ANTEPARTUM HAEMORRHAGE

INTRODUCTION
Antepartum bleeding or hemorrhage is
bleeding from vagina that takes place after
24th week of gestation. It occurs 2-5% of all
cases. In the absence of pregnancy, uterus
receives 1% of the heart’s output. This
increases dramatically to approximately
about 20% of output in the third trimester.
As such uterine bleeding which can occur
due to various causes can be substantial
during pregnancy
 Post partum
Haemorrha
ge (PPH)

Antepartum
hemorrhage

Bleeding
in
pregnancy

Bleeding
in early
pregnancy
DEFINITION
Antepartum hemorrhage is bleeding from
or into the genital tract, occurring from 24
weeks of pregancy ad prior to the birth of
the baby.
IMPORTANCE
Obstetric emergency
Attention should be sought immediately.
If left untreated can lead to death of the
mother &or fetus
Management reduce the risk of premature
delivery &maternal/ perinatal
morbidity /mortality
INCIDENCE
According to confidential enquiry into
maternal and child health (CEMACH)
(2005), the mortality rate due to obstetric
hemorrhage was 0.66 per 1,00,000
maternities.
Affects 3-5% of all pregnancies. It is 3
times more common in multiparous than
in primiparous women.
CAUSES
Placental abruption: Most common
pathological cause (1/100)
Placenta previa: Second most common
pathological cause (1/200)
CAUSES
Vasa previa: Often difficult to diagnose,
frequently leads to fetal demise (1/2000-
3000)
Uterine rupture: (<1% in scarred uterus)
Bleeding from the lower genital track
Cervical bleeding – Cervicitis
Cervical neoplasm
Cervical polyp Cevical
ectropion Vaginal bleeding -
CAUSES
- Trauma
Neoplasm
Vulval varices
Infection
Inherited bleeding problems: Very rare, 1 in
10000women
Unexplained: no definite cause is diagnosed in
about 40% of APH
Bleeding that may be confused with
vaginal bleeding
GI bleeding: Hemorrhoids, inflammatory
bowel disease etc.
Urinary tract bleed: UTI, etc
COMPLICATIONS OF APH
MATERNAL   FETAL
•Anaemia
COMPLICATIO
•Infection
•Maternal shock NS •Fetal hypoxia
•Renal tubular necrosis •Fetal growth
•Consumptive coagulopathy restriction
•Postpartum haemorrhage •Prematurity
•Prolonged hospital stay (iatrogenic &
•Psychological problems spontaneous)
•Complications of blood •Fetal death
transfusion
PLACENTA PREVIA
DEFINITION
Insertion of the placenta, partially or
completely, in the lower segment of the
uterus 
RISK FACTORS FOR PLACENTA
PREVIA
Previous placenta previa
Previous Caesarean section
Previous termination of pregnancy
Multiparity
RISK FACTORS FOR PLACENTA
PREVIA
Advanced maternal age (>40 years)
Multiple pregnancy
Deficient endometrium due to presence or
history of:
•Uterine scar
RISK FACTORS FOR PLACENTA
PREVIA
•Endometritis
•Manual removal of placenta
• Curettage
•Submucous fibroid
Assisted conception
Smoking 
 DEGREES OF PLACENTA PREVIA
Type I: Placenta
encroaches lower
segment but does not
reach the internal os
Type II: Reaches
internal os but does not
cover it
Type III: Covers part of
the internal os
Type IV: Completely
covers the os, even when
the cervix is dilated 
 CLINICAL FEATURES
 Recurrent painless vaginal bleeding (not always)
 Abdominal findings
Uterus- soft, relaxed, non tender & proportionate to POG
 Contraction may be palpated
 Abnormal presentations
High floating head in cephalic presentation
Maternal cardiovascular compromise
 Fetal condition satisfactory until severe maternal
compromise
Vulval inspection- presence of bleeding, character of
blood
Vaginal examination- should not be done
INVESTIGATION
Diagnosis by ultrasound scan (USS) showing
placenta coming in to lower segment
Transvaginal ultrasound (TVS) is safe & is more
accurate than transabdominal ultrasound (TAS) in
locating placenta
Leading edge within 2 cm from internal os or
completely covering internal os is incompatible with
normal vaginal delivery
Transperineal (TPS)
Colour Doppler flow study
MRI
 CONFIRMATION OF DIAGNOSIS
LOCALIZATION OF CLINICAL
PLACENTA  By internal
 Transabdominal examination (double
ultrasonography set up)
 Transvaginal  Direct visualization
ultrasonography during CS
 Colour doppler flow study  Examination of
 MRI placenta following
delivery
 PLACENTA PRAEVIA - MANAGEMENT
Near term / Term
Delivery is considered
Type Ia, Ib & IIa - May be able to deliver
vaginally
Type IIb, III and IV - Will require caesarean
section by senior obstetrician
Should anticipate PPH
 PLACENTA PRAEVIA -
MANAGEMENT
Pregnancy below 34 weeks POG
Continuation of pregnancy better if possible
• Need bed rest
• Educate patient regarding condition & risk
• cross matched blood should be reserved till
delivery
• Fetal well being & growth should be
monitored –BPP,CTG,USS
• Medications may be given to prevent
premature labor- Nifedipine, Atosiban
ABRUPTIO PLACENTA
PLACETAL ARUPTION
DEFINITION
Premature separation of a normally
situated placenta in a viable fetus.
RISK FACTORS FOR PLACENTAL
ABRUPTION
The most predictive is abruption in previous pregnancy.
 Abruption recurs in 19-25% of women who have had two
previous pregnancies complicated by abruption.
 Increased age and parity
Vascular diseases: hypertension in pregnancy, renal
disease, SLE & APS
 Mechanical factors: Trauma, amniocentesis, sudden
decompression of uterus, polyhydramnios, multiple
pregnancy
 Smoking, cocaine use
 Uterine myoma, septum
 Supine hypotension syndrome 
 PATHOPHYSIOLOGY
Spasm of vessels in uteroplacental bed (decidual
spiral artery) anoxic

