Antepartum Hemorrhage

Lecture
Petrenko N., MD, PhD
Introduction
 Definition:
Vaginal bleeding which occurs after fetal
.viability

 Incidence:
.% 6 – 2
ANTEPARTUM HEMORRHAGE
.Per vagina blood loss after 20 weeks’ gestation 

Complicates close to 4% of all pregnancies and is a 

!MEDICAL EMERGENCY

Is one of the leading causes of antepartum 

hospitalization, maternal morbidity, and operative
.intervention
Causes
Placental: Non-placental:
 Abruptio placenta.  Vasa previa.
 Placenta previa.  Bloody show.
 Trauma.
 Uterine rupture.
 Cervicitis.
 Carcinoma.
 Idiopathic.
Abruptio Placenta
Introduction
 Definition:
It is the separation of the placenta from its site
of implantation before delivery of the fetus.

 Incidence:
1 in 200 deliveries.
Risk Factors
 Increased age & parity.  Smoking.
 Hypertensive  Thrombophilia.
disorders.  Cocaine use.
 Preterm ruptured  Prior abruption.
membranes.  Uterine fibroid.
 Multiple gestation.
 Trauma.
 Polyhydramnios.
Types
 Total or partial.

 Concealed or reveiled.
Placental Abruption
external hemorrhage 
concealed hemorrhage 
Total 
Partial 
Presentation
 Vaginal bleeding.
 Uterine tenderness or back pain.
 Fetal distress.
 High frequency contractions.
 Uterine hypertonus.
 Idiopathic PTL.
 IUFD.
Diagnosis
 The diagnosis is primarily clinical, but may be
supported by radiologic, laboratory, or
pathologic findings.

 It is generally obvious in severe cases.

 In milder forms the diagnosis is often made

by exclusion.
Diagnosis
The echogenic appearance depends upon the
onset of symptoms:

 Acute hemorrhage is hyperechoic to

isoechoic compared with the placenta.

 Resolving hematomas is hypoechoic within

one week and sonolucent within two weeks.
Diagnosis
Laboratory testing is not useful in making the
diagnosis:
 Kleihauer-Betke test: sensitivity 17%.
 CA-125: elevated.
 D-dimer: sensitivity 67, specificity 93%
 Thrombomodulin: sensitivity 88, specificity
77%.
 Hypofibrinogenemia < 200 mg/dL.
 Thrombocytopenia < 100,000/microL.
Diagnosis
 Gross examination of the placenta often
reveals a clot and/or depression in the
maternal surface.

 It may be absent with acute abruption.

Initial Management
 Stabilization of the maternal cardiopulmonary
status.
 Blood work:
- CBC.
- Coagulation profile.
- Fibrinogen.
- Blood type and Rh.
Initial Management
 Large-bore intravenous lines and continuous
fetal monitoring
 Correction of the intravascular fluid deficit via
crystalloid +/- PRBC.
 If the PT and PTT > 1.5x control  2u FFP.
 If the platelet count is < 50,000/microL  6u
plt.
Initial Management
 Heparin or other anticoagulants ?

 Tocolysis is generally contraindicated.

 Delivery is the optimal treatment. DIC &

hemorrhage will resolve over 12 hours when
the placenta is removed.
Initial Management
Medical treatment of coagulopathy for:
 Marked thrombocytopenia (< 20,000/microL)
 Moderate thrombocytopenia(<50,000/microL)
&serious bleeding or planned cesarean
delivery.
 FFP or cryoprecipitate if fibrinogen is <100
mg/dL
Mild Abruption
 Expectant management with short term
hospitalization.

 Corticosteroid.

 Tocolysis may be of value in mild cases.

Delivery
The mode and timing of delivery depend upon:
 GA.
 The condition of the fetus.
 The condition of the mother (eg, hypotension,
coagulopathy, hemorrhage).
 The status of the cervix.
Delivery
 The term or near term fetus should be
expeditiously delivered.

 Amniotomy with placement of a fetal scalp

electrode.

 Oxytocin may be used to augment uterine

activity.
Delivery
 C/S is performed in the presence of a
nonreassuring fetal heart rate pattern & when
delay in delivery will endanger the mother or
fetus.

 It should be done after rapid maternal

hemodynamic and clotting factor stabilization.
Complications
 Maternal:  Fetal:
1. Hypovolemia. 1. IUGR.
2. DIC. 2. IUFD.
3. Renal failure.
4. Death.
Placenta Previa
Introduction
 Definition:
The presence of placental tissue overlying or
proximate to the internal cervical os after
viability.

