Dr. Maryam Al –Jaber Dr.

Omnia Darweesh
Consultant, Family Medicine Resident, Family Medicine

March, 2015
1) Identify major causes of late pregnancy bleeding

2) Systematic approach to antepartum hemorrhage

3) Specific treatment based on diagnosis

4) Identify causes of postpartum hemorrhage

5) Prevention and management of postpartum

hemorrhage
Antepartum hemorrhage (APH) is defined as
bleeding from or in to the genital tract, occurring
from 24+0 weeks of pregnancy and prior to the
birth of the baby.
RCOG Guidelines
APH complicates 3–5% of pregnancies and is a
leading cause of perinatal and maternal mortality
worldwide.
HPI: 37 yo pregnant female of 33 weeks gestation
presents to the ER because of significant vaginal
bleeding over the past hour. The patient also reports
some contractions, but denies any continuing
abdominal pain. She denies any recent trauma.
No prior antenatal care

Past Obsetrical History:

-G3 P2002 (3 gestations, 2 full term, 0 pre-term, 0
miscarriages, 2 currently living)
-2 previous SVD’s (spontaneous vaginal delivery)
-Last birth was 9 years ago by SVD, weighed 3800
grams
-No previous obstetrical complications or
No past medical or surgical history
Social History: Patient lives with her husband in the
Santiago district of Cuzco. Denies any smoking, alcohol or
drug use. No spousal abuse. Works as a housewife. Low
economic status.
Physical Exam:
Vital Signs: Stable (BP – 110/70, P – 72)
General Appearance: No apparent distress, appeared
clinically stable
Skin: Elastic, capillary reflex < 2 seconds
Uterine Height: 30 cm
Fetal Lie: Longitudinal
Contractions: Present
Fetal Heart Tones: 144
x minute
1) What is your differential diagnosis?
2) What is your next step to exclude/confirm diagnosis?
3) You confirmed the presence of placenta previa. What
are the types of placenta previa and risk factors?
4) After 1 hour the bleeding recurred and now the
patient’s BP is 90/60 and pulse 110. What is your next
step?
5) If the same patient presented at 28 weeks of gestation
with minimal bleeding and vitally stable, what is your
management? What is your advice to the patient?
6) What are the complications of antepartum
hemorrhage?
A 40 year old Gravida 5 Para 4 at 35 weeks gestation
presented to the emergency room with sudden onset of
severe abdominal pain followed by vaginal bleeding.
No history of trauma or abuse.
She did not receive antenatal care in any pregnancy and had
all previous vaginal deliveries with no complications.
She has no past medical history or surgeries. She is not
receiving any medications.
She is a housewife, living with her husband and children,
she does not drink alcohol or use recreational drugs
however she smokes ½ pack of cigarettes daily.
The patient looks anxious and distressed.
Her vitals are:
BP: 160/100 Pulse:120 T: 37 RR: 24

On examination:
Uterus is rigid and tender, fundus felt at xiphisternum.
The fetal lie was longitudinal with head presenting.
Vaginal examination showed bleeding and clots,
cervix effaced and 4 cm dilated.

CTG: Fetal bradycardia and late decelerations

Urine dipstick: +3 proteinuria

(1) What are the causes of antepartum hemorrhage?
(2) What is your diagnosis?
(3) What are the risk factors?
(4) What is your initial management?
(5) What are the alarming signs in this case?
(6) If the same patient presented but without bleeding
what is your diagnosis?
A 34 y/o G3P2 presents at 35 weeks gestation in
active labor. No past medical history. She has history
of previous precipitous delivery at 36 weeks. An
U/S at 18 weeks gestation showed bilobed placenta.
Umbilical cord insertion was normal at the time. The
patient is having regular contractions 3-5 minutes
apart. She is 6 cm dilated. Suddenly, SROM occurs
followed by red bright clots. Within one minute the
fetal heart rate drops to 70 bpm.

1) What is your most likely diagnosis?

2) What are the risk factors for this condition?
3) What tests can you use to confirm diagnosis?
Placenta Previa
Placental Abruption Major, Life-threatening
Ruptured Vasa Previa
Uterine scar disruption

Cervical Polyp
Bloody show
Cervicitis
Vaginal trauma
Cervical cancer
RCOG guidelines
-The process of triage includes history taking to assess
coexisting symptoms such as pain, an assessment of the
extent of vaginal bleeding, the cardiovascular condition of the
mother, and an assessment of fetal wellbeing.

-Signs and symptoms of shock are late findings in pregnant

women and represent blood loss >30%

-Maternal resuscitation, follow ABCs, 2 wide bore cannulas,

prompt fluid resuscitation and/or blood transfusion.
-Abdominal palpation

-Avoid digital examination, Perform sterile speculum.

