Ante partum hemorrhage

Dr Haddis (MD)
 overview
• Obstetrics is "bloody business.”
• Hemorrhage still is a leading cause of
maternal mortality
• Abortion, Ectopic, GTD, APH, Rupture, PPH
 APH
- Bleeding after viability and before delivery –
APH
- Bleeding prior to viability – Abortion
- Bleeding after delivery – PPH
 Causes are:
Obstetric causes Non-obstetric causes
 PP • cervical infection
 AP • cervical cancer, polyps,
 Bloody Show • Vaginitis
 vasa previa • Vaginal laceration
 bleeding disorders (DIC)
 Uterine rupture
 Marginal sinus bleed
Abruptio Placentae
 Definition and Pathogenesis:
 Premature separation of a normally implanted placenta
from the uterus
 Causes:
Defective maternal vessels in the deciduas basalis rupture and
cause the separation (Typical cause)
A disruption of the fetal-placental vessels (rarely)
 The damaged vessels cause bleeding, which results in a
decidual hematoma that can lead to:
Placental separation,
Destruction of placental tissue, and
A loss of maternal-fetal surface area for nutrient and gas exchange
 Incidence:
• 1 in 75 to 1 in 226 deliveries.
• 1/3 of all antepartum bleeding
 Clinical Manifestations:
- Vaginal bleeding or occult uterine bleeding,
- Abdominal pain,
- Uterine contractions or hypertonus,
- Uterine tenderness,
- DIC
- Decreased or cessation of fetal movement
- NRFHR patterns or fetal death, &
• 80 percent occur before the onset of labor.
- The dx is confirmed with certainty by the
macroscopic inspection of a placenta:
- Adherent retro placental clot, &
- Depression/disruption of the underlying
placental tissue
 Acute Abruption:
-Abdominal and/or back pain
-Painful vaginal bleeding
-Uterine contractions
-The uterus may be rigid and tender
-FHR abnormalities, fetal death, complications
-Preterm labor.
N.B:- the amount of bleeding is poor indicator of
severity.
 contd
• Occasionally, a woman with placental
abruption will present with only preterm
labor, and no vaginal bleeding. "Concealed"
abruption.
 Concealed bleeding is likely due to :
 Placenta margins remain adherent.
 The placenta is completely separated yet the
membranes retain their attachment to the uterine wall.
 Blood gains access to the amnionic cavity after breaking
through the membranes.
 The fetal head is so closely applied to the lower uterine
segment that the blood cannot make its way past it.
N.B. Sooner or later the membrane is dissected off the
uterine wall & bleeding becomes visible.
 Classified into three grades:
1) Grade 1(A mild abruption):
- slight vaginal bleeding, &
- minimal uterine irritability.
- BP, PR, and fibrinogen levels are unaffected,
- FHR pattern is normal.
- 40 % of AP are grade 1.
3) Grade 3 (A large or complete abruption):
- moderate to severe vaginal bleeding or
- painful, tetanic uterine contractions
(indicates occult uterine bleeding ).
- hypotension and tachycardia
- coagulopathy is frequently
(fibrinogen < 150mg/dl)
- along with fetal death.
- comprise 15 % of AP.
2) Grade 2: (A partial abruption):
- mild to moderate vaginal bleeding and
- significant uterine irritability or contractions.
- BP is maintained, but the pulse is often elevated
and postural blood volume deficits may be present.
- The fibrinogen 150 - 250 mg/dl
- NRFHR.
- account for 45 % of all placental abruptions
 Risk Factors:
o Increasing parity (1 v 2.5 % for primi & grands)
o Increasing maternal age
o Cigarette smoking  (40 x than non smokers; ischemia &
necrosis)
o Cocaine abuse
o Trauma  (motor vehicle & domestic abuse)
o Maternal hypertension
o preeclampsia, gestational hypertension, &chronic
hypertension,
o Preterm PROM (cause or effect)
o Multiple gestation
o Polyhydramnios with rapid uterine
decompression
o Inherited or acquired thrombophilia
o Uterine malformations or fibroids
o Placental anomalies
o Previous abruption
 Diagnosis:
- primarily clinical, with
- support from sonographic, laboratory, and
pathologic studies.
- Any vaginal bleeding in the third trimester of
pregnancy should prompt an investigation to
determine its etiology !
- vaginal bleeding is the hallmark sign,
- but 10 to 20 % have an occult or concealed
hemorrhage.
 Management:
1- Careful evaluation of extent of blood loss.
- Blood loss is frequently underestimated since the
bleeding may be largely concealed
2- Baseline laboratory assessment (hemoglobin,
hematocrit, platelet count,
blood group & Rh, renal function
3- Coagulation studies;
- PT, PTT
- fibrinogen level.
- clotting test
4- Intravenous access (large-bore catheter),
5- Availability of blood products,
6- Continuous fetal heart rate and contraction
monitoring, and
7- Communication with operating room and
neonatal personnel.
 Complications:
Maternal:
- Hypovolemia related to blood loss
- Need for blood transfusion for severe anemia & blood loss.
- DIC
- PPH, couvelaire
- Renal failure
- ARDS
- Multisystem organ failure
- Death
Fetal:
- Growth restriction (with chronic abruption)
- Fetal hypoxemia or asphyxia
- Preterm birth
- Perinatal mortality
 Placenta Previa
Definition and incidence:
- Placenta previa is defined as the presence of
placental tissue over or adjacent to the
cervical os
- 4/1,000 deliveries at delivery
- and 4 to 6 % at 2nd trimester
- Placental “migration”
- development of the lower uterine segment.
- lower uterine segment increases from

