Antepartum hemorrhage (APH)
Objective
At the end of this lesson student will be able to
Define APH
Describe major cause of APH
Describe major diagnostic of APH
Explain management of option
Antepartum hemorrhage (APH)
Ante partum Hemorrhage (APH)
Is bleeding from the genital after the fetus has
reached the age of viability before the fetus is
delivered.
It occurs in 2- 4% of fall pregnancies.
Is one of the leading causes of ante partum
hospitalization, maternal morbidity, and operative
intervention.
Antepartum hemorrhage (APH)
Cause of APH
The causes could broadly be grouped into two.
1. Obstetric causes which include placenta previa,
abruption placenta, bleeding from vase previa,
ruptured uterus and heavy show.
2. Non obstetric (local or incidental causes) include
cervicitis, cervical plyop, cervical cancer,
codyloma accuminata, varices, foreign body,
traumantic lesions and others.
Antepartum hemorrhage (APH)
I. Placenta Previa
Defined as a placenta implanted in the lower
segment of the uterus; located over or very near
the internal os.
1 in 200 to 250 deliveries
It is more common in multiparas.
Perinatal morbidity and mortality are primarily
related to the complications of prematurity,
because the hemorrhage is maternal.
Placenta previa
1. Grade 1 or low-lying placenta – the placenta occupies
the lower uterine segment, but does not reach the
internal cervical os.
2. Grade 2 or placenta previa marginalis – the placenta
reaches the internal os but does not cover it.
3. Grade 3 or placenta previa partialis – the placenta
covers the internal os but only partially, even at full
dilatation.
4. Grade 4 or placenta previa totalis – placenta covers
the whole internal os even at full cervical dilatation
Placenta previa
cause Placenta previa
The exact cause is unknown, but there are a number of
predisposing factors.
1. Any uterine scar
previous vigorous curettage,
cesarean section,
myomectomy.
2. Multiparity
3. Bulky placental tissue
multiple pregnancy
erythroblastosis fetails
4. Others include high altitude, smoking, previous history of
antepartum hemorrhage
Placenta previa
Clinical Features
Painless bright red vagina bleeding in the third
trimester which range from spotting to massive.
It tends to come without warning but may
follow coitus or pelvic examination,
It is recurrent in nature with increasing bleeding
occurring in subsequent episodes.
Placenta previa
Changes in maternal pulse, blood pressure and the
degree of pallor are usually proportional to the external
blood loss.
Findings on abdominal examination
i. Non-tender
ii. Normal toned uterus
iii. High presenting part
iv. Abnormal fetal lie.
Fetal distress occurs if the mother is in shock or in
labor as the result of downward pressure on the
placenta.
Placenta previa
Diagnosis
1. History – clinical feature mostly
2. Physical examination
Digital or speculum vaginal examination should never
be done in any woman with APH until placenta previa
is ruled out.
3. U/S is used for confirmation
Ultrasonograpahy is used to diagnosis
i. placenta previa
ii. Grade placenta previa
iii. condition of the fetus
iv. gestational age.
Placenta previa
Examination of U/S that done before 30 weeks
should be repeated later as the position of the
placenta may change as the lower segment forms
and increases in size.
Vaginal examination only done in the operating
theatre with everything ready for cesarean section
if necessary (double set up examination).
It should only be done in instances where
ultrasound is not available and termination of
pregnancy is planned.
Placenta previa
General principles
No vaginal examination unless "double set-up"
serial sonography
To assess placental location
Fetal growth
Avoidance coitus and activity restrictions
Counseling about labor symptoms, vaginal bleeding
Prevent and treat maternal anemia, and early medical
attention if any vaginal bleeding occurs
Placenta previa
Management depends on:-
Amount of bleeding
Gestational age
Fetal and maternal condition
Degree of the placenta
Types of management
Conservative
Active
Placenta previa
1. Conservative
Indication
preterm fetus
no active uterine bleeding
Hospitalized bed rest with close observation
Fetal and maternal condition
Amount of bleeding
steroids
keep the maternal hematocrit greater than 30%
Blood group and cross match
Anti D for RH negative
Placenta previa
2. Active
indication
If bleeding continues
Non-reassuring FHR pattern
Maternal compromise
Mature foetus
Dead foetus
Open IV line
Blood group and cross blood at hand at least 2 unit
Delivery
Placenta previa
Delivery
1. Vaginal delivery
Low lying placenta previa
Aminotomy
oxytocin
2. C/S
Severe uncontrolled bleeding
Fetal distress
Other co-factors
Complication of Placenta previa
Maternal Fetal
Maternal hemorrhage Preterm
Haemorrhagic shock Fetal hypoxia
operative trauma Growth restriction
infection CNS damage
embolism Perinatal death
Maternal death Fetal death
II. Placenta abruption
Defined as the premature separation of the
normally implanted placenta before third stage
of labor
It come from Latin word abruptio placentae,
means "rending asunder of the placenta.
Occurs in 1-2% of all pregnancies
Account for high maternal mortality (119 per
1000 births)
Placenta abruption
The bleeding could be
1. Concealed (internal) or
2. Revealed (external) or
3. Combination of both internal and external bleeding
(mostly occur)
Separation also could be
1. Partial
2. Total
Placenta abruption
Depending on clinical and laboratory finding, it
is categories into three grade
1. mild (grade I),
2. moderate (grade II)
3. severe (grade III) types.
Grades one and two each account for around 40%
while grade three only for 15%
Placenta abruption
Cause of abruptio placenta
The exact cause of abruption placentae is unknown but there
are a number of well established risk factors, including
a. Hypertensive disorders of pregnancy - single most important
factor
b. Trauma such as a hard abdominal blow
c. Sudden decrease in uterine volume,
rupture of membranes in a mother with polyhydramnios
delivery of first twin.
d. Previous abruption placentae
e. Others like poor socioeconomic condition and malnutrition,
smoking and short cord.
Placenta 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.
Clinical feature of abruptio placenta
Pain that vary from mild cramping to severe pain
is hallmark feature
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.
Also negative findings with ultrasound
examination do not exclude placental abruption.
Placenta abruption
Clinical feature vary with degree of bleeding
Bleeding is usually small in amount and dark red in color is
present in most case.
Abdominal pain ranging from labor like pain to unrelenting
pain.
History of hypertension and/ or trauma
Vital signs derangement that not be proportional to the degree
of blood loss.
Abdomen is almost always tender.
In severe cases, the uterus is board like and tetanically
contracted.
The fetus is in distress or dead.
The presenting part is usually deeply engaged
Placenta abruption
Diagnosis
History (darken bleeding and pain)
P/E tender and engaged of present body
Additional investigation U/S not much
indicator (25%)
Management of abruptio placenta
Admit
intravenous line,
determine hemtocrit
blood group and Rhesus factor assessment,
prepare at least two units of cross matched blood.
Crystalloids should be administered depending on
the needs.
Assessment coagulation factors
close fetal monitoring is needed to detect fetal
distress.
Management of abruptio placenta
Delivery:-vaginal route is preferred whether the
fetus is alive or dead.
Shortening of the second stage by instruments.
Avoid episiotomy or laceration.
Third stage should be managed actively.
