ANTEPARTUM HAEMORRHAGE
GOALS
1. To identify and recognize causes of APH
2. To be able to resuscitate properly
3. To be able to manage appropriately
ANTEPARTUM HAEMORRHAGE
PV bleeding after 22 weeks till birth of baby
Incidence: 3 – 5%
Before 22 weeks – miscarriage/abortion
E.g. threatened miscarriage
Have to differentiate from “show”
blood-stained mucoid discharge
CAUSES
Indeterminate 45%
Abruptio Placenta 30%
Placenta Praevia 20%
Local causes 5%
(e.g. vaginitis, cervical polyp, ectropion,
carcinoma)
HISTORY
Colour, quantity of bleeding
Precipitating factors e.g. trauma, intercourse
Contractions
Leaking liquor
Fetal movement
Previous ultrasound
GENERAL MEASURES
Call for help
Resuscitation: A, B, C
BP,PR
2 IV access
Blood ix
FBC, coagulation profile
Rhesus
Cross match blood 4 units
Ultrasound
Identify Cause of bleeding
NO VE until cause determined
PLACENTA PRAEVIA
Placenta lying partly or wholly within the lower uterine
segment (> 28 weeks)
< 28 weeks - Low-lying placenta
Upper segment
Lower segment
CLASSIFICATION
PP I : Within lower segment (5cm)
PP II : Reaches internal os
PP III : Partially covers os
PP IV : Completely covers os
INCIDENCE
18 weeks: 26%
32 weeks: 5%
Term: 0.5%
Only about 1 in 10 of low lying placenta persists as
clinically relevant placenta praevia towards term
RISK FACTORS
Maternal
Previous caesarean section (associated with placenta
accreta)
Previous placenta praevia
Grandmultip
Elderly
Smoking
Fetal
Twins
COMPLICATIONS
Maternal
PPH
Placenta accreta
Maternal death
Fetal
Prematurity
IUGR
Congenital malformations (2-fold increase
in PP and abruptio)
MANAGEMENT
Diagnosis by U/S (ideally with transvaginal U/S)
No V/E
Active PV bleeding- immediate delivery
Bleeding stop- hospitalized till delivery
MORBIDLY ADHERENT PLACENTA
Placenta penetrates through the
myometrium of uterus
Includes
- Placenta accreta
- Placenta increta
- Placenta percreta
Risk factors
- Previous scar
- Previous D&C
Women with previous caesarean section and at the
same time had placenta praevia at increase risk of
morbidly adherent placenta
Increase in maternal morbidity and mortality
LINK BETWEEN NUMBER OF PREVIOUS CAESAREAN
SECTION AND RISK OF MORBIDLY ADHERENT PLACENTA
& HYSTERECTOMY
NUMBER OF NUMBER OF NUMBER OF CHANCE OF NUMBER OF
PREVIOUS C- WOMEN WOMEN WITH PLACENTA HYSTERECTOMIES
SECTION PLACENTA ACCRETA IF
ACCRETA PRAEVIA
0 6201 15 (0.24%) 3% 40 (0.65%)
1 15808 49 (0.31%) 11% 67 (0.42%)
2 6324 36 (0.57%) 40% 57 (0.9%)
3 1452 31 (2.13%) 61 % 35 (2.4%)
4 258 6 (2.33%) 67 % 9 (3.49%)
PLACENTA ABRUPTIO
Premature separation of the placenta prior to the 3rd
stage of labour
Incidence: 1-2%
Placental separation if severe enough, can cause
inadequate nutrition and oxygenation of the fetus –
fetal death
Can be concealed, revealed or mixed (most common)
RISK FACTORS
Maternal
Previous abruptio
Grandmultipara
PIH
Trauma, fall, massage
ECV
Substance abuse
Smoking
Fetal
Twins
Polyhydramnios (with sudden decompression on rupture of
membrane)
MANAGEMENT (FETUS ALIVE)
Assess maternal and fetal stability
ARM to augment labour and prevent amniotic fluid
embolism
Continuos CTG monitoring
LSCS for:
Fetal distress
Persistent bleeding
Vaginal delivery not imminent
If mother not stable (need to resuscitate first!)
Paeds for neonatal resuscitation
Watch for PPH
MANAGEMENT (FETUS DEAD)
Assess maternal stability and coagulopathy
Vigorous replacement of fluid and blood products
Correct any coagulopathy
Vaginal delivery unless severe haemorrhage
Watch for PPH
MATERNAL COMPLICATIONS
Couvelaire uterus
Blood seeping into uterus (myometrium) causing
uterine atony
Coagulopathy
Due to profuse bleeding
Due to thromboplastin release from decidua
Hypovolaemic shock
Renal cortical necrosis
Amniotic fluid embolism
Maternal death
FETAL COMPLICATIONS
IUGR
Birth asphyxia
Perinatal death
How to differentiate? Clinical presentation
PRAEVIA ABRUPTIO
Painless Painful
Revealed Can be concealed
Uterus soft Uterus tense/ tender
FH usually present FH may be absent
May have abnormal lie May be hard to feel
or malpresentation fetal parts
INDETERMINATE APH
If there is no identifiable cause of APH
Deliver by 40 weeks – due to possibility of minor
abruption (may lead to placental insufficiency)
Refer if undelivered by 40 wks + 0 days
VASA PRAEVIA
Bleeding with onset at rupture of
membranes
Immediate delivery
High perinatal mortality from fetal
exsanguination
PRINCIPLES OF MANAGEMENT
Assess maternal condition and stabilize if necessary.
Then assess the fetal condition.
Determine the cause of the bleeding
Manage according to underlying cause.
