Antepartum Hemorrhage
Learning objectives
• Definition
• Classification
• Etio pathogenesis
• Clinical features
• Diagnosis
• Management of APH
Introduction
Hemorrhage has been identified as the
single most important cause of maternal
death worldwide, accounting for almost
half of all maternal deaths in developing
countries
(PPH,APH,Ectopic)
Definition
• Any bleeding from genital tract from 20- 24 wks
of pregnancy
• 4% of all pregnancy
Causes of APH
• Placental causes ( 50 -70%)
– Placenta previa
– Placental abruption
– Velamentous insertion of cord /Vasa previa ( rare)
• Local causes
– Cervical polyp
– Cervical ectopy( erosion) / infections
– Carcinoma cervix / other tumours
– Vaginal / vulval varicosities
• Excessive show
Indeterminate bleeding
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
Abruptio placentae / accidental hemorrhage
• Types:
– Revealed / External hemorrhage
– Concealed hemorrhage – carries worse risk ,
due to increased risk of consumptive
coagulopathy / extent of hemorrhage not
appreciated
• Total / partial
• Incidence : 5%
Grading of abrupion
• Grade o: An asymptomatic RPC seen after
delivery
• Grade 1: Vaginal bleeding & uterine tenderness;
visible RPC after delivery
• Grade 3: Abruption severe enough to cause fetal
distress & RPC visible after delivery
• Grade 4: Significant maternal signs- uterine
tetany, abdominal pain, hypovolemia; IUD. 30%
of these women will develop DIC
Etiology of abruptio placentae
• Advancing maternal age / High parity
• Race- more common among African American
as compared to Asians
• Hypertension
• PPROM
• Cigarrete smoking / cocaine
• Congenital / acquired thrombophilias
• Trauma / Sudden uterine decompression
• Abnormal placentation /Retroplacental location
of fibroid
• previous abruption
Concealed Hemorrhage
Retained or concealed hemorrhage is likely when:
• There is an effusion of blood behind the placenta but its
margins still remain adherent.
• The placenta is completely separated yet the
membranes retain their attachment to the uterine wall.
• Blood gains access to the amnionic cavity after breaking
through the membranes.
• The fetal head is so closely applied to the lower uterine
segment that the blood cannot make its way past it.
Chronic Placental Abruption
In some women, hemorrhage with
retroplacental hematoma formation is
somehow arrested completely without
delivery
Clinical features
• Symptoms & signs don’t correlate with the
severity of abruption
• Bleeding and abdominal pain
• back pain, uterine tenderness, frequent
uterine contractions, and persistent uterine
hypertonus
• Posterior abruptio placenta – pain /
tenderness may be absent
• Anemia / shock /oliguria
Abruptio placentae
• USG – retroplacental
sonolucent area
• Negative findings with
ultrasound examination do not
exclude placental abruption
• Initial phase – hemorrhage is
isoechoic with placenta
• No collection in revealed type
Differential diagnosis
Bleeding with pain abdomen
• Painful bleeding : abruption ( but abrruption
pain may mimic labour pain / posterior placental
abruptio n painless)
• Painless bleeding : placenta previa ( but ,
placenta with labour pains –painful)
Other differential diagnosis for pain
abdomen in later half of pregnancy
• Preterm labour / premature contractions
• Imminent ecclampsia ( R UQ tenderness /
epigastric pain)
• UTI
• Red degeneration fibroid
• Other surgical / medical illness
Complications of abruption
• Fetal : fetal distress , fetal death &
FetoMaternal Hemorrhage ( FMH)
– Nontraumatic abrupion – 20%
– Traumatic abruption – much more common
( due to tear in the placenta)
• Maternal – abruption severe enough to
cause IUD Anemia / shock /oliguria &
consumptive coagulopthy
Couvelaire
uterus( uteroplacental apoplexy)
Couvelaire uterus
Investigations
• USG : may not help in excluding abruption, but can
exclude p. previa, confirm viability & well being & AFI
• Clotting screen
• Kleihauer count in Rh negative women
• (Maternal – abruption severe enough to cause
IUD ) , send for DIC profile ( fibrinogen - < 150mg/dl;
FDPs & D- Dimer +ve)
• RFT / LFT
Management
• With a live and mature fetus, and if vaginal delivery is not
imminent, then emergency cesarean delivery is the
choice
• clinically evident placental abruption should be
considered a contraindication to tocolytic therapy
• If the fetus is dead, vaginal delivery is preferred unless
hemorrhage is so brisk that it cannot be successfully
managed even by vigorous blood replacement or in the
presence of other complications that necessitate C.S
Management
Role of vaginal delivery :
• Mature fetus / no evidence of distress /
advanced cervical dilation – amniotomy &
oxytocin augmentation
• Adequate resucitation : fluid & blood
replacement ( to prevent ARF & to correct
the coagulopathy)
Placent previa
• Incidence of low lying placenta – 5% at 18-
23weeks
• Incidence of placenta previa at term -0.5%
Placenta previa - Types
• Total placenta previa. The internal cervical os is covered
completely by placenta
• Partial placenta previa. The internal os is partially
covered by placenta
• Marginal placenta previa. The edge of the placenta is at
the margin of the internal os.
