This is the full concept of APh for a medical student, No more detail is needed.

1. AntepartumAntepartum
Haemorrhage (APH)Haemorrhage (APH)
Nadir khan AurakzaiNadir khan Aurakzai
Batch ‘’M’’Batch ‘’M’’
08-23108-231
Ayub Medical College, AbbottabadAyub Medical College, Abbottabad

2. ContentsContents
• Definition
• Importance
• Causes
• Management of APH
• Prognosis

3. Bleeding
In
Pregnancy
Bleeding in
early
Pregnancy
Antepartum
haemorrhage
(APH)
Post partum
Haemorrhage
(PPH)

4. Antepartum HaemorrhageAntepartum Haemorrhage
• 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

5. 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

6. CausesCauses
• 1: Placental causes:
• A. Placental abruption
• B. Placenta previa
• C. Vasa previa
• 2: Causes in genital tract:
• A. Labour
• B: rupture of uterus
• C. Trauma
• D. Infection (cervicitis & vulvovginitis)
• E. Tumours

7. • 3: Bleeding disorders
• A. Congenital (von willebrand’s disease)
• B. Acquired ( DIC)

8. Placenta praeviaPlacenta praevia
• Definition
Insertion of the placenta, partially or fully,
in the lower segment of the uterus

9. EtiologyEtiology
• No definitive cause
• Endometrial factors:
– A scarred endometrium
– Curettage for several times
– Abnormal uterus
• Placental factors
– Large plcenta
– Abnormal formation of the placenta

10. Risk factors for Placenta praeviaRisk factors for Placenta praevia
• Multiparity
• Advanced maternal age
• Prior LSCS or other uterine surgery
• Prior placenta praevia
• Uterine structural anomaly

11. Degrees of Placenta praeviaDegrees of Placenta praevia

12. Classification of degrees ofClassification of degrees of
Placenta praeviaPlacenta praevia
• Four grades:
– Type I ( Low lying): Placenta encroaches
lower segment but does not reach the
internal os
– Type II (Marginal placenta previa): Reaches
internal os but does not cover it
– Type III (Partial Placenta previa): Covers part
of the internal os
– Type IV (Complete): Completely covers the
os, even when the cervix is dilated

13. Placenta praevia-Placenta praevia- ClinicalClinical
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

14. InvestigationInvestigation
• 1: For Localization of placenta:
• Ultrasound:
• Abdominal ultrasound can easily diagnose
placenta previa with an accuracy of 93-
97%.
• Transvaginal ultrasound is safe and is more
accurate than transabdominal ultrasound in
locating the placenta
• 2: Haematological Investigations:
• A. Complete blood picture.
• B. Blood grouping. C:Renal profile

15. Placenta praevia-ComplicationsPlacenta praevia-Complications
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
• Disseminated intravascular coagulopathy (DIC)

16. Placenta praevia-Placenta praevia-
Complications cont….Complications cont….
Foetal
• IUD
• Hypoxic ischemic encephalopathy
• Cerebral paulsy
• Placental abruption
• Premature labour

17. 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

18. EtiologyEtiology
Risk factors
1.Increased age and parity
2.Vascular diseases: preeclampsia, maternal
hypertension, renal disease,SLE
3.Mechanical factors: Trauma, intercourse
Sudden decompression
of uterus
Polyhydroamnios
Multiple pregnancy
4. Smoking, cocaine use,
5.Premature rupture of membranes

19. 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

20. Revealed abruption Concealed abruption

21. Diagnosis-Clinical FeaturesDiagnosis-Clinical Features
•Vaginal bleeding associate with
persistent abdominal pain
• Tenderness on the uterus
• “Woody” hard uterus
• Change of foetal heart rate
• Features of hypovolemic shock

22. Complication ofComplication of PlacentalPlacental
abruptionabruption
Maternal
• Disseminated intravascular coagulopathy
• Hypovolemic shock
• Amnionic fluid embolism
• Renal tubular necrosis and acute renal failure
• Post partum haemorrhage
• Maternal death

23. Complication ofComplication of PlacentalPlacental
abruptionabruption
Feotal
• Premature labour
• IUGR in chronic abruption
• Hypoxic ischemic encepalopathy and
cerebral paulsy
• Foetal death

24. InvestigationsInvestigations
• 1: Diagnostic investigations:
• 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
• 2: Laboratory investigations
1. Investigation for Consumptive coagulopathy – Platelet
count/BT/CT/PT/INR & APTT
2. Liver and Renal function tests

25. 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%)

26. Vasa praeviaVasa praevia

27. 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

28. Eccentric (velamentous) cord insertion

29. Diagnosis - Vasa praeviaDiagnosis - Vasa praevia
1.Moderate vaginal bleeding + feotal distress
2.Vessels may be palpable through dilated
cervix
3.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

30. Management of APH

31. Management of APHManagement 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 & FBC , coagulation
profile,Liver & renal function

32. Management of APHManagement 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

33. Management of APH cont…Management of APH cont…
History
• Obtain a history if patient’s condition allow
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

34. Management of APH cont…Management of APH 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

35. Management of APH cont…Management of APH cont…
Investigations
• Arrange urgent ultrasound scan
• Foetal monitoring
Continuos electronic foetal monitoring
is indicated

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

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

38. Placenta praevia – ManagementPlacenta praevia – Management
cont…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
• Medications may be given to prevent premature
labour- Nifidipine, Atosiban

39. Placental abruption –Placental abruption –
Management ctdManagement ctd
• Small abruption
Conservative management depending
on gestational age
Careful monitoring of feotal condition

40. 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

41. Vasa Previa managementVasa Previa management
• Urgent delivery
Most of the time urgent LSCS
• Neonatologist involvement
• Aggressive resuscitation of the baby with
blood transfusion following delivery

42. 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