-Ultrasound

-Blood count, coagulation screen, 4 units of blood cross-

matched, urea, electrolytes, LFTs, fibrinogen level

-Kleihauer-Betke test to all Rh negative women to determine

dose of Rho-gam

-Continuous fetal monitoring

-The implantation of the placenta over or near the internal os
of the cervix

-4% finding in U/S done at 20-25 weeks gestation

-0.4% of term pregnancies

Risk Factors:

1) Hypertensive diseases of pregnancy

2) Multiparity
3) Multiple gestations
4) Older age
5) Previous cesarean delivery
6) Tobacco use
7) Uterine curettage
HISTORY:

Painless, bright red vaginal bleeding (often after

intercourse) that often stops spontaneously and then recurs
with labor.

Contractions may or may not occur simultaneously with the

bleeding.

Suspect in any case of persistent malpresentation.

Placenta previa often leads to preterm delivery, with 44%

of pregnancies with placenta previa delivered before 37
weeks.
PHYSICAL EXAMINATION:

-Any pregnant woman beyond 1st trimester who presents with

vaginal bleeding requires a speculum examination followed by
diagnostic ultrasonography, unless previous documentation
confirms no placenta previa.

-Because of the risk of provoking life-threatening hemorrhage,

a digital examination (vaginal and rectal) is absolutely
contraindicated until placenta previa is excluded.
-Uterine activity monitoring reveals that approximately 20%
of patients have concurrent contractions with their bleeding.

-Other findings:
•Profuse hemorrhage
•Hypotension
•Tachycardia
•Soft and nontender uterus
•Normal fetal heart tones (usually)
Total placenta previa—the internal os is covered completely by
placenta

Partial placenta previa—the internal os is partially covered by

placenta

Marginal placenta previa—the edge of the placenta is at the

margin of the internal os (within 2 cm)

Low-lying placenta—the placenta is implanted in the lower

uterine segment such that the placental edge does not reach the
internal os, but is in close proximity to it (2-3.5 cm)

Vasa previa—the fetal vessels course through membranes and

present at the cervical os
WORKUP:

-Transabdominal U/S (96-98% sensitivity)

-Transvaginal U/S (almost 100% sensitivity)

-Ultrasound can not only diagnose placenta previa, but

further define it as complete, partial, or marginal, which
can have implication in how to manage the patient

-Imaging with color flow Doppler to evaluate for placenta

accreta

-MRI for diagnosis of invasive placenta and organ

involvement in placenta percreta
Laboratory Studies

-CBC
--hCG levels
-Rh compatibility test
-FSP levels and fibrinogen
- PT/aPTT
-Blood type and cross; hold for at least 4 units
-Apt test to determine fetal origin of blood (as in the case of vasa
previa)
-Wright stain applied to a slide smear of vaginal blood to look
for nucleated red blood cells (RBCs), not adult blood
-L/S ratio for fetal maturity
-Kleihauer-Betke test (fetal-maternal transfusion)
-Bedside clot test
Management:

Women can fall in one of the following categories:

1)The fetus is preterm and there are no other indications for

delivery

2) The fetus is reasonably mature

3) Labor has ensued

4)Hemorrhage is so severe as to mandate delivery despite

gestational age.
-Outpatient management is appropriate for patients without
active bleeding who can rapidly access a hospital with
operative labor and delivery services.

-The main therapeutic strategy is to prolong pregnancy until

fetal lung maturity is achieved

-Tocolytic agents may be used safely to prolong gestation if

vaginal bleeding occurs with preterm contractions.

-Corticosteroids should be administered to women who have

bleeding from placenta previa at 24 to 34 weeks' estimated
gestation.
-Cervical cerclage has been proposed as a means of
prolong. ing pregnancies complicated by placenta previa

-If placental edge is 2 cm or more from the internal os at

term can deliver vaginally unless heavy bleeding
ensues.

-If placenta is located 1-2 cm from the os may attempt

vaginal delivery in a facility capable of moving rapidly to
cesarean delivery if necessary.

-Double-set up.

-Regional anesthesia is safer, less blood loss.

Patient Education:

-Women with asymptomatic previa in 2nd trimester can continue

normal activities until follow-up U/S is performed at 28 weeks.

-Women with persistent previa in 3rd trimester should report any

bleeding and abstain from intercourse and use of tampons and
no digital examination.

-Counsel patients about the risk of recurrence. Instruct them to

notify the obstetrician caring for their next pregnancy about
their history of placenta previa.

-Encourage patients with known placenta previa to maintain

intake of iron and folate as a safety margin in the event of
bleeding.
Risk Factors:
1) Hypertensive diseases of pregnancy
2) Previous history of abruption
3) Advanced maternal age/parity
4) Trauma (abuse or accidents)
5) Prolonged rupture of membranes
6) Smoking
7) Cocaine, Alcohol
8) Over-distention e.g polyhydramnios
9) Unexplained elevation of MSAFP
10) Thrombophilias
Note that the amount of bleeding observed is not indicative of the amount of loss
or compromise. Always refer to the patients vitals and condition!
HISTORY: Ask about… “risk factors”

SYMPTOMS: vaginal bleeding, contractions,

abdominal tenderness, and decreased fetal movement

Vaginal bleeding - 80%

Abdominal or back pain and uterine tenderness - 70%
Fetal distress - 60%
Abnormal uterine contractions (eg, hypertonic, high
frequency) - 35%
Idiopathic premature labor - 25%
Fetal death - 15%
PHYSICAL EXAM:
-Signs of Circulatory instability
-Abdominal examination:
Palpable contractions, height (expanding
Fundal hematoma), tenderness