Endothelial damage, rupture of vessels &

hemorrhage in decidua basalis

Decidua splits decidual hematoma

(retroplacental) separation

compression, destruction of the adjacent

TYPES OF ABRUPTION
Concealed abruption
Revealed abruption
Mixed type
 CLASSIFICATION OF PLACENTAL
ABRUPTION
Grade 0- Asymptomatic – small retroplacental clot
Grade 1 (40%) - External vaginal bleeding present.
Uterine tenderness and tetany may be present. NO
SIGN OF MATERNAL SHOCK OR FETAL
DISTRESS
 CLASSIFICATION OF PLACENTAL
ABRUPTION
Grade 2 (45%) - External vaginal bleeding may or
may not be present. NO SIGNS OF MATERNAL
SHOCK, BUT FETAL DISTRESS IS PRESENT
Grade 3 (15%) - External bleeding may or may not
be present. Marked uterine tetany, a board-like
rigidity on palpation. Persistent abdominal pain,
MATERNAL SHOCK and fetal distress are present.
Coagulopathy may become evident in 30% of cases.
 CLINICAL FEATURES
Severe type
Mild type  Abruption > 1/3
• Abruption≤ 1/3
 Large retroplacental hematoma
• Vaginal bleeding  Vaginal bleeding associated
may be present or with persistent abdominal pain
absent  Tenderness on the uterus
 “Woody” hard uterus
 Change of fetal heart rate –
CTG changes
 Features of hypovolemic shock
 Painful vaginal bleeding
 Pain- usually continuous
 INVESTIGATIONS
Ultrasonography

Mainly to exclude placenta previa

Can detect
• Retroplacental hematoma
• Fetal viability
Most of the time findings will be negative
Negative findings does not exclude placental abruption
CTG – Sinusoidal pattern, Fetal tachycardia or
bradycardia
Laboratory investigations

Investigation for Consumptive coagulopathy – Platelet

count/BT/CT/PT/INR & APTT
Liver and Renal function tests
 MANAGEMET
Small abruption
Conservative management depending on
gestational age Careful monitoring of fetal
condition
Moderate or severe placental abruption
•Restore blood loss
•Ideally measure central venous pressure
(CVP) & adjust transfusion accordingly
•Prevent coagulopathy
•Monitor urinary output
 MANAGEMET
•Delivery

