Antepartum heamorrhage

1. Neoh Hui Pheng
Batch 22/A2
ANTEPARTUM HAEMORRHAGE

2. reference
 RCOG Guidelines
 Obstetrics today

3. Definition
 Antepartum haemorrhage (APH) is defined as bleeding
from or in to the genital tract, occurring from 22 weeks
(>500g) of pregnancy and prior to the birth of the baby.
 complicates 3–5% of pregnancies
 leading cause of perinatal and maternal mortality
worldwide.
 Up to one-fifth of very preterm babies are born in
association with APH
 Most of the time unpredictable.
RCOG

4. Severity
NO consistent definitions of the severity of APH.
It is recognised that the amount of blood lost is often
underestimated .
The amount of blood coming from the introitus may not
represent the total blood lost (for example in a
concealed placental abruption).
It is important to assess for signs of clinical shock. The
presence of fetal compromise or fetal demise is an
important indicator of volume depletion.
RCOG Guidelines

5. Different terminologies used:
 Spotting – staining, streaking or blood spotting noted on
underwear or sanitary protection
 Minor haemorrhage – blood loss less than 50 ml that has
settled
 Major haemorrhage – blood loss of 50–1000 ml, with no
signs of clinical shock
 Massive haemorrhage – blood loss greater than 1000 ml
and/or signs of clinical shock.
 Recurrent APH - > one episode
RCOG Guidelines

6. Etiology
 Placenta praevia
 Abruptio placenta
 Vasa praevia
 Excessive show
 Local causes ( bleeding from cervix, vagina and
vulva )
 Inderterminate APH

7. Placenta Praevia (PP)
 Implantation of placenta over or near the internal
os of cervix.
 Confirm diagnosis of PP can be done at 28 weeks
when LUS forming.
Leading cause of vaginal bleeding in the 2nd and 3rd
trimester.

8. Classification

9. Risk Factors of Placenta Praevia
 Previous placenta praevia (4-8%)
 Previous caesarean sections ( risk with numbers of c-section)
 Previous termination of pregnancy
 Multiparity
 Advanced maternal age (>40 years)
 Multiple pregnancy
 Smoking
 Deficient endometrium due to presence or history of:
- uterine scar
-endometritis
-manual removal of placenta
- curettage
-submucous fibroid
 Assisted conception
RCOG

10. Clinical classification
 Minor :
 Type 1 (anterior/posterior)
 Type 2 anterior
 Major:
 Type 2 posterior (dangerous type)
 Type 3
 Type 4
Deliver vaginally
Type 1 Posterior > likelihood of
fetal distress
Caesarean section
Type 2 posterior >
chance of fetal distress
Type 3 & 4 anterior –cut
through placenta to
deliver. Hence need to be
fast and efficient.

11. Abruptio Placenta (AP)
 Separation of normally located placenta after 22
weeks of gestation ( > 500g) and prior to delivery
of fetus.

12. Risk factors:
- Previous history of AP
- Maternal hypertension
- Advanced maternal age
- Trauma ( domestic violence, accident, fall)
- Smoking/alcohol/cocaine
- Short umbilical cord
- Sudden decompression of uterus (
PROM/delivery of 1st twins)
- Retroplacental fibroids
- Idiopathic

13. Obstetrics Emergency!!
Diagnosed CLINICALLY :
 Painful vaginal bleeding -80%
 Tense and tender abdomen/back pain (70%)
 Fetal distress( 60%)
 Abnormal uterine contractions (hypertonic and high
frequency)
 Preterm labour ( 25%)
 Fetal death ( 15%)
Ultrasound is NOT USEFUL to diagnose AP.
Retroplacental clots (hyperechoic) easily missed.
Obstetrics today

14. Vasa Praevia (VP)
 Rupture of fetal vessels that run in membrane
below fetal presenting part which is unsupported
by placenta/ umbilical cord.
 Predisposing Factors:
-Velamentous insertion of the umbilical cord
-Accesory placental lobes
-Multiple gestations
Obstetrics today

15. The term velamentous
insertion is used to
describe the condition in
which the umbilical cord
inserts on the
chorioamniotic
membranes rather than on
the placental mass.

17. Diagnosis of VP
 Antenatal diagnosis –reduced perinatal mortality and
morbidity.
 Painless vaginal bleeding at the time of spontaneous
rupture of membrane or post amniotomy
 Fetal bradycardia
 Fetal shock or death can occur rapidly at the time of
diagnosis due to blood loss constitutes a major bulk of
blood volume is fetus ( 3kg fetus-300ml)
 Hence, ALWAYS check the fetal heart after rupture of
membrane or amniotomy.
 Definitive diagnosis by inspecting the placenta and
fetal membrane after delivery.
Obstetrics today

18. Complications of APH
Maternal complications Fetal complications
Anaemia Fetal hypoxia
Infection Small for gestational age and fetal
growth restriction
Maternal shock Prematurity (iatrogenic and
spontaneous)
Renal tubular necrosis Fetal death
Consumptive coagulopathy
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Complications of blood transfusion
RCOG Guidelines

19. Clinical assessment in APH
 First and foremost Mother and fetal well
being (mother is the priority)
 establish whether urgent intervention is required
to manage maternal or fetal compromise.
 Assess the extent of vaginal bleeding,
cardiovascular condition of the mother
 Assess fetal wellbeing.

