ANTEPARTUM

HEMORRHAGE
By:- Michiale H. (BSc Mw, MSc Mw)
Lecturer, Department of Midwifery
Dire Dawa Universty CMHS

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• Ante-partum hemorrhage (APH) is vaginal bleeding from the 28th week
of gestation till the fetus (last fetus in case of multiple pregnancies) is
delivered.
CAUSES
Placental causes
Abruptio placentae
 Placenta previa
 Rare causes: vasa previa and other placental abnormalities
Non-Placental causes
 Heavy show
 Uterine rupture
Local lesions of the cervix, vagina and vulva
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PLACENTAL ABRUPTION
• Placental abruption (also called abruptio placentae) is a separation of the
normally implanted placenta before delivery of the fetus.
• RISK FACTORS
Previous history of abruptio placentae,
hypertension,
multiparity,
maternal age greater than 35 years,
multiple pregnancy, PROM,
 low socioeconomic status, smoking, trauma (e.g., ECV),
 polyhydramnios
short cord.
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CLASSIFICATION
Mild (Grade1)
Amount of blood- <400 mL
Uterine irritability (pain/tenderness) -Normal / slightly increased
Fetal condition -No fetal heart
Shock- Absent
Fibrinogen level- Normal

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Moderate (Grade 2)
Amount of blood- 400-1000 mL
Uterine irritability (pain/tenderness) -increased
Fetal condition –Abnormal
Shock -Mild, postural hypotension
Fibrinogen level – slightly increased

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Severe (Grade 3)
Amount of blood- >1000 mL
Uterine irritability (pain/tenderness) -reactive,tender on palpation
Fetal condition -fetal death,distress
Shock- sever,always present
Fibrinogen level- decreased

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 Types of Haemorrhage
1. Revealed type:
All bleeding appears vaginally from the start.
2. Concealed type:
All bleeding retained inside the uterus with formation of retro placental haematoma. In
concealed accidental haemorrhage there is no external bleeding.
3. Mixed type:
Bleeding is partially concealed and partially revealed.
DIAGNOSIS
• The clinical presentation of abruptio placenta mainly depends on the
extent of placental separation, rate of separation and flow of blood
through the cervix (concealed/ revealed).
 Vaginal bleeding: menstrual-like (dark), totally concealed or the amount
is less than the degree of the shock
Abdominal pain/ (uterine) tenderness:
NRFHRP or absent fetal heart beat
Coagulation defect: frank bleeding (epistaxis, ecchymosis, petechiae)

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INVESTIGATIONS:
 HCT
 Blood group and Rh,
 Coagulation profile: Platelet count, PT, PTT, fibrinogen or bedside
clotting and bleeding test
 Ultrasound: Fetal assessment, retroplacental clot and for exclusion of
placenta previa.

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TREATMENT:
 Resuscitate and stabilize on arrival, and admit the patient
 Assess maternal and fetal wellbeing
 Prepare cross matched blood (at least 2 units)

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• Expectant management: <37 weeks, patient in stable condition and
reassuring fetal condition
 Give dexamethasone 6 mg IM BID or Betamethasone 12 mg IM every
24 hours for 48 hours if GA< 37 weeks
Anti D 300µg IM if Rh negative and not sensitized
 Closely monitor maternal and fetal conditions
Prevent and treat anemia

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• Immediate delivery:
Gestational age is >37 weeks/
estimated fetal weight >2.5 Kg,
deranged vital signs, heavy bleeding,
NRFHRP, IUFD, malformed fetus,
established labor
Mode of delivery: Vaginal delivery is preferred.
 Cervical ripening and induction of labor, amniotomy
Emergency cesarean section: For severe bleeding endangering maternal
life, NRFHR or other Obstetrics indications

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COMPLICATIONS
 Hemorrhagic shock (acute kidney injury, congestive heart failure),
DIC
 Utero-placental insufficiency that may lead to IUGR, fetal distress or
IUFD.
PPH

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PLACENTA PREVIA
Placenta previa is defined as the presence of placental tissue over or
adjacent to the cervical os.
CLASSIFICATIONS
Placenta previa: Internal cervical os is covered partially or completely by
placenta (synonyms: central PP, major PP)
Low lying: Placenta lies within 2 cm of the cervical os but doesn’t cover it.
(synonyms: marginal PP, minor PP)

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 Degrees Of Placenta Praevia

Low lying placenta Marginal placenta

praevia
(PP lateralis)

Partial placenta Total placenta

praevia praevia
(incomplete) (complete)
RISK FACTORS
Scarred uterus: previous uterine surgery (CS, myomectomy)
 Previous history of placenta previa
 Large placenta: Multiple pregnancy, diabetes, smoking,
 High parity and advanced maternal age

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DIAGNOSIS
Vaginal bleeding: bright red, painless and recurrent.
 Ultrasound (trans abdominal/ trans vaginal): for placental location and
fetal wellbeing assessment.
Double setup examination: Used only in areas where U/S is not
available/or the U/S is not done by experienced person.
The procedure is done only after termination is decided to diagnose the
cause of bleeding and decide the mode of delivery

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TREATMENT
 Resuscitate and stabilize on arrival and admit the patient
Assess maternal and fetal wellbeing
Prepare cross matched blood (at least 2 units)

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• Expectant management:<37 weeks, patient in stable condition and
reassuring fetal condition
 Give dexamethasone 6 mg IM BID or Betamethasone 12 mg IM every 24
hours for 48 hours if GA < 37 weeks
 Anti D 300µg IM if Rh negative and not sensitized
 Closely monitor maternal and fetal conditions with APH chart
Prevent and treat anemia

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Immediate delivery:
Gestational age is >37 weeks
deranged vital signs,
heavy bleeding,
NRFHRP,
IUFD,
lethal congenital anomaly of the fetus,

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COMPLICATIONS
 PPH
 Hemorrhagic shock,
 Adherent placenta
 Fetal distress or IUFD

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Mode of delivery:
Vaginal delivery can be allowed cautiously for marginal placenta
 Cesarean delivery: Placenta previa, excessive bleeding, NRFHR or other
obstetric indications in low-lying placenta

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