• 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.
Etiology of placenta previa
• Advancing maternal age /Multiparty
• Multifetal gestations
• Prior cesarean delivery / myomectomy /
curettage
• A prior uterine incision with a previa increases
the incidence of cesarean hysterectomy.
• Smoking
Associations
• Fetal abnormality - rate of abnormality
doubled with placenta previa
• IUGR –( 15%)
• 10% of women with placenata previa will
have coexisting abruption
Clinical features
• Painless bleeding ( unprovoked)
• Warning bleeding ( 34 wks)
• Mechanism of bleeding
• Formation of lower segment – tear of placental
attatchments + inability of lower segment to contract
as effectively
• Unengaged presenting part / malpresentation
( breech or transverse in 30%)
• Fetal condition remains good until there is maternal
hemodynamic compromise as well
complications
• Maternal :
– hemorrhage & consequences of hemorrhage,
DIC less as compared to abruption.
– Operative intervention including risk of
hysterectomy
• Fetal: Perinatal morbidity & mortality
• Prematurity
• IUGR
Diagnosis - TAS
• Transabdominal
sonography
• 96-98 % accuracy
• False +ve due to full
bladder
• False –ve : Uncommonly –
as abundant placenta is
found in upper segment ,
failure to identify in lower
segment
Transvaginal ultrasonography
• Better accuracy
• Particulary useful in
posterior placenta
• Found to be safe
• Magnetic
Resonance
Imaging- not widely
used
Placental ‘Migration’
• Placentas that lie close to the internal os, but not
over it, during the second trimester, or even
early in the third trimester, are unlikely to persist
as previas by term.
• Those covering the os, about 40 percent
persisted as a previa
• Likelihood that placenta previa persists is more
in the presence of a cesarean scar
Placental ‘Migration’
Once low lying placenta diagnosed @
20wks scan , Rpt scan @ 32-34 wks or rpt
only if there is vaginal bleeding,
malpresentation or if placenta was
covering the os @ 20wks
Morbidly adherent placenta previa
• Risk factor- uterine scarring
• The incidence is on the rise due to increasing
cesarean section rate
– Accreta ( 80%)
– Increta
– Percreta
• Most of the time diagnosis made in third
stage
• Small % - diagnosis made antenatally
Management
Women with a placenta previa may be
considered as follows:
• Those in whom the fetus is preterm / minimal
bleeding and there is no indication for delivery.
• Those in whom hemorrhage is so severe as to
mandate delivery despite fetal immaturity
• Major degree / minor degree ( vaginal Vs C.S)
Other issues in management
• Home Vs Hospital
• Home management
– Should have an adult with her / conveyance /
abstinence
• Hospital :
– long term hospitalisation – financial & psychological
implications
• Inpatient management for patients for women
who have had episodes of bleeding
• Complete assessment @36weeks. Major degree
unlikely to move after 36 wks, but a minor may
do so
Planning for vaginal delivery
• If placenta within 2cms within internal os –C.S
• > 4.5 / 5 cms – vaginal delivery
• 2-5cms – grey area ( clinical picture / station /
placenta anterior or posterior)
Caesarean section for placenta previa
• Planned C.S @ 38weeks ( if C.S required
prior to that , administer steroids)
• X-match adequate amount of blood
• Senior team / regional anesthesia
• Technique : Pfennensteil’s , lower segment
scar
• Delivery : cut through / go round the margin of
placenta
• Third stage-oxytocics. If accreta
encountered , proceed with hysterectomy
Bleeding from placental bed
• Over sewing ( figure of 8) individual bleeding
sinuses
• Extra oxytocics ( as in management of atonic
PPH)
• Packing the cavity
• Uterine artery ligation / internal iliac artery
ligation / embolisation techniques
• Hysterectomy
• Post delivery – in HDU
• Postnatal counselling
Management of women presenting with APH
• Rapid assessment of both mother & fetus
• Quick clinical history
• LMP / previous scan report
• Amount of bleeding / clots / abdominal
pain/ previous episodes of bleeding
• Trauma / coitus / liquor loss
• Previous uterine surgery
• Fetal movements / blood group
Management of women presenting with APH
• Maternal assessment : vital signs / pallor /
• Obstetric – size, tenderness & presenting
part
• No P/ V
• Establish fetal viability & fetal well being /
commence monitoring
Management of women presenting with APH
• Group 1 : bleeding minor; both mother &
fetus ok
• Group 2 : bleeding heavy & continuing,
either compromised / likely to be
compromised
Management of women presenting with APH
Group 1 : if placenta previa for expectant
management ( Johnson & Macafee regime)
• Bed rest / make sure Hb ok / steroids / pad chart/
abstinence
• Tocolysis : in women who exhibit uterine activity
• Severe : proceed with LSCS + simultaneous
resuscitation ( regardless of gestational age)
• Investigations: FBC, X-match, clotting screen,
Kleihauer count in Rh negative women, USG
Thank you
