ANTEPARTUM

HEMORRHAGE
Definition: Per vaginal bleeding during pregnancy from 24w of gestation to term

A. SEVERE/SIGNIFICANT BLEEDING
1.Placenta Previa

2.Abruptio Placenta

3.Preterm Labour

4.Uterine Rupture

B.SPOTTING HEMORRHAGES:
1.Sexual Intercourse

2.Trichomonas Vaginalis

3.Recent Vaginal Examination

4. Haemorrhoids
C.OTHERS:
1.Lacerations

2.Polyps

3.Ectropion

4.Severe cervicitis

5.Carcinoma

6.Morbidly Adherent Placenta (accrete, increta, percreta)

7.Undeterminate APH
 DEF: Placenta implanted over or very near to the internal
cervical os diagnosed >34w

CLASSIFICATION:

TYPE 1: Placenta is <5cm from internal os (low lying)-

minor

PLACENTA
PREVIA TYPE 2: Placenta reaching internal os margin-minor

TYPE 3: Placenta overlies partially of the internal os-

major

TYPE 4: Placenta completely covers internal os-major

RISK FACTOR:

1.Advanced maternal age

2.Multipara

3.Previous uterine scar (caesarean/other uterine surgery)

4.Uterine anatomical abnormality

5.Smoking
 COMPLICATION
Maternal Fetal
Maternal haemorrhage • Malpresentation
causing :
• Anemia
• Shock
• PPH

Obstructed labour IUGR

High risk to have Preterm labour

“Morbidly Adherent
 CLINICAL FEATURE
History Fetal
Recurrent painless Soft, non-tender
prevaginal in 3rd abdomen
trimester
Spontaneously/ after High presenting
hard exercise or post- part/malpresentation
coital

Risk factors Compromised maternal

circulation
INVESTIGATION

1. Transabdominal Ultrasound
- confirm diagnosis by repeated scan after 34th weeks.

2. Colour Doppler Ultrasound

- if patient has high risk of Morbidly Adherent Placenta
TREATMENT

A. Minor PP
-manage conservatively as outpatient
-may allow SVD

B.Major PP
-if no previous bleeding, counsel patient for:
1. Avoid abdominal massage
2. No coitus
3. Bed rest
4. TCA stat if having sign & symptoms of labour
-if had previous bleeding
• Admit anw from 34w

• For expectant management

1. biweekly scan

2. Weekly CTG and FBC

3. To inform if having per vaginal

bleeding

4. Watchout for sign & symptoms of

labour
 Clinical Assessment

MANAGEMENT
Mother Stable Mother Unstable

OF
< 34 weeks > 34 weeks Stabilize
PLACENTA
Admit In patient management
ABC
2 large bore cannulas.
PREVIA
IM dexamethasone until delivery Fluid / Blood
replacement

Aim LSCS at 38-39 Aim LSCS at 38-39

Delivery via LSCS
weeks weeks

Recurrent APH Recurrent APH

Expedite LSCS Expedite LSCS