0.5 cm at 20 weeks to > 5 cm at term

- Trophotropism - or the growth of trophoblastic
tissue away from the cervical os toward the
fundus
 Four Grades or Degrees are identified:
Grade I (Complete placenta previa)
- The placenta completely covers the internal os .
- A central placenta previa occurs when the internal os is
approximately equidistant from the anterior and
posterior placental edges. Twenty to 30 percent of
placenta previa are central.
Grade II (Partial placenta previa)
- The placental edge partially covers the internal
cervical os, which must be partly dilated for this to
occur.
 cont’d
Grade III (Marginal placenta previa)
- The placenta is adjacent to the internal os,
but does not cover it.
Grade IV (Low-lying placenta)
- placental edge that lies within 2 to 3 cm of
the internal os.
classification

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 Clinical Feature:
- painless vaginal bleeding after 20 wks of GA, often small & recurrent
- 70 to 80 %.
- incidentally by u/s and remain asymptomatic
- < 10 %.
- Causes of bleeding:
- development of lower segment
- uterine contractions, dilation & effacement of cx
- coitus
- digital PV examinations
- These causes sheering and detachment of placenta.
 Placenta Previa Risk Factors:
1) Due to prior Endometrial scaring:
- Increasing parity; 0.2 % nulliparous, 5 % grandmulties   
- Increasing maternal age ;
- 0.03 in nulliparous age b/n 20-29;
- 9 folds in age > 40 yrs 
- Prior curettage   
- Prior c/s; >10 % for >3 previous c/s 
  
2) Due to need for increased placental surface
area to compensate for a reduction in
uteroplacental oxygen:
- Cigarette smoking
- Residence at higher altitude   
- Multiple gestation   
- Previous placenta previa; 8 fold, cause
unknown.
 Associated conditions
• Placenta accreta complicates 5 to 10% of previa
• Malpresentation
• Preterm premature rupture of the membranes
(PPROM)
• Intrauterine growth restriction
• Vasa previa and velamentous umbilical cord
• Congenital anomalies
• Amniotic fluid embolism

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 Diagnosis;
1) Ultrasound
- transabdominal 95 %
- placental margin < 2-3 cm
- bladder shouldn’t be over distended, but partially
full!!
- difficult in cases of posterior PP, esp. at term
- transvaginal 100%
- translabial(transperineal)
- 26% of complete PP persists in to term
- 2.5% of marginal PP persist in to term
- anterior PP migrates more often & faster than posterior PP.
2) Double set up examination
Expectant Management of Preterm Patients
- mild bleeding
- < 37 wks, alive fetus & reasuring status
- no labor,
- set up for c/s available
- Correction of anemia
- counselling
- prepare blood
- Antenatal corticosteroids
- Rh(D) immune globulin
- Fetal assessment, maturity testing
- Tocolysis
 Delivery indications :
- severe bleeding
- labor
- NRBPP
- fetal death
- term or mature fetus
Route
- c/s if complete, partial, or post marginal PP, active
bleeding with or without v/s derangement.
- vaginal (induction or spont labor), in others
Complications:
- hemorrhage – APH &/or PPH
- need of blood
- placenta accereta
- hysterectomy
- fetal morbidities & mortality
- maternal death
 Uterine rupture
• Involves all layers of uterine
• Occult incomplete rupture- intact visceral
peritonium
• It usually become complete
• Ruptures usually occur during the course of
labor.
• On trial of VBAC
 Risk factors
• history of hysterotomy (cesarean section,
myomectomy, metroplasty, cornual resection),
• trauma (motor vehicle accident, rotational
forceps, extension of a cervical laceration),
• uterine overdistention (hydramnios, multiple
gestation, macrosomia),
• uterine anomalies, placenta percreta, and
choriocarcinoma.
• Fetal heart rate abnormalities.
• Increased suprapubic pain and tenderness
with labor.
• Sudden cessation of uterine contractions with
a "tearing" sensation.
• Vaginal bleeding.
• Recession of the fetal presenting part
(prominent easily palpable fetal parts).
• The maternal mortality rate is 4.2%.
• The perinatal mortality rate is approximately
46%.
Vasa previa