Antepartum Haemorrhage

Saad Bin Zafar Mahmood

DefinitionHemorrhage from the vagina

after the 24th week of gestation till end of pregnancy

Blood loss of greater than 300mls

Incidence : 3-5% of all pregnancies

Antepartum Haemorrhage: TypesSimple:

◦ Local Vagina – Trauma Cervical – Infection or tumor

- Blood dyscrasias Thrombocytopenia Anticoagulants

Complicated:◦ Abruptio Placentae◦ Placental praevia◦ Vasa Praevia

Abruptio PlacentaePremature separation of the placenta.

Pathophysiology of placental abruption:◦Bleeding into the decidua basalis layer◦Hematoma forms causing further

placental separation◦Fetal blood supply is further compromised◦Complication - Couvelaire Uterus

(Retroplacental blood goes into the peritoneal cavity)

ClassificationClinical classificationClass 0 - AsymptomaticClass 1 - Mild (represents

approximately 48% of all cases)Class 2 - Moderate (represents

approximately 27% of all cases)Class 3 - Severe (represents

approximately 24% of all cases)

Placental abruption: typesPlacental abruption can be broadly

classified into two types:◦ Revealed◦ Concealed◦ Mixed

Presentation Symptoms

◦Vaginal bleeding - 80%◦Abdominal or back pain and uterine

tenderness - 70%◦Fetal distress - 60%◦Abnormal uterine contractions (eg,

hypertonic, high frequency) - 35%◦Idiopathic premature labor - 25%◦Fetal death – 15%

Presentation Physical Examination

◦Should be done after stabilizing the patient

◦Ultrasound should be done first to assess the location of placenta. Only then should a digital pelvic exam be conducted

◦Profuse bleeding in waves◦Uterine contraction / Uterine hypertonus◦Shock◦Absence of fetal heart sounds◦Increased fundal height (due to hematoma)

Risk factors of Abruptio Placentae

◦Maternal hypertension◦Maternal trauma◦Cigarette smoking◦Alcohol consumption◦Cocaine use◦Short umbilical cord◦Maternal age <20 or >35 years◦Low socioeconomic status◦Elevated second trimester maternal serum

alpha-fetoprotein (associated with up to a 10-fold increased risk of abruption)

◦Previous placental abruption

InvestigationsLaboratory studies

◦CBC◦PT & APTT◦Fibrinogen levels◦BUN / creatinine

Imaging studies◦Transvaginal ultrasonography◦Transabdominal ultrasonography

Complications of Abruptio placentae - Maternal

Can lead

to DIC

Fetal complications include◦Hypoxia or hypoxic-ischemic encephalopathy

(HIE)◦growth retardation◦CNS abnormalities◦Intra uterine death.

Complications of Abruptio placentae – Fetal

Placenta praeviaImplantation of placenta over the internal

cervical os and therefore in front of the presenting part

Pathophysiology◦ Delay in implantation of blastocyst so that it

occurs in the lower part of uterus◦ In third trimester isthmus of uterus thins to form

lower uterine segment◦ Placental attachment is disrupted as the area

gradually thins in preparation of the onset of labor

◦ This leads to bleeding from the venus sinuses

Placenta previa: typesComplete placenta previaPartial placenta previaMarginal placenta previa (placenta

approaching the border of os)

Grading of placenta previa:Grade I – The placenta is in the lower

segment, but the lower edge does not reach the internal os.

Grade II – The lower edge of the low-lying placenta reaches, but does not cover the internal os.

 Grade III – The placenta covers the internal os.

 Grade IV – The placenta covers and entirely surrounds the internal os

Presentation Symptoms

◦Painless vaginal bleeding◦Bleeding stops spontaneously and recurs

with labor◦Malpresentation (Breech, transverse lie)

Physical Exam◦Digital exam is contraindicated◦Uterus is soft and non tender◦Concurrent contractions with bleeding

are present

Placenta previa : Risk factors

Previous placenta previa.Multiple pregnancies- due to the

placenta occupying a large surface area.