20. Full History
Should be taken after the mother is stable.
 associated pain with the haemorrhage?
Continuous pain : Placental abruption.
Intermittent pain : Labour.
 Risk factors for abruption and placenta praevia
should be identified.
 reduced fetal movements?
 If the APH is associated with spontaneous or
iatrogenic rupture of the fetal membranes : ruptured
vasa praevia
 Previous cervical smear history possibility of Ca
cervix. Symptomatic pregnant women usually present
with APH (mostly postcoital) or vaginal discharge.

21. Examination
 General: PULSE & BP ( a MUST!)
 Abdomen:
- The tense, tender or ‘woody’ feel to the uterus
indicates a significant abruption.
- Painless bleeding, high fetal presenting part –
Placenta praevia
- soft, non-tender uterus may suggest a lower
genital tract cause or bleeding from placenta or
vasa praevia.

22. Examination
 Speculum :
-identify cervical dilatation or visualise a lower
genital tract cause.
 Digital vaginal examination
- Should NOT be done until Placenta Praevia has
been excluded by USG.
RCOG Guidelines

23. Investigations
 FBC
 Coagulation profile
 Blood Grouping and CXM, GSH.
 Ultrasound- TRO PP/ IUD
 D-dimer : AP
 colour doppler TVS – VP
 In all women who are RhD-negative, a Kleihauer test
should be performed to quantify FMH to gauge the
dose of anti-D Ig required.
Fetal monitoring:
 CTG monitoring
RCOG Guidelines

24. Management
 WHEN to admit?
 Based on individual assessment
-Discharge after reassurance and counselling
Women presenting with spotting who are no longer
bleeding and where placenta praevia has been
Excluded.
However, a woman with spotting + previous IUD due to
placenta abruption, an admission would be
appropriate.
- All women with APH heavier than spotting and women
with ongoing bleeding should remain in hospital at
least until the bleeding has stopped.

25. Management
 If preterm delivery is anticipated, a single course of
antenatal corticosteroids ( dexamethasone 12mg 12 hourly
,2 doses) to women between 24 and 34 weeks 6 days of
gestation.
 Tocolytics should NOT be given unless for VERY preterm
women who need time to transfer to hospital with NICU.
 For very preterm ( 24-26 weeks) ,
-conservative management if mother is stable .
-Delivery of fetus – life threatening
At these gestations, experienced neonatologists should be
involved in the counselling of the woman and her partner
RCOG

26. Management
For Placenta Praevia
 Conservative – MaCafee’s regime
( premature < 37 weeks;mother haemodynamically
stable,no active bleeding, fetus stable)
-advise bed rest, keep pad chart, vital signs
monitoring , Ultrasound, steroids, GSH, Daily
CTG and biophysical profile, fetal movement
count.
 Plan for delivery ( >37 weeks)
Crossmatch 4 units of blood.

27. Definitive treatment
Type I,II(ant) Type II( post), III,IV
ARM +/- oxytocin
Satisfactory progress
without bleeding
Vaginal delivery
Bleeding continues
Caesarean section
Caesarean section

28. For Abruptio placenta,(obs
emergency)
 ICU admission : Close monitoring and
resuscitation!
- ABC ( high flow O2, aggressive fluid
resuscitation)
- Continuous Vital signs monitoring and urine
output
- Monitor vaginal bleeding – strict pad chart
- Continuous CTG for fetal heart rate
- Crossmatch 4 units of blood
- FFP – coagulopathy
- Dexamethasone – preterm

29. Abruptio Placenta
Decide Mode of delivery
 Vaginal delivery – when fetal death
 Caesarean section –if maternal/ fetal health
compromised
- Indicated when early DIC sets in
- Consent should be taken for hysterectomy in
case bleeding could not be controlled.
Obstetrics today

30. Management
 For Rh negative mothers,
Anti-D Ig should be given to all after any presentation
with APH, independent of whether routine antenatal
prophylactic anti-D has been administered.
In the non-sensitised RhD-negative woman for all
events after 20 weeks of gestation, at least 500 iu
anti-D Ig should be given followed by a test to identify
FMH, if greater than 4 ml red blood cells; additional
anti-D Ig should be given as required.
RCOG Guidelines