ANTEPARTUM

HAEMORRHAGE
DR NURUL IFTIDA BASRI
LECTURER AND SPECIALIST
OBSTETRICS & GYNAECOLOGY
DEPARTMENT
LEARNING OUTCOMES
Knowledge
• Able to describe the aetiology and presentation of
Antepartum haemorrhage

Clinical Competencies
• Able to plan initial investigations and management of APH
• Interpret the abnormal vital signs and investigation results
of scan, blood test and fetal parameters performed in the
case of APH

Professional skills & attitudes

• Empathise with patient and her family should an
adverse event occur as result of APH
 DEFINITION
■ RCOG: Bleeding from or in to the genital tract, occurring
from 24+0 weeks of pregnancy and prior to the birth of the
baby.
■ Malaysia: used 22+0 weeks as cut off gestation for fetal
viability

■ complicates 3–5% of pregnancies

■ leading cause of perinatal and maternal mortality worldwide
 AETIOLOGY
Placenta praevia

Placenta abruptio

Vasa praevia- rare

Local causes- genital tract

Undeterminate APH
PLACENTA PRAEVIA

DEFINITI
Implantation of
ON placenta near or at
internal cervical os

INCIDEN
CE 0.5-1%
 PLACENTA PRAEVIA
Risk Factors
■ Previous placenta praevia (4-8%)
■ Previous caesarean section (risk increases with increase number of CS)
■ Previous termination of pregnancy
■ Advanced maternal age (>40 years old)
■ Multiparity
■ Smoking
■ Multiple pregnancy
■ Deficient endometrium due to history of:
– Uterine scar, endometritis, D&C, MRP, submucous fibroid
 PLACENTA PRAEVIA
Clinical Classification
Minor
-Type 1 anterior and • Can deliver
posterior
-Type 2 anterior
vaginally
Major
-Type 2 posterior
• Delivery via
-Type 3 and Type 4 caesarean section
PLACENTA PRAEVIA
 PLACENTA PRAEVIA
Clinical presentation
■ Symptoms
– Painless per vaginal bleeding
– Tends to be recurrent

■ Signs
– Can have hypovolaemic shock- hypotensive, tachycardia
– Abdominal examination: abnormal lie, high presenting part, normal uterine tone, uterus size
equals to dates

■ Investigations
– Diagnosis by ultrasound (transabdominal or transvaginal)
– Role of MRI if suspect morbidly adherent placenta

– Vaginal examination is contraindicated, perform US first to exclude PP prior to VE

 PLACENTA PRAEVIA
Management
■ Asymptomatic
– Inpatient management from 32-34 weeks onwards
▪ Maccafee (1945) regime
– Hospital admission
– Blood & blood products readily available
– OT & obstetrician available
– Anaemia identified & corrected
▪ Role of outpatient management- controversial
 PLACENTA PRAEVIA
Management
■ Symptomatic
– Assess maternal and fetal well being
– ABC- resuscitate and stabilisation: 2 large bore branula, FBC and GXM
– Hospital admission
– Ultrasound for placenta localisation
– CTG
– Rhogum (anti-D) for rhesus negative mother
– Decision for delivery or conservative management depends of clinical
status of woman, amount of bleeding, gestational age
MORBIDLY ADHERENT PLACENTA
 PLACENTA ABRUPTIO

Separation of normally
DEFINITI located placenta after 22
ON
weeks gestation prior to
delivery of the fetus

INCIDEN 0.4-1%
CE
 PLACENTA ABRUPTIO
Risk factors

■ History of abruptio placenta (up to 5% increased risk)

■ Hypertensive disease
■ Advanced maternal age
■ Trauma (fall, MVA, domestic violence)
■ Smoking, alcohol intake
■ Sudden decompression of uterus (rupture of membrane)
■ Polyhydramnios
■ FGR
 PLACENTA ABRUPTIO

REVEAL MIXE CONCEAL

ED D ED
 PLACENTA ABRUPTIO
Clinical presentation
■ Symptoms
– Painful per vaginal bleeding
– Abdominal pain without bleeding
■ Signs
– Tense, woody hard, rigid and tender uterus
– Uterus larger than dates
– Signs of fetal compromise- fetal bradycardia or unable to detect FH
– Severe abruptio commonly results in IUD and woman may present in labour
■ Investigations
– ultrasound examination is less useful
– Retroplacental clots may be seen

– ABRUPTIO PLACENTA IS A CLINICAL DIAGNOSIS

PLACENTA ABRUPTIO

Couvelaire uterus
 PLACENTA ABRUPTIO
Management
■ Hospital admission
■ Resuscitation-2 large bore branula, FBC, GXM
■ Stabilise mothers (priority)- fluid resuscitation, transfusion of blood and blood
components
■ Treat associated condition (hypertension)
■ Ultrasound and CTG to assess fetal condition
■ Term-> deliver (either by induction of labour or CS), in IUD (aim for vaginal
delivery)
■ Preterm->aim to prolong pregnancy, corticosteroids, monitor mother and fetus
(minor bleeding and stable maternal condition), otherwise for delivery
■ If fetal compromise-> deliver
VASA PRAEVIA

Very rare

Rupture of
Fetal vessels run membrane leads to
through the free damage of fetal
placenta membane vessels leading to
death
(fetal mortality 60%)
 LOCAL CAUSES

■ Cervical ectropion
■ Cervicitis
■ Cervical polyp
■ Cervical malignancy
■ Infection
■ Trauma
■ Labour- heavy show
 UNDETERMINATE APH

Unclassified or
Can be minor
unexplained cause Up to 50% of APH
abruptio
of bleeding

Monitor fetal growth

(placenta function) Deliver at 40
throughout weeks
pregnancy
 COMPLICATIONS OF APH
Maternal Fetal

• Anaemia • Fetal hypoxia

• Maternal shock • Fetal growth restriction /
• Renal tubular necrosis SGA fetus
• DIVC • Prematurity
• PPH • Fetal death
• Prolonged hospital stay
• Psychological sequelae
• Complications of blood
transfusion
 HOW TO APPROACH WOMEN
PRESENTING WITH APH
■ HISTORY- amount of bleeding, colour, associated pain, precipitating
factors, contraction, ascertain fetal movement, review US report for
placenta site, ascertain blood group
■ EXAMINATION-assess maternal and fetal well-being
■ INVESTIGATION-US, CTG, bloods (FBC, GSH/GXM, RP)
■ CORTICOSTEROIDS- in preterm for lung maturity
■ CARE FOLLOWING APH- follow up if conservative management is
taken
■ LABOUR AND DELIVERY-timing and mode of delivery
■ RHESUS NEGATIVE MOTHER- Rhogum/ Anti-D
Admit to hospital for assessment

2 large bore branula, blood for FBC, GXM, renal

function

May need resuscitation (ABC) if shock or severe

bleeding- replace volume with crystalloid or
colloid, blood and blood products

Involve consultant obstetrician, anaesthetist,

blood bank, neonatalogist

Decide timing and mode of delivery in severe

bleeding or fetal compromise
 REFERENCES

■ RCOG Greentop Guidelines (GTG 27) -www.rcog.org.uk

■ Obstetrics Ilustrated Churchill Livingstone 7th Edition
■ Ten Teachers