Ante partum Hemorrhage

March,2024
• Obstetrics is a bloody business
• Obstetrics hemorrhage is one of the five leading cause of Maternal
Death
• MMR has ↓ed markedly in dev.ed but not dev.ing countries:-
• Promotion of basic obstetrics care:-

- hospitalization

- availability of blood products

- improvement in anesthesia care

- prompt surgical intervention↑

• Bleeding during the later half of pregnancy = 3-4%

 Ante Partum Hemorrhage
• Defn. :-

- is the occurrence of vaginal bleeding (VB) after 28th wks of

gestation and before delivery of the fetus

- VB in the 2nd trimester is also a concern = ↑ed PNMR [Perinatal

Mortality Rate]
Ethiology
• Generally fall into 5-6 categories:-

1.Placenta previa
2.Abruptio placenta
3.Uterine rupture
4.Local causes
5.Unexplained causes
6.Other rare causes
- circumvallate placenta, vasa previa
A. Placenta Previa(PP)
• Definition:-

- is implantation of the placenta in the LUS, with the placenta

either overlying or reaching the cervix, usually in advance of
the presenting part.
Four types:-
1.Low lying placenta previaType I
2.Marginal placenta previa Type II
3.Partial placenta previa Type III
4.Total placenta previa Type IV
Major degree PP= Type I & II
The degree of PP dep . On cxal dilitn. At the time of dx.
• Low-lying placenta —
(1) to describe an apparent placenta previa in the
second trimester,
(2) the exact relationship of the placenta to the os has
not been determined, or
(3) to describe a placental edge that lies within 2 to 3
cm of the internal os
• associated with an increased risk of bleeding,
although less than with true placenta previa
• Incidence of PP: 1 in 200 births

• Etiologies of PP:
- the specific cause is not known
- many factors may affect placental implantation

Defective decidual vascularization (ex. Grand multiparity)

Prior trauma to the endometrium (ex. C/S scar, curettage, etc.)

Placental hypertrophy (ex. DM, Erythroblastosis, etc.)

• Associated factors :-
1. ↑ed maternal age
- 1/1500 = teenagers ; 1/100 = >35yrs.

2. Multyparity
- 1/1500 = nullipara Vs 1/20 = grandmultypara
3. Prior uterine scar
- C/S, D & C, PID, Myomectomy, Metroplasty, etc
= C/S → 5 - fold ↑ed incidence
→ 2% with 2 prior C/S
→ 4% with > 2 prior C/S
- risk of TAH ↑ed with repeat C/S for PP (25% Vs 6%)
4. Smoking = hypoxemia → Placental hypertrophy
5. Twins = b/c of ↑ed placental surface area.
• Clinical course and diagnosis

The mean GA at Dx. = 32.5 wks.

PAINLESS, CAUSELESS, BRIGHT RED Vag. bleeding
Why bleeding?
- formation of the LUS → detachment of the placenta
- placentitis
- direct trauma → coital, PV exam., douching
Can also remain asymptomatic
1st episode usually slight → get more sever later on
The GA at 1st episode → ass. With perinatal outcome
• Other clinical findings :-

 Hypovolemia
Anemia
Soft uterus
Malpresentation
Floating presenting part
• Diagnosis

 the clinical presentation

- painless Vag. bleeding in 3rd trimester is PP !!!!
 Imaging techniques :-
1. ultrasound
- abdominal Vs Vaginal
2. MRI
 Double set up examination
- preparation is needed
 Complications
A) Maternal

• Blood loss & shock

• Adherent placenta
• Transfusion risks
• Longer hospital stay
• Surgical morbidity
• Post partum hemorrhage
• Recurrence rate — 4 to 8 percent
 B) Fetal / Neonatal
1.↑ed PNMR from prematurity

2.↑ed risk of fetal anomalies ( 5x)

3.↑ed IUGR (20% Vs 5%)

4.Birth trauma ( b/c of malpresentation)

5.Neonatal anemia
 Management
• Principles :-
Admit or Refer all patients to a hospital

NEVER NEVER NEVER do PV- EXAM

Take Resuscitative measures

Plan further management

• Resuscitation :-

Secure IV – line ( 1 or 2 IV – lines)

Administer fluids depending upon the patient status

Take blood for BG & RH, HCT

X – match at least two units of blood

Transfuse if indicated (HCT < 30%)

 Plan further management

1.Expectant management
- no active vaginal bleeding
- preterm fetus
- hemodynamicaly stable,
- no anemia
- follow maternal & fetal status
• Maternal • Fetal
vital signs every 4 – 6 hrs. Ascertain GA
Watch for Vxal bleeding & Kick chart
onset of labor FHR 4-6 hrs.
Serial HCT BPP 2x/week
Iron supplementation Growth monitoring
Avoid douching Steroid therapy if GA <34
Decrease mobility weeks
2. Termination of pregnancy

a. term pregnancy
b. labor
c. torrential bleeding
d. IUFD
e. lethal malformation
• Mode of delivery:

1.Vaginal
- type I & type II anterior PP

 Determine the Dx. By double set up

examination or by U/S!!!
2. Cesarean section

- all other major degree PP

- cesarean hysterectomy
- abnormal adherence(placenta acccreta syndrome)
- Rh(D)-negative women should receive Rh(D)-immune globulin if they
have APH if there is bleeding even before delivery.
OUTCOME
• MMR due to PP has fallen from 25 % to 1 %
- but remains high in developing countries:-
maternal anemia,
lack of medical resources, and
home births are common.
• PNM due to PP has fallen from 60 to 10 percent.
The principal causes for PNM are related to preterm
delivery
 2.Abruptio Placenta(AP)
• Definition:-
- premature separation of the normally implanted
placenta
- also called accidental hemorrhage/ placental abruption
Types
1. revealed / external
2. Concealed: in most AP
- it might as well be:-
= partial abruption
= total abruption
= marginal separation
• Incidence
- 1/75 to 1/225 births ( 0.4 – 1.3%)
- 1/3rd of all APH
- sever AP that kills the fetus = 1/ 830 ( 0.12%)
Pathogenesis
- It is not clear whether Abruptio placentae results from a single
pathologic event or is the culmination of a longer-standing
disorder of the fetal-placental interface.

