Antepartum Haemorrhage

Amir Hilmi Abd AzizNur Aqilah Nasri

Case

• HOPI: Mrs NMO, 29 y/o, Malay lady, G2P1 with POG of 33w, presented with painless vaginal bleed on the day of admission. The bleed was spontaneous and happened whilst patient was sleeping and it soaked the back of her sarong. This is her first episode. The blood was red in colour and there was no clot or mucus present. There was no contraction, history of trauma, lethargy, palpitation, SOB fever, vaginal discharge or passage of fluid.

• Current Obstetric Hx:– LMP – 2/2/14– Pregnancy confirmation was done by USS at 12w –

viable fetus corresponding to date – EDD – 9/11/14– Hb: 12 g/dL– BP: 130/95

• Past Obstetric Hx:– 2010, SVD, Boy, 3.0 kg, no antenatal/postnatal

complications

• Menstrual Hx– Menarche at 12 y/o– Regular period with 7 days bleed and cycle of 28

days– No dysmenorrhoea, menorrhagia, intermenstrual

bleed and post coital bleed– Last pap smear: 2010 – normal

• No significant PMHx and PSHx

• Drug Hx– NKDA, NKFA– Iron tablets, Folic Acid, Multivitamin

• No significant FHx

• SHx– Teacher, live in Seri Manjung. Husband works with

MPSM. Her baby sitter is taking care of her son. – Never smoke and non drinker

• Examination– On examination, patient is alert, conscious, lying

comfortably and not in distress.– No conjunctival pallor and CRT < 2sec.– Vitals : PR 90, BP 130/95, RR 20, T 36.1oC– Abdomen is distended with gravid uterus (straie

gravidarum and linea nigra). No dilated veins or scars. The SFH is 32cm which correspond to gestation date. There is a singleton with longitudinal lie, cephalic presentation. The head is not engaged and FHR was 144bpm

Investigations

• Diagnostic Tests: Transabdominal Ultrasound– Number of Gestations: 1– Lie: Longitudinal– Presentation: Cephalic– Position: Right– Fetal Heart Rate: 144 x minute– Fetal Movements: Present– Placenta: Placenta edge lies approximately 2cm

from margin of internal os

Differential Diagnosis

• Placenta Previa• Placental abruption • Vasa Previa• Show• Local causes: infection of cervix/vagina,

trauma to cervix/vagina

Antepartum Hemorrhage

Bleeding from the genital tract > 24 weeks of gestation before onset of

labor

Causes of APH

• Unexplained (97%)• Placenta previa (1%)• Placenta abruptio (1%)• others

Maternal Fetal 

ShowInfection of cervix/ vaginaTrauma of cervix/ vaginaCervical erosionGenital tract tumor

Vasa previa

Assessment of APH

• Initial assessment (maternal & fetal condition)– History– Maternal assessment (vital signs, abdominal examination)– *never perform VE in per vaginal bleed without excluding placenta previa

first.

• Once excluded, do speculum examination to assess the degree of bleeding, local causes and determine if membrane is rupture or not.

• Fetal assessment– CTG, USS

Management of APH

Placenta previa Placenta abruptio

Abnormal implantation of placenta, partially or entirely in lower uterine segment after 24 weeks

Premature separation of normally placed placenta from uterus after 24 weeks

Painless Painful

Patient is less distressed Patient is distressed

Soft abdomen Tense, tender abdomen

Abnormal lie and malpresentation Normal lie and presentation

CTG normal CTG abnormal

Not associated with pre eclampsia Associated with pre eclampsia

No coagulation defect, proportional heamodynamic signs

has signs of hypovolemic shock- High PR, low BP

Placenta previa Placenta abruptio 

Types:

Minor (SVD possible)-type I: edge of placental does not reach internal os or > 5cm distant-Type IIa: edge of placental at margin of internal os but not cover it - anterior

Major (ELSCS)-type IIb: edge of placental at margin of internal os but not cover it - posteriorType III: placenta completely covers internal os when os closed, partially covers when cervix dilateType IV: placenta covers internal os completely

Types:

Concealed-no external bleeding evident-has uterine pain,Possibly with maternal shock or fetal distress without obvious bleeding

Revealed-has vaginal bleeding-has minimal or no pain

Management of placenta previa

• those with major previa who have previously bled should be admitted from approximately 34 weeks of gestation.

• while outpatient care can be considered for those with minor previa or those who are asymptomatic.

• RCOG Green-top Guideline No. 27

Management of placenta previaMaternal • Vital sign monitoring

• Strict pad chart and inform if any immediate PV bleeding• KNBM but if no PV bleeding, encourage oral intake• Weekly FBC if symptomatic or continuous PV bleed• Ask everyday any PV bleed or abdominal pain

Fetal • Fetal kick chart, inform any reduce fetal movement• Biweekly CTG and USS

Labor • Prolonged the pregnancy• Plan on mode of delivery depend on the type of placenta previa

DON’T FORGET ABOUT DEXAMETHASONE IF FOUND BEFORE 34 WEEKS

Management of placenta previa

• Delivery

– ELSCS at 38 weeks of POG if placental edge is <2cm from internal os and the placenta is thick.

– Allow SVD at term in minor PP unless there is fetal or maternal compromised.

Management of placenta abruptio

• Stabilization of mother condition– Draw blood for FBC, BUSE, coagulation profile and

GXM– Monitor BP and PR– Left lateral position– Oxygen mask 8L/min– IV fluid– If DIVC, give DIVC regime (6unit cryoprecipitate, 4unit

platelet, 2unit fresh frozen plasma)– CBD for I/O monitoring

• CTG and US for fetal well being and laborReactive + Contraction Non-reactive +/- 

contractionNo fetal heart beat  +/- contraction

Active Phase →  ARM and pitocin → SVD

Latent Phase → SVD/LSCS

SVD/LSCS decided by specialist

ARM +/- pitocin → SVD or LSCS decided by specialist

DON’T FORGET ABOUT DEXAMETHASONE IF FOUND BEFORE 34 WEEKS

Management of Vasa Previa

• With presence of active bleed of vasa previa, with signs of fetal distress, EMLSCS should be performed

• In confirmed cases of vasa previa at term, delivery should be carried out by elective caesarean section in a timely manner.

• In cases of vasa previa identified in the second trimester, imaging should be repeated in the third trimester to confirm persistence.

• In cases of confirmed vasa previa in the third trimester, antenatal admission from 28 to 32 weeks of gestation to a unit with appropriate neonatal facilities will facilitate quicker intervention in the event of bleeding or labour.

• In view of the increased risk of preterm delivery, administration of corticosteroids for fetal lung maturity should be considered.

Management of Local Causes

• Infections – Treat with antibiotics/antifungal accordingly

• Trauma – stop any active bleeding and reassure patient. However, if bleeding doesn’t stop a surgical intervention may be necessary.