 Incidence:
Complicates approximately 1 in 300
pregnancies.
 Risk Factors
 Increasing parity: incidence 0.2 percent in nulliparas
versus up to 5 percent in grand multiparas.
 Maternal age: incidence 0.03 percent in nulliparous
women aged 20 to 29 versus 0.25 percent in
nulliparous women 40 years of age.
 Number of prior cesarean deliveries incidence 10
percent after four or more.
 Number of curettages for spontaneous or induced
abortions.
Independent Risk Factors
 Maternal smoking
 Residence at higher altitudes
 Male fetus
 Multiple gestation: 3.9 and 2.8 previas per
1000 live twin and singleton births,
respectively
 Gestational age: the prevalence of placenta
previa is much higher early in pregnancy than
at term
Classification
 Complete placenta previa: The placenta
completely covers the internal os.
 Partial placenta previa: The placental edge
does not completely cover the internal
cervical os but partially covers it.
 Marginal placenta previa: The placenta is
proximate to the internal os.
 Low-lying placenta: in which placental edge
lies within 2 to 3 cm of the internal os.
(reference)
Maggie Myles: Textbook for Midwives
Clinical Manifestations
 Painless vaginal bleeding occurs in 70 to 80
percent of patients.

 10 to 20 percent present with uterine

contractions associated with bleeding.

 Fewer than 10 percent are incidentally

detected by ultrasound.
Associated Conditions
 Malpresentation.
 PPROM.
 Congenital anomalies.
 IUGR.
Diagnosis
 The diagnosis is based upon results of
ultrasound examination.

 Clinical findings are used to support the

sonographic diagnosis.

 Placenta previa should be suspected in any

woman beyond 24 weeks of gestation who
presents with painless vaginal bleeding.
Transabdominal US
 It has a diagnostic accuracy as high as 95%
in detecting placenta previa, with a false
negative rate of 7%.

 Sagittal, parasagittal and transverse

sonographic views should be obtained.
Transabdominal US
 It requires the identification of echogenic
placental tissue overlying or proximate to the
internal cervical os (a distance >2 cm).
Transvaginal US
 It has become the gold standard for the
diagnosis of placenta previa.

 It is a safe and effective technique, with

diagnostic accuracy greater than 99 percent.

 The probe does not need to come into

contact with the cervix to provide a clear
image.
Ultrasound
 Both the transabdominal and transvaginal US
should be used as complementary studies.

 Initial transabdominal examination, with

transvaginal sonography if there is any
ambiguity in the placental position.

 Translabial ultrasound imaging is an

alternative technique.
Antepartum Management
 Avoidance of coitus and digital cervical
examination.
 Counseling to seek immediate medical
attention if there is any vaginal bleeding.
 Women are also encouraged to avoid
exercise, decrease their activity, and notify
the physician of uterine contractions.
 Serial ultrasound evaluations every two to
four weeks to assess placental location and
fetal growth.
Acute Care of Symptomatic
Placenta Previa
 Large bore IV access & administration of
crystalloid.
 Type and cross-match for four units of PRBC.
 Transfuse to maintain a Hct of 30% if the
patient is actively bleeding.
 Maternal pulse and blood pressure every 15
minutes to 1 hour depending upon the degree
of blood loss.
Acute Care of Symptomatic
Placenta Previa
 The fetal heart rate is continuously monitored.
 Quantitative monitoring of vaginal blood loss.
 The source of the vaginal blood (maternal
versus fetal) is intermittently assessed by
either an Apt test or Kleihauer-Betke analysis.
 Urine output is evaluated hourly with a Foley
catheter & should be at least 30 mL/hour.
Acute Care of Symptomatic
Placenta Previa
 Hb & Hct.

 Serum electrolytes and indices of renal

function.

 Coagulation profile (fibrinogen, Plt, PT & PTT)

are checked especially if there is a suspicion
of coexistent abruption.
Delivery
 Tocolysis is not administered to actively
bleeding patients.

 Delivery is indicated if:

          (1) there is a nonreassuring fetal heart
rate.
         (2) life threatening refractory maternal
hemorrhage.
Mode of Delivery
 Cesarean delivery is the delivery route of choice.

 Vaginal delivery may be considered in the presence

of:
1. a fetal demise
2. previable fetus
3. some cases of marginal previa, as long as the
mother remains hemodynamically stable.
Conservative Management of Stable
Preterm Patients
 The patient is hospitalized at bedrest with bathroom
privileges.

 Stool softeners and a high-fiber diet help to minimize

constipation and avoid excess straining.

 Periodic assessment of the maternal hematocrit.

 Ferrous gluconate supplements (300 mg orally three

or four times per day) are given with vitamin C to
improve intestinal iron absorption.
Conservative Management of Stable
Preterm Patients
 Cross match to provide two to four units of
packed red blood cells.

 Prophylactic transfusions to maintain the

maternal hematocrit above 30 percent in
stable asymptomatic patients in anticipation
of future blood loss.
Conservative Management of Stable
Preterm Patients
 A single course of corticosteroid between 24
and 34 w.

 Rh(D)-negative women should receive Rh(D)-

immune globulin if they bled.

 Readministration is not necessary if delivery

or rebleeding occurs within three weeks,
unless a large fetomaternal hemorrhage is
detected by KBT.
Conservative Management of Stable
Preterm Patients
 Fetal growth, amniotic fluid volume, and
placental location are evaluated
sonographically every two to four weeks.

 Tocolysis may be safely utilized if

contractions are present and delivery is not
otherwise mandated by the maternal or fetal
condition.
Conservative Management of Stable
Preterm Patients
 Amniocentesis can be done at 36 weeks to
assess pulmonary maturity.

