Antepartum & Postpartum

Hemorrhage (APH &PPH)

Basim Abu-Rafea, MD, FRCSC, FACOG

Assistant Professor & Consultant

Obstetrics & Gynecology
Reproductive Endocrinology & Infertility
Advanced Minimally Invasive Gynecologic Surgery
Department of Obstetrics & Gynecology
College of Medicine
King Saud University

Antepartum & Postpartum Hemorrhage

Obstetrics is "bloody business."
Death from hemorrhage still remains a
leading cause of maternal mortality.
Hemorrhage was a direct cause of more
than 18 percent of 3201 pregnancyrelated maternal deaths.

Antepartum & Postpartum Hemorrhage

Causes of 763 Pregnancy-related Deaths Due to Hemorrhage
Causes of Hemorrhage

Number (%)

Abruptio placentae

141 (19)

Laceration/uterine rupture

125 (16)

Uterine atony

115 (15)

Coagulopathies

108 (14)

Placenta previa

50 (7)

Placenta accreta / increta / percreta

44 (6)

Uterine bleeding

47 (6)

Retained placenta

32 (4)

ANTEPARTUM HEMORRHAGE
Per vagina blood loss after 20 weeks gestation.
Complicates close to 4% of all pregnancies and
is a MEDICAL EMERGENCY!
Is one of the leading causes of antepartum
hospitalization, maternal morbidity, and
operative intervention.

What are the most common causes of

Antepartum Hemorrhage ?

COMMON CAUSES

Placenta Previa
Placental Abruption
Uterine Rupture
Vasa Previa
Bloody Show
Coagulation Disorder
Hemorrhoids
Vaginal Lesion/Injury
Cervical Lesion/Injury
Neoplasia

Key point to Remember

The pregnancy in which such bleeding occurs remains at
increased risk for a poor outcome even though the
bleeding soon stops and placenta previa appears to
have been excluded by sonography.

Placenta Previa

Defined as a placenta implanted in the lower segment of

the uterus, presenting ahead of the leading pole of the
fetus.
1. Total placenta previa. The internal cervical os is covered
completely by placenta.
2. Partial placenta previa. The internal os is partially covered by
placenta.
3. Marginal placenta previa. The edge of the placenta is at the
margin of the internal os.
4. Low-lying placenta. The placenta is implanted in the lower
uterine segment such that the placenta edge actually does not
reach the internal os but is in close proximity to it.

Placenta Previa

Bleeding results from small

disruptions in the placental
attachment during normal
development and thinning of the
lower uterine segment

Placenta Previa
Incidence about 1 in 300
Perinatal morbidity and mortality are
primarily related to the complications of
prematurity, because the hemorrhage is
maternal.

Placenta Previa
Etiology:
Advancing maternal age
Multiparity
Multifetal gestations
Prior cesarean delivery
Smoking
Prior placenta previa

Placenta Previa
The most characteristic event in placenta previa
is painless hemorrhage.
This usually occurs near the end of or after the
second trimester.
The initial bleeding is rarely so profuse as to
prove fatal.
It usually ceases spontaneously, only to recur.

Placenta Previa
Placenta previa may be associated with
placenta accreta, placenta increta or
percreta.
Coagulopathy is rare with placenta previa.

Placenta Previa
Diagnosis.
Placenta previa or abruption should always be suspected in
women with uterine bleeding during the latter half of pregnancy.
The possibility of placenta previa should not be dismissed until
appropriate evaluation, including sonography, has clearly proved
its absence.
The diagnosis of placenta previa can seldom be established
firmly by clinical examination. Such examination of the cervix
is never permissible unless the woman is in an operating
room with all the preparations for immediate cesarean
delivery, because even the gentlest examination of this sort
can cause torrential hemorrhage.

Placenta Previa
The simplest and safest method of placental localization
is provided by transabdominal sonography.
Transvaginal ultrasonography has substantively
improved diagnostic accuracy of placenta previa.
MRI
At 18 weeks, 5-10% of placentas are low lying. Most
migrate with development of the lower uterine segment.

Placenta Previa
Management
Admit to hospital
NO VAGINAL EXAMINATION

IV access
Placental localization

Placenta Previa
Management
Severe
bleeding
Moderate
bleeding

Resuscitate
>34/52
Gestation
<34/52
Resuscitate
Steroids

Mild
bleeding

Caesarean
section

Gestation

<36/52
>36/52

Unstable
Stable
Conservative
care

Placenta Previa
Management
Delivery is by Caesarean section
Occasionally Caesarean hysterectomy
necessary.