-Ultrasound can miss 20% of cases

-Fetal monitoring: look out for late decelerations, loss

of variability, fetal bradycardia
Mild
Abruption:
stable patient, small partial abruption, premature fetus, may
go for conservative management. Tocolytics may be given
to allow administration of steroids.
Severe Abruption:

-Rapid stabilization of mother, ABCs, assessment of fetal

well being.
-Non-reassuring fetal heart tracing necessitates rapid cesarean
delivery.
-A decision-to-delivery interval 20 minutes or less improves
neonatal outcomes.
-If fetal demise is present, vaginal delivery is the goal.
-Treatment of preeclampsia with magnesium slufate
decreases risk of placental abruption.
-1/3 of patients with abruption and fetal demise will develop
coagulopathy
-Can be occult dehiscence up to symptomatic rupture.
-0.03-0.08 % of all women
-Up to 1.7% of women with uterine scar
-Most common reason is previous cesarean incision.

Risk Factors:
-Previous uterine surgery
-Uterine or fetal anomaly
-Uterine over-distention or trauma
-Placenta increta/percreta
-Gestational trophoblastic neoplasia
-Adenmyosis
-Excessive uterine stimulation
-Classical presentation for significant rupture includes:

-Vaginal bleeding, Pain, Cessation of contractions, Absent

fetal tones, Loss of station, easily palpable fetal parts
through abdomen, profound maternal tachycardia and
hypotension.

-Most cases present with abnormal fetal monitoring.

-13% of cases occur outside the hospital

-Asymptomatic scar disruption: Expectant

-Symptomatic rupture: Emergency C/S

-Maternal:
Hemorrhage, anemia, bladder rupture, hysterectomy, death

-Fetal:
Respiratory distress, hypoxia, acidemia, death
-Vasa previa is present when fetal vessels traverse the
fetal membranes over the internal cervical os.

-These vessels may be from either a velamentous

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

fetoplacental circulation, and fetal exsanguination will
rapidly occur, leading to fetal death.
RISK FACTORS:

1) Velamentous insertion of the cord

2) Placenta previa
3) IVF
4) Bilobed and succenturiate-lobed placenta
5) Multiple gestation
The classic triad of the vasa praevia is:

Membrane rupture
Painless vaginal bleeding
Fetal bradycardia

May be detected
antenatally by color
Doppler

Average blood volume of fetus is 250 ml so exsanguination

is rapid

Rarely vessels are palpated in the presenting membranes

-In case of fetal distress: immediate C/S, resuscitation with
immediate administration of NS 10-20 cc/kg bolus to
neonate

-If fetal heart tones are reassuring:

•Blood sample is taken from vaginal vault to confirm
origin.
•Kleihauer-Betke test, hemoglobin electrophoresis: sensitive
but slow
•Apt test: bed-side, fast test but low sensitivity

-Neonatal survival with antenatal diagnosis 97% vs 44%

without antenatal diagnosis.
PPH is defined as blood loss >500 mL following delivery.

Loss of >1000 mL is considered major PPH and is an

emergent situation resulting in hemodynamic instability.

PPH is the most common maternal morbidity in developed

countries and major cause of mortality worldwide.

Occurs in up to 18% of births.

Risk Factors:

-In most cases no identifiable risk factors

-Prolonged third stage of labor
-Preeclampsia
-Cesarean section
-Previous PPH
-Multiple pregnancy
-Fetal macrosomia
-Episiotomy (more in mediolateral)
The best preventive strategy is active management of the
third stage of labor (NNT=12), decreasing incidence by
60%

1)Administering utertonic drug with, or soon after delivery

of anterior shoulder (oxytocin 10 U IM).

2) Controlled cord traction to deliver placenta

3) Uterine massage

4) Delayed cord clamping at 60 seconds.

70% 10%

20% 1%
Diagnosis of postpartum hemorrhage begins with recognition
of excessive bleeding and methodic examination to
determine its cause (Figure 1).
Uterine Massage:

Uterotonic agents:

-Oxytocin 20 Units in 1000 ml NS, infused IV at 250ml/hr

-Carboprost (PGF2 analog) 0.25 mg IM or IMM q15-90
minutes for total dose 2 mg
-Misoprostol (PGE2 analog) 1000 mcg rectally
-Methylergonovine 0.2 mg IM q2-4 hours
 HEAD ARMS
-Airway -Check pulse and BP
-Breathing -Establish 2 large bore IV
-Oxygen -Blood count, clotting, cross-
-Lie Flat match 4-6 units
-Note Time -Start 2 liters crystalloid
-Drugs:
UTERUS Oxytocin/Syntocinon
-Call for HELP Methylergonovine
-Uterine Massage PG F2a
-Helper at head, both arms
-Empty Bladder with catheter
-Bimanual compression
-Review other causes 4 Ts
-Move to surgery