 Scheduled abdominal delivery is suggested

@ 37w or upon confirmation of pulmonary
maturity.
Delivery
 Abdominal delivery.

 Two to four units of PRBC should be

available for the delivery.

 Appropriate surgical instruments for

performance of a cesarean hysterectomy
should also be available since there is a 5 to
10 percent risk of placenta accreta.
C/S
 The surgeon should try to avoid disrupting the
placenta when entering the uterus.

 If the placenta is encountered upon opening

the uterus then it is necessery to cut through
the placental tissue to deliver the fetus.
Outpatient Managaement
 Women who have never bled.

 Women with placenta previa if bleeding has

stopped for more than one week.

 There are no other pregnancy complications,

such as fetal growth restriction.
Outpatient Management
 Live within 15 minutes of the hospital.
 Have an adult companion available 24 hours
a day who can immediately transport the
woman to the hospital if there is light bleeding
or call an ambulance for severe bleeding.
 Be reliable and able to maintain bed rest at
home.
 Understand the risks entailed by outpatient
management.
Outcome
The maternal and perinatal mortality rates in
pregnancies complicated by placenta previa
have been reduced over the past few
decades because of:
 The introduction of conservative obstetrical
management.
 The liberal use of cesarean rather than
vaginal delivery.
 Improved neonatal care.
Vasa Previa
Introduction
 Vasa previa refers to vessels that traverse
the membranes in the lower uterine segment
in advance of the fetal head.

 Rupture of these vessels can occur with or

without rupture of the membranes and result
in fetal exsanguination.

 The incidence is 1 in 2000 – 3000 deliveries.

Associated Conditions
 Low-lying placenta.
 Bilobed placenta.
 Multi-lobed placenta.
 Succenturiate-lobed placenta.
 Multiple pregnancies.
 Pregnancies resulting from IVF.
Diagnosis
 The diagnosis of vasa previa is considered if
vaginal bleeding occurs upon rupture of the
membranes.

 Concomitant fetal heart rate abnormalities,

particularly a sinusoidal pattern.

 Ideally, vasa previa is diagnosed antenatally

by US with color flow Doppler.
Antenatal Management
 Consider hospitalization in the third trimester
to provide proximity to facilities for emergency
cesarean delivery.
 Fetal surveillance to detect compression of
vessels.
 Antenatal corticosteroids to promote lung
maturity.
 Elective cesarean delivery at 35 to 36 weeks
of gestation.
Antepartum Management
 Immediate C/S.

 Avoid amniotomy as the risk of fetal mortality

is 60-70% with rupture of the membranes.
Uterine Rupture
Risk Factors
 The most common risk factor is a previous
uterine incision.

 The rate is higher with classical & T-shape

uterine incision in comparison to low vertical
& transverse incisions.

 The rate increases with the number of

previous uterine incisions.
Risk Factors
 High parity.  Trauma.
 Labor complications:  Delivery complications:
1. CPD. 1. Difficult forceps.
2. Abnormal 2. Breech extraction.
presentation. 3. Internal podalic version.
3. Unusual fetal
enlargement
(hydrocephalus).
Presentation
 Sudden severe fetal heart decelerations.

 Abdominal pain & PV bleeding ( <10%).

 Diaphragmatic irritation.

 Loss of fetal station.

 Cessation of uterine contractions.

Prognosis
 Fetal death 50-75%.

 Maternal mortality is high if not diagnosed &

managed promptly.

 Maternal morbidity: hemorrhage & infection.

Management
 stabilization of maternal hemodynamics.

 Prompt C/S with either repair of the uterine

defect or hysterectomy.

 Antibiotics.
A 23-y-o PG, @ 29w comes to A&E for evaluation
following a RTA in which a restrained passenger in
the back seat. She denies any symptoms &
examination is normal with fetal heart rate of
150bpm. Before discharging the patient your
recommendation regarding electronic fetal
monitoring:
1. Do none.
2. Monitor for 2-6h.
3. Monitor for 6-12h.
4. Monitor for 12-18h.
5. Monitor for 18-24h.
 In counseling a woman with a prior C/S
regarding IOL, you tell her that the highest
risk of uterine rupture is associated with:
1. Osmotic cervical dilator.
2. Transcervical Foley balloon placement.
3. Prostaglandins.
4. Oxytocin.
 A 34-y-o woman G3P2, present @38w in
early labor. V/E: 3cm with a firm ridge in the
membranes by palpation. U/S: placenta
located both anteriorly & posteriorly in the
lower uterine segment. There is no placenta
previa. A tocolytic is administered. What
should be the next step in management?
1. Allow continued labor.
2. Speculum examination.
3. Amniocentesis.
4. Color flow Doppler U/S.
5. Amniotomy.
 A 19y-o PG admitted @ 34w with heavy
vaginal bleeding & regular contractions. She
reports no leakage of fluid. BP:156/98. F Ht
35cm. CTG is reactive. U/S: anterior
placenta & no retroplacental sonolucency.
V/E: 4cm. The most likely Dx is:
1. Vasa previa.
2. Placental abruption.
3. Chorioangioma.
4. Placenta accreta.
5. Placental succenturiate lob.
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