivery take into account clinical
factors as well as ultrasound findings and the woman’s preferences,
especially if the fetal head has entered the pelvis. Ultrasound can
add to this information in terms of where the fetal head is relative to
the leading edge of the placenta, and the thickness of the
encroaching tongue of the placenta has been shown to influence
outcome: the thicker the placenta (over 1 cm), the greater the
likelihood of abdominal deliver rwise planned caesarean section.
 At what gestation should elective delivery
occur?
• Elective delivery by caesarean section in asymptomatic women is not
recommended before 38 weeks of gestation for placenta praevia, or
before 36–37 weeks of gestation for suspected placenta accreta

• Individual characteristics should be considered, but with the planning

needed for the especially high-risk cases suspected of having placenta
accreta, planned delivery at around 36–37 weeks of gestation (with
corticosteroid cover92) is a reasonable compromise,
• while in those with uncomplicated placenta praevia delivery can be
delayed until 38–39 completed weeks of gestation.
 What preparations should be made before
surgery?

• Placenta praevia without previous caesarean section carries a risk

of massive obstetric haemorrhage and hysterectomy and should be
carried out in a unit with a blood bank and facilities for high
dependency care.

• The care bundle for suspected placenta accreta should be applied

in all cases where there is a placenta praevia and a previous
caesarean section or an anterior placenta underlying the old
caesarean scar scar.
 What blood products are needed?

• Placenta praevia Blood should be readily available for the

peripartum period;
• whether ready cross-matched blood is required and in what amount
will depend on the clinical features of each individual case and the
local blood bank services available.
• When women have atypical antibodies, direct communication with
the local blood bank should enable specific plans to be made to
match the individual circumstance.