Antepartum Antepartum Haemorrhage (APH)Haemorrhage (APH)

DR:HUSSEIN H AKLDR:HUSSEIN H AKL

O&G SPECIALISTO&G SPECIALIST

HOSPITAL SEGAMATHOSPITAL SEGAMAT

JOHORJOHOR

ContentsContents

• Definition• Importance• Causes• Management of APH• Prognosis

Bleeding In

Pregnancy

Bleeding in early

Pregnancy

Antepartum

haemorrhage (APH)

Post partum Haemorrhag

e (PPH)

Antepartum Antepartum HaemorrhageHaemorrhage

• Antepartum haemorrhage (APH,prepartum hemorrhage) is bleeding from the vagina during pregnancy from twenty four weeks of gestational age to term.

• Epidemiology Affects 3-5% of all pregnancies 3 times more common in multiparous than primiparous women

ImportanceImportance• Obstetric emergency• Attention should be sought

immediately• If left untreated can lead to death of

the mother and/or foetus• Can leads to DVT• Management reduce the risk of

premature delivery and maternal/perinatal morbidity/mortality

CausesCauses

• Blood stained show (benign) - Most common cause of APH

• Placental abruption - Most common pathological

cause (1/100) • Placenta praevia - Second most common

pathological cause (1/200) • Vasa praevia- Often difficult to diagnose,

frequently leads to foetal demise (1/2000-3000) • Uterine rupture - (<1% in scarred uterus)

Causes ctd…Causes ctd…• Bleeding from the lower genital tract Cervical bleeding – Cervicitis , cervical neoplasm, cervical polyp, Cervical ectropion Vagina bleeding - Trauma, neoplasm, Vulval varices , infection

• Inherited bleeding problems - Very rare, 1 in 10,000 women• Unexplained - No definite cause is diagnosed in about 40% of APH

Bleeding that may be Bleeding that may be confused with vaginal confused with vaginal

bleedingbleeding• GI bleed - Hemorrhoids, inflammatory

bowel disease

• Urinary tract bleed - UTI

Placenta praeviaPlacenta praevia

• Definition Insertion of the placenta, partially or

fully, in the lower segment of the uterus

EtiologyEtiology• No definitive cause• Endometrial factors:

– A scarred endometrium– Curettage for several times – Abnormal uterus

• Placental factors– Large plcenta– Abnormal formation of the placenta

• Development retardation of fertilized egg

Risk factors for Placenta Risk factors for Placenta praeviapraevia

• Multiparity• Advanced maternal age• Prior LSCS or other uterine surgery• Prior placenta praevia• Uterine structural anomaly• Assisted conception

Degrees of Placenta praeviaDegrees of Placenta praevia

Classification of degrees Classification of degrees of Placenta praeviaof Placenta praevia

• Four grades:– Grade I: Placenta encroaches lower

segment but does not reach the cervical os

– Grade II: Reaches cervical os but does not cover it

– Grade III: Covers part of the cervical os– Grade IV: Completely covers the os,

even when the cervix is dilated

Placenta praevia-Placenta praevia- Clinical Clinical FeaturesFeatures

• Recurrent painless vaginal bleeding (not always)• Abdominal findings Uterus is soft, relaxed and non tender Contraction may be palpated Presenting part is usually high Abnormal presentations • Maternal cardiovascular compromise• Foetal condition satisfactory until severe

maternal compromise• Vaginal examination- should not be done

InvestigationInvestigation• Diagnosis by ultrasound scan showing

that the placenta coming in to the lower segment

• Transvaginal ultrasound is safe and is more accurate than transabdominal ultrasound in locating the placenta

• Leading edge within the 2 cm from internal os or completely covering the internal os is incompatible with normal vaginal delivery

Placenta praevia-Placenta praevia-ComplicationsComplications

Maternal • Major hemorrhage, shock, and death• Renal tubular necrosis and acute renal failure• Post partum haemorrhage• Morbid adherence of Placenta : placenta accreta

complicates approximately 10% of placenta praevia cases

• Anaemia in chronic haemorrhage• Sensitization of mother for foetal blood in Rh (-)

patients• Disseminated intravascular coagulopathy (DIC)

Placenta praevia-Placenta praevia-Complications cont….Complications cont….