Placental Abruption
Defined as the premature separation of the
normally implanted placenta.
The Latin abruptio placentae, means "rending
asunder of the placenta
Occurs in 1-2% of all pregnancies
Perinatal mortality rate associated with placental
abruption was 119 per 1000 births compared with
8.2 per 1000 for all others.

Placental Abruption

external hemorrhage
concealed hemorrhage
Total
Partial

Placental Abruption
What are the risk factors for placental
abruption?

Placental Abruption
The primary cause of placental abruption is unknown, but
there are several associated conditions.
Increased age and parity

Cigarette smoking

Preeclampsia

Thrombophilias

Chronic hypertension

Cocaine use

Preterm ruptured
membranes

Prior abruption

Multifetal gestation

External trauma

Hydramnios

Uterine leiomyoma

Placental Abruption
Pathology
Placental abruption is initiated by hemorrhage
into the decidua basalis.
The decidua then splits, leaving a thin layer
adherent to the myometrium.
development of a decidual hematoma that leads
to separation, compression, and the ultimate
destruction of the placenta adjacent to it.

Placental Abruption
Bleeding with placental abruption is almost
always maternal.
Significant fetal bleeding is more likely to be
seen with traumatic abruption.
In this circumstance, fetal bleeding results from
a tear or fracture in the placenta rather than from
the placental separation itself.

Placental Abruption
The hallmark symptom of placental abruption is pain
which can vary from mild cramping to severe pain.
A firm, tender uterus and a possible sudden increase in
fundal height on exam.
The amount of external bleeding may not accurately
reflect the amount of blood loss.
Importantly, negative findings with ultrasound
examination do not exclude placental abruption.
Ultrasound only shows 25% of abruptions.

Placental Abruption
Shock
Consumptive Coagulopathy
Renal Failure
Fetal Death
Couvelaire Uterus

Placental Abruption
Management: Treatment for placental abruption varies
depending on gestational age and the status of the
mother and fetus.
Admit
History & examination
Assess blood loss
Nearly always more than revealed

IV access, X match, DIC screen

Assess fetal well-being
Placental localization

Uterine Rupture
Reported in 0.03-0.08% of all delivering women, but
0.3-1.7% among women with a history of a uterine
scar (from a C/S for example)
13% of all uterine ruptures occur outside the hospital
The most common maternal morbidity is
hemorrhage
Fetal morbidity is more common with extrusion

Uterine Rupture
Classic presentation includes vaginal bleeding,
pain, cessation of contractions, absence/
deterioration of fetal heart rate, loss of station of
the fetal head from the birth canal, easily
palpable fetal parts, and profound maternal
tachycardia and hypotension.
Patients with a prior uterine scar should be
advised to come to the hospital for evaluation of
new onset contractions, abdominal pain, or
vaginal bleeding.

What are the risk factors

associated with uterine rupture?

Uterine Rupture
Excessive uterine
stimulation

Multiparity

Hx of previous C/S

Non-vertex fetal
presentation

Trauma

Shoulder dystocia

Prior rupture

Forceps delivery

Previous uterine surgery

Uterine Rupture
Management: Emergent laparotomy

Vasa Previa
Rarely reported condition in which the fetal
vessels from the placenta cross the entrance to
the birth canal.
Incidence varies, but most resources note
occurrence in 1:3000 pregnancies.
Associated with a high fetal mortality rate (5095%) which can be attributed to rapid fetal
exsanguination resulting from the vessels
tearing during labor

Vasa Previa

There are three causes typically noted

for vasa previa:
1. Bi-lobed placenta
2. Velamentous insertion of the umbilical cord
3. Succenturiate (Accessory) lobe

Vasa Previa

Vasa Previa

Vasa Previa
Risk Factors:
Bilobed and succenturiate placentas
Velamentous insertion of the cord
Low-lying placenta
Multiple gestation
Pregnancies resulting from in vitro fertilization
Palpable vessel on vaginal exam

Vasa Previa
Management:
When vasa previa is detected prior to labor, the baby
has a much greater chance of surviving.
It can be detected during pregnancy with use of
transvaginal sonography.
When vasa previa is diagnosed prior to labor, elective
caesarian is the delivery method of choice.

Kleihauer-Betke Test
Is a blood test used to measure the
amount of fetal hemoglobin transferred
from a fetus to the mother's bloodstream.
Used to determine the required dose of Rh
immune globulin.
Used for detecting fetal-maternal
hemorrhage.