Cigarette smokingIncreased maternal ageUterine scar (previous caesarean

section)Endometritis

InvestigationsLaboratory studies

◦CBC◦PT & APTT

Imaging studies◦Transvaginal ultrasonography◦Transabdominal ultrasonography

Abruptio Placentae Placenta Previa

Pain Abdominal pain, low back pain Painless unless in labour

Uterus Tender, irritable Nontender, soft (unless contracting)

Presentation Not associated with abnormal presentation Breech or high presenting part

Fetus Fetal heart tracing abnormal, atypical

Fetal tracing not affected since blood is maternal

ShockShock/anemia out of proportion to amount of blood seen

Shock/anemia proportionate to blood seen

Imaging U/S cannot rule out U/S sensitive

Differential DiagnosisAbruptio Placentae Placenta Previa

Labour with bloody show Abruptio Placentae

Vasa previa Cervicitis

Vaginal trauma Premature rupture of membranes

Vaginitis Vaginitis

Preterm labour Preterm labour

Non Placental causes of APH

Vasa previa:

Vasa previa is a condition when fetal vessels traverse the fetal membranes over the internal os.

These vessels course within the membranes (unsupported by the umbilical cord or placental tissue) and are at risk of rupture when the supporting membranes rupture.

Management of Antepartum Hemorrhage

Initial management

Assessing the airways:Assessing the breathing:Assessing the circulation

Cannula inserted for◦Drug adminstration◦Blood sampling◦IV fluid adminstration

Placenta previaIf uncomplicated pregnancy no need of

interventionVitamins and Iron supplements should be

takenIf minimal bleeding expected management

may be continuedIf needed tocolytics may be considered to

administer antenatal steroidsBefore the delivery the following should be

consulted◦ Obstetric anesthesiologist◦ Interventional radiologist◦ General surgeon◦ Urologist

Placenta previaIf placental edge is more than 2cm from

internal cervial os trial of labour can be offered.

If the distance is less than 2cm cesarian section is done although an SVD can be done

Delivery is mostly done at 36-37 weeks of gestation

Low transverse uterine incision is usedIf the patient is at risk of invasive

placentation than informed consent should be taken for cesarian hysterectomy

Abruptio placentaeVitamins and Iron supplements should be takenInitial managementTransfusion, correction of coagulopathy and Rh

immune globulin if neededCesarian section preferable mode of delivery

◦ Vertical incision◦ Hysterectomy might be needed if severe blood loss

Tocolytics may be used in case of preterm delivery only if◦ Hemodynamically stable◦ No fetal distress◦ Preterm fetus may benefit from corticosteroid therapy

In case of fetal death mode of delivery is SVD

Types of tocolyticsTypes of Tocolytics

B2 agonist

Calcium channel blockers

Oxytocin antagonist – Atosiban

NSAIDs

Uterine rupture-managementIt is an emergency Laprotomy is urgently doneUterine rupture can be an

antepartum or postpartum event

Vasa previa

When vasa previa is diagnosed antenatally, an elective Caesarean section should be offered prior to the onset of labour.

In cases of vasa previa, premature delivery is most likely, therefore, consideration should be given to administration of corticosteroids at 28 to 32 weeks

Antepartum hemorrhage

History and Physical Examination

Fetal monitoring

Massive bleeding

Normal Bloody show

Routine Evaluation

Severely distressed fetus

Suspect Vasa Previa

Urgent Cesarean delivery

Inflamed cervix or mucopurulent

discharge

Probable cervical infection

Culture and treat as

appropriate

Uterine pain ??

No pain or pain only with

contractions. Non tender fundus

Pain between contractions and

tender fundus

Cesarean delivery if in

labour

Suspect Placenta previa

Immediate ultrasound

examination if available

Consider abruptio

placentaeConsider uterine

rupture

Consider urgent lapartomy

Monitor fetus. Supportive

mother care

Cesarean if fetal distress

SVD if fetal death

Call for helpEvaluate ABCsAdminister IV

fluidsConsider

transfusionConsider CS