Foetal• IUD• Hypoxic ischemic encephalopathy• Cerebral paulsy• Placental abruption• Premature labour

Placental abruptionPlacental abruption

• Definition Premature separation of a normally situated placenta in a viable foetus • Placental abruption should be

considered in any pregnant woman with abdominal pain with or without PV bleeding, as mild cases may not be clinically obvious

Placental abruptionPlacental abruptionConcealed haemorrhage

Retro placental blood clot

EtiologyEtiologyRisk factors1.Increased age and parity2.Vascular diseases: preeclampsia, maternal

hypertension, renal disease,SLE and APS3.Mechanical factors: Trauma, intercourse Sudden decopression of

uterus Polyhydroamnios Multiple pregnancy 4. Smoking, cocaine use, 5. Uterine myoma6. Premature rupture of membranes7. Supine hypotensive syndrome

PathologyPathology• Main changes Hemorrhage into the decidua basalis →

decidua splits → decidural hematoma → separation, compression, destruction of the placenta adjacent to it

• Types of abruption 1. Revealed abruption 2. Concealed abruption 3. Mixed type

Revealed abruptionConcealed abruption

Diagnosis-Clinical Diagnosis-Clinical FeaturesFeatures

• Painful vaginal bleeding• Pain is usually continuous

1.Mild type• Abruption≤ 1/3 • Vaginal bleeding may be present or absent

Diagnosis-Clinical Features Diagnosis-Clinical Features ctdctd

2.Severe type

• Abruption > 1/3• Large retroplacental haematoma • Vaginal bleeding associate with persistent abdominal pain • Tenderness on the uterus• “Woody” hard uterus• Change of foetal heart rate –CTG

changers• Features of hypovolemic shock

Complication of Complication of Placental Placental abruptionabruption

Maternal • Disseminated intravascular coagulopathy• Hypovolemic shock• Amnionic fluid embolism• Renal tubular necrosis and acute renal

failure• Post partum haemorrhage• Sensitization of Rh(-) mother for foetal blood• Sheehan’s syndrome• Maternal death

Complication of Complication of Placental Placental abruptionabruption

Feotal• Premature labour• IUGR in chronic abruption• Hypoxic ischemic encepalopathy and

cerebral paulsy• Foetal death

InvestigationsInvestigations• Ultrasonography Mainly to exclude placenta praevia Can detect Retroplacental hematoma Feotal viability Most of the time findings will be negative Negative findings do not exclude placental abruption• CTG – Sinosoidal pattern,Feotal tachycardia or

bradycardia• Laboratory investigations1. Investigation for Consumptive coagulopathy – Platelet

count/BT/CT/PT/INR & APTT2. Liver and Renal function tests

Vasa praeviaVasa praevia

• Foetal blood vessels from the placenta or umbilical cord cross the internal os beneath the baby

• Rupture of membranes leads to damage of the foetal vesseles leading to exsanguination and death

• High foetal mortality (50-75%)

Vasa praeviaVasa praevia

Risk factorsRisk factors

• 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

Succenturiate lobe

Bilobate placenta

Eccentric (velamentous) cord insertion

Diagnosis - Vasa praeviaDiagnosis - Vasa praevia1.Moderate vaginal bleeding + feotal distress2.Vessels may be palpable through dilated

cervix3.Vessels may be visible on ultrasound

(Transvaginal colour Doppler ultrasound)• Difficult to distinguish from abruption• Can look for feotal Hb (Kleihauer-Betke test)

or nucleated RBC’s in shed blood• Tachycardia or bradycardia in CTG

Rupture of UterusRupture of Uterus• Uterine scar dehiscence:

– Foetal membranes remain intact, foetus is not extruded intraperitoneally, separation limited to old scar, peritoneum overlying is intact

– Usually no foetal distress / maternal Hemorrhage

• Uterine rupture: – Separation of scar extension, rupture of

foetal membranes with extrusion– Results in foetal distress / maternal

hemorrhage– Maternal mortality– Foetal mortality = 35%

Rupture of UterusRupture of Uterus

Rupture of UterusRupture of Uterus

• High Index of clinical suspicion

• In all cases of antepartum and intra partum haemorrhage uterine rupture must be excluded

Risk factorsRisk factors•Scarred uteri –Previous caesarian section & other uterine surgeries

•Grand multiparous •Inadvertent use of oxytocin & prostaglandins

•Shoulder dystocia•Forceps deliveries•Trauma•Uterine abnormalities

Rupture of Uterus-Rupture of Uterus-Clinical Clinical featuresfeatures

Maternal • Pain in between contractions• Scar tenderness• Vaginal bleeding• Profound maternal tachycardia and

Hypotension• Loss of uterine contractions• Haematurea• Postpartum haemorrhage may be a sign