1.Caesarean section
2.Vaginal- If coagulopathy present
If fetus is not compromised
If fetus is dead 
 COMPLICATIONS OF PLACENTAL
ABRUPTION
Maternal
Sensitization of Rh(-) mother for
Fetal
Prematurity
fetal blood
Amnionic fluid embolism IUGR in
Post partum hemorrhage chronic
Hypovolemic shock abruption
Renal tubular necrosis & acute renal Hypoxic
failure ischemic
Disseminated intravascular encephalopathy
coagulopathy (DIC) Cerebral palsy
Puerperal sepsis
Fetal death 
Sheehan’s syndrome
Maternal death 
 VASA PREVIA
Fetal blood vessels from placenta or
umbilical cord cross the internal os
beneath the baby
Rupture of membranes lead to damage of
the fetal vessels leading to exsanguination
and death
 High fetal mortality (50-75%) 
 RISK FACTORS OF VASA PREVIA
Eccentric (velamentous) cord insertion
Bilobed or succenturiate lobe of placenta
Multiple gestation
Placenta praevia
In vitro fertilization (IVF) pregnancies
History of uterine surgery or D & C
DIAGNOSIS - VASA PRAEVIA
Moderate vaginal bleeding + fetal distress
Vessels may be palpable through dilated
cervix
 Vessels may be visible on ultrasound (TV
colour Doppler ultrasound)
 Difficult to distinguish from abruption
 Can look for fetal Hb (Kleihauer-Betke
test) or nucleated RBC’s in shed blood
 Tachycardia or bradycardia in CTG
 VASA PREVIA
MANAGEMENT
 Urgent delivery
Most of the time urgent LSCS
Neonatologist involvement
Aggressive resuscitation of the baby with
blood transfusion following delivery
Management of APH
Advised to report all vaginal bleeding to
antenatal care provider
 Admit to hospital for clinical assessment
& management
Senior staff must be involved – Senior
obstetrician, anesthetist, neonatologist
Management of APH
 May need resuscitation measures if in shock or
severe bleeding
Airway(A), breathing(B) & circulation(C)
Two wide bore cannula
 Take blood for Grouping, CBC, coagulation
profile, Liver & renal function
 Volume should be replaced by Crystalloid
/colloid until blood is available
Severe bleeding or fetal distress: Urgent
delivery of baby irrespective of gestational age
 Management of APH
 To establish whether urgent intervention is
required to manage maternal or fetal
compromise The process of TRIAGE includes –
history taking to assess coexisting symptoms
such as pain
an assessment of the extent of vaginal bleeding
cardiovascular condition of mother
assessment of fetal well-being 
 Management of APH
History
Obtain history if no maternal compromise
o Colour and consistency of bleeding
o Quantity & rate of blood loss
o Precipitating factors i.e. Sexual intercourse,
Vaginal examination
o Degree of pain, site and type
o Placental location-review ultrasound report if
available
o Ascertain fetal movements
o Ascertain blood group
 Management of APH
Examination
To assess amount & cause of APH
 Assess maternal & fetal well-being
 Pallor, record temperature, pulse & BP
 Perform abdominal examination
• Note areas of tenderness & hypertonicity •
Determine gestational age of fetus, presentation
• & position, auscultate fetal heart
 No vaginal examination should be attempted at
least until placenta previa is excluded
 Do speculum examination to assess cervix /
bleeding & exclude local lesions   
 Management of APH
Investigations
 Arrange urgent ultrasound scan Does not
exclude abruption Glantz and colleagues
reported the sensitivity, specificity, and
positive and negative predictive values of
ultrasonography for placental abruption to be
24%, 96%, 88%, and 53%, respectively.
 Fetal monitoring
Continuous electronic fetal monitoring
indicated where knowledge of fetal condition
influence timing & mode of delivery
 Management of APH
Rhesus negative woman should have a
Kleihauer test & be given prophylactic anti-
D immunoglobulin
 For preterm delivery between 24+0 & 34+6
weeks POG, antenatal corticosteroids - to
promote fetal lung maturity
• Betamethasone
• Dexamethasone
Management of APH
Role of tocolytic therapy in women
presenting with APH having uterine activity –
• preterm needing transfer to hospital with
NICU facility
• incomplete course of corticosteroids
Calcium antagonist (Nifedipine) best avoided
with cases of maternal hypotension
Drug of choice should have fewest maternal
cardiovascular side effects
FURTHER MANAGEMENT OF APH
Depend on –
 Cause of APH
 Extent of bleeding
 Presence of fetal distress
 Gestational age & fetal maturity
 POINTS TO REMEMBER
Women presenting with APH before 37+0
weeks POG, where there is no maternal or
fetal compromise & bleeding has settled,
there is no evidence to support elective
premature delivery of fetus
 Following an episode of major APH that has
settled or recurrent unexplained APH it is
reasonable to arrange delivery of the fetus
after 37+0 weeks POG
 POINTS TO REMEMBER
 If presenting after 37+0 weeks it is important
to establish if the bleeding is an APH or blood
stained „show ; if the blood is streaked
through mucus it is‟ unlikely to require active
intervention
In the event of major APH, IOL with aim of
achieving vaginal delivery should be
considered in order to avoid adverse
consequences potentially associated with a
further APH
PROGNOSIS OF APH
Fetus may die from hypoxia during heavy
bleeding
Perinatal mortality more than 50 per 1000
even with tertiary care facilities
High rates of maternal mortality