- Likely to involve a chronic pathologic vascular process at the

fetal-placental interface with abruption as the culmination of a
long chain of events
• Initially hemorrhage into desidua basalis
↓
decidual hematoma & desidua splits
↓
1.further separation → more blood loss → shock
and/or
2.compression & destruction of adjacent placenta
↓
Acute placental insufficiency
↓
Fetal demise
-Since Uterus is still distended → don't contract and compress
the torn vessels that supply the placental bed
• Risk factors for AP:-
1.Prior abruption = 4-5%
2.Advanced age and parity = 2.5%
3.Preeclampsia = 5 fold
4.Chronic hypertension = 5 fold
5.Trauma
6.Race and ethnicity = Black Vs Asia
7.PPROM = cause or result
8.Multifetal pregnancy = twin B, 3 fold
9.Cigarette smoking = 2.5 fold
10.Thrombophilias
11.Cocaine use
12.Myoma
13.Folate deficiency
• Clinical feature

- highly variable depend on the severity & +/- compl.

Vaginal bleeding = dark red, painful (80%)
Uterine tenderness & back pain & abd. Pain (50%)
Uterine hyper tonus ( focal or generalized)
Idiopathic preterm labor
Fetal distress / NRFHRP [Non Reassuring Fetal Heart…]
ARF
Coagulopathy
- the amount of bleeding does not correlate with the extent of
maternal hemorrhage!!! ( concealed type)
• The classic symptoms with out vaginal bleeding
↓
concealed hemorrhage (20%)
-how?
Placental margins remain adherent to uterine wall
Membranes retain their attachment during marginal
separation = sts. Invade amniotic cavity =“ PORT WINE”
Fetal head obstructs egress of blood through cervix

= blood may extravasate into the myometrium

↓
Couvelaire uterus ( Apoplexy)
 Grades of AP
SSx I II III

bleeding slight Mild- mod Mod-severe

PR normal +/- elevated elevated

BP normal maintained shock

Ux irritabilit Uly.present irritable Tetanic/pain

FHRP normal distress Death

Fibrinogen normal 150-250 <150

Separation <25% 25-50% >50%

Blood loss <1L 1-3L >3L

• Diagnosis:-
primarily clinical, supported by:-
Ultrasonography
- appearance depend on time of scanning
= acute hemorrhage – hyper / isoechoec
= resolving hematoma – hypoechoec (1 week)
-- sonolucent (2 weeks)
- most imp. Is to R/O placenta previa!!!
Laboratory tests
- none is diagnostic
- fibrinogen level, platelet count
Pathologic examination
-after delivery, clot or depression
• Differential diagnosis for AP:-

Placenta previa in labor (b/c pain,bleeding)

Uterine rupture(b/c pain, bleeding)

Sepsis / DIC

Scar dehiscence (b/c pain, bleeding)

Management
• Principles :-
Admit or Refer all patients to a hospital

NEVER do PV- EXAM unless PP is R/O

Take Resuscitative measures

Plan further management dep on GA & severity

A) Mild AP ( grade I)
 Expectant Mx. If preterm
- secure IV-line
- hct, BG & RH, X-match blood
- platelet, PT, aPPT, fibrinogen
- continuous FHR monitoring (CTG)
- follow maternal hemodynamic status
= V/S q 15’, OUP q 1hr., bleeding, S-hct, labor, coagulopathy,
uterine tenderness
= terminate if any deterioration in mother or fetus or term
B. Moderate or sever AP (type II / III)
No place for expectant Mx.
Restore the blood volume

- correct anemia
- correct acid base imbalance
- prevent or correct coagulopathy
- monitor the renal function
- continuous FHR monitoring
• Mode of delivery
A) Vaginal

 Dep. on cervical status, maternal & fetal condition

 Rule out PP by U/S or double set up examination
 Amniotomy
 Induction / augmentation
 electronic FHR monitoring
 Frequent V/S monitoring
B. Cesarean section
Indication:-

Uncontrolled hemorrhage
Protracted labor suspected
Fetal distress
Other obstetric indications
- avoid regional anesthesia in hypotension and DIC
• Complications:-
Maternal
Hypovolemic shock = MOD = death!!!
Acute renal failure
DIC
PPH
Surgical morbidity
Fetal / Neonatal
Prematurity
IUGR
PNM
Future neurological sequelle
 3. Local Causes
Causes:
Trauma to cx, vx before delivery
Leech infestation
Cervicitis

Diagnosis:
Speculum exam after PP is R/O

Management:
Manage the local cause
4. Idiopathic

The commonest cause of APH

Bleeding may not be heavy
Even if no identified cause, MM and PMR is high

Therefore termination of pregnancy at term, do not wait for

spontaneous labor.
Thank You