Rupture of Uterus-Rupture of Uterus-Clinical features cont..Clinical features cont..Foetal• Foetal distress-CTG changers• Loss of station• Absence of FHS• Palpable foetal parts through maternal

abdomen

ComplicationsComplications• Maternal

– Hemorrhage– Bladder rupture– Maternal death– PPH– DIC

• Foetal– Respiratory distress– Hypoxia and cerebral paulsy– Acidemia– Death

Comparison of Presentation Comparison of Presentation of of

Abruption v. Previa v. Abruption v. Previa v. RuptureRupture Abruption Praevia Rupture

Abd. pain present absent variableVag. blood old or fresh fresh freshDIC common rare rareAcute foetal common rare common

distress

Management of APH

Management of APH Management of APH • Admit to hospital for assessment and management• May need resuscitation measures if shocked or severe bleeding

Airway, breathing and circulation

Senior staff must be involved –Consultant

obstetrician and consultant anaesthetist,

neonatalogist

Two wide bore canula

Take blood for Grouping & DT,FBC , coagulation

profile,Liver & renal function

•

•

• Severe bleeding or fetal distress: urgent delivery of baby irrespective of gestational age

Management of APH Management of APH

• Volume should be replaced by

Crystalloid / colloid until blood is available

• Severe bleeding or feotal distress: Urgent delivery of baby irrespective of gestational age

Management of APH Management of APH cont… cont… History

• Obtain a history if patient’s condition including: • Colour and consistency of bleeding • Quantity and rate of blood loss • Precipitating factors i.e. Sexual intercourse, Vaginal examination • Degree of pain, site and type • Placental location-review ultrasound report if available • Ascertain foetal movements • Ascertain blood group

Management of APH Management of APH cont…cont…Examination

• Assess maternal and foetal well-being Pallor, record temperature, pulse and BP • Perform abdominal examination Note areas of tenderness and hypertonicity Determine gestational age of foetus,

presentation and position, auscultate foetal heart• No vaginal examination should be attempted at

least until a placenta praevia is excluded• Do speculum examination to assess cervix / bleeding

and exclude local lesions  

Management of APH Management of APH cont…cont…

Investigations• Arrange urgent ultrasound scan• Foetal monitoring Continuos electronic foetal

monitoring is indicated

Management of APH Management of APH cont…cont…

• Rhesus negative woman should have a klihaver test and be given prophylactic anti-D immunoglobulin (Rhogum)

• For pre-term delivery when immediate delivery is not necessary, maternal steroids - to promote feotal lung maturity

Betamethasone Dexamethasone

Further management of Further management of APHAPH

• Further management will depend on Cause of the APH Extent of bleeding Presence of feotal distress Gestational age and feotal

maturity

Placenta praevia - Placenta praevia - ManagementManagement

1.Near term / Term• Delivery is considered Grades I and II - May be able to deliver vaginally Grades III and IV - Will require caesarean section by senior obstetrician

• Should anticipate PPH

Placenta praevia – Placenta praevia – Management cont…Management cont…

2.Early in pregnancy• Continuation of pregnancy better if possible• Need bed rest• Educate patient regarding condition and risk• 3 pint of crossed matched blood should be

available till delivery• Foetal well being and growth should be

monitored –KCC,CTG,USS• Medications may be given to prevent premature

labour- Nifidipine, Atosiban

Placental abruption – Placental abruption – Management ctdManagement ctd

• Small abruption Conservative management

depending on gestational age Careful monitoring of feotal

condition

Placental abruption - Placental abruption - managementmanagement

• Moderate or severe placental abruption:• Restore blood loss• Ideally measure central venous pressure (CVP)

and adjust transfusion accordingly• Prevent coagulopathy• Monitor urinary output • Delivery 1.Caesarean section 2.Vaginal If coagulopathy present If feotus is not compromised If feotus is dead

Rupture of UterusRupture of Uterus ManagementManagement

Emergency laparotomy Deliver the baby Uterine repair if possible specially in primi gravida PPH haemostasis sequence Caesarian hysterectomy (may be preferred)

Vasa Previa Vasa Previa managementmanagement

• Urgent delivery Most of the time urgent LSCS• Neonatologist involvement• Aggressive resuscitation of the baby

with blood transfusion following delivery

Prognosis of APHPrognosis of APH

• Feotus may die from hypoxia during heavy bleeding

• Perinatal mortality more than 50 per 1000 even with tertiary care facilities

• High rates of maternal mortality

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Egypt