Apt test
The test allows the clinician to determine whether the
blood originates from the infant or from the mother.
Place 5 mL water in each of 2 test tubes
To 1 test tube add 5 drops of vaginal blood
To other add 5 drops of maternal (adult) blood
Add 6 drops 10% NaOH to each tube
Observe for 2 minutes
Maternal (adult) blood turns yellow-green-brown; fetal blood
stays pink.
If fetal blood, deliver STAT.

Postpartum Hemorrhage
In spite of marked improvements in management, PPH
remains a significant contributor to maternal morbidity
and mortality both in developing and developed
countries.
One of the most challenging complications a clinician will
face.
Prevention, early recognition and prompt appropriate
intervention are the keys to minimizing its impact.

Hematological Changes in Pregnancy

40% expansion of blood volume by 30 weeks
600 ml/min of blood flows through intervillous space
Appreciable increase in concentration of Factors I
(fibrinogen), VII, VIII, IX, X
Plasminogen appreciably increased
Plasmin activity decreased
Decreased colloid oncotic pressure secondary to 25%
reduction in serum albumin

PPH
Excessive bleeding affects approximately 5 to 15 percent
of women after giving birth.
Hemorrhage that occurs within the first 24 hours
postpartum is termed early postpartum hemorrhage.
While excessive bleeding after 24 hours is referred to as
late postpartum hemorrhage.
In general, early PPH involves heavier bleeding and
greater morbidity.

PPH
The mean blood loss in a vaginal delivery is
500 ml & 1000 ml for cesarean section.
Definition:
Blood loss greater than 500 ml for vaginal and 1000
ml for cesarean delivery.
However, clinical estimation of the amount of blood
loss is notoriously inaccurate.
Another proposed definition for PPH is a 10% drop
in haematocrit.

Reduced Maternal Blood Volume

Small stature
Severe preeclampsia/eclampsia
Early gestational age

PPH

PPH

The etiologies of early PPH are most easily understood as

abnormalities of one or more of four basic processes.

Bleeding will occur if for some reason the uterus is not able to
contract well enough to arrest the bleeding at the placental site.

Retained products of conception may cause large blood losses

postpartum

Genital tract trauma may cause large blood losses postpartum

Coagulation abnormalities can cause excessive blood loss alone or

when combined with one of the other processes.

The four T processes.

The Four T
Tone
Tissue
Trauma
Thrombin

PPH Risk Factors

Many factors affect a womans risk of
PPH.
Each of these risk factors can be
understood as predisposing her to one or
more of the four T processes.

PPH Risk Factors

PPH Risk Factors

PPH Risk Factors

PPH Risk Factors

PREVENTION OF PPH
Although any woman can experience a PPH, the
presence of risk factors makes it more likely.
For women with such risk factors, consideration
should be given to extra precautions such as:

IV access
Coagulation studies
Crossmatching of blood
Anaesthesia backup
Referral to a tertiary centre

PREVENTION OF PPH
UTEROTONIC DRUGS
Routine oxytocic administration in the third stage of
labour can reduce the risk of PPH by more than 40%
The routine prophylaxis with oxytocics results in a
reduced need to use these drugs therapeutically
Management of the third stage of labour should
therefore include the administration of oxytocin after
the delivery of the anterior shoulder.

MANAGEMENT OF PPH
Early recognition of PPH is a very
important factor in management.
An established plan of action for the
management of PPH is of great value
when the preventative measures have
failed.

MANAGEMENT OF PPH

MANAGEMENT OF PPH

MANAGEMENT OF PPH

DRUG THERAPY FOR PPH

MANAGEMENT OF PPH

MANAGEMENT OF PPH

MANAGEMENT OF PPH

MANAGEMENT OF PPH

MANAGEMENT OF PPH

Summary: Remember 4 Ts

Tone
Tissue
Trauma
Thrombin

Summary: remember 4 Ts
TONE
Rule out Uterine
Atony

Palpate fundus.
Massage uterus.
Oxytocin
Methergine
Hemabate

Summary: remember 4 Ts
Tissue
R/O retained placenta

Inspect placenta for

missing cotyledons.
Explore uterus.
Treat abnormal
implantation.

Summary: remember 4 Ts
TRAUMA
R/O cervical or
vaginal lacerations.

Obtain good
exposure.
Inspect cervix and
vagina.
Worry about slow
bleeders.
Treat hematomas.

Summary: remember 4 Ts
THROMBIN

Check labs if
suspicious.