APH

By Gemechu M(MD)
Antepartum Hemorrhage(APH)
• APH is Vaginal bleeding from the 28th week of gestation till the fetus
(last fetus in case of multiple pregnancies) is delivered
• One of late pregnancy complication
• Occurs in 3-4% of pregnancies and may be obstetric or nonobstetric

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Causes of APH

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 1.Placental Abruption/Abruptio Placenta
• Premature separation of a normally implanted placenta before delivery
of fetus
• Represent about 1/3rd of all antepartum bleeding
• Defective maternal vessels in the decidua basalis rupture and cause the
separation or rarely caused by a disruption of the fetal-placental
vessels
• Damaged vessels bleeding decidual hematoma placental
separation destruction of placental tissue and a loss of maternal-
fetal surface area for nutrient and gas exchange

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 Cont..
• Thrombin, which is released in response to decidual hemorrhage or
hypoxia, appears to play an active role in the pathogenesis
• Thrombin acts as a direct uterotonic, enhances the action of matrix
metalloproteinases, upregulates apoptosis genes, and increases the
expression of inflammatory cytokines
• These thrombin-mediated events initiate a cyclic pathway of vascular
disruption, hemorrhage, inflammation, contractions, and rupture of
membranes

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 RISK FACTORS

• Previous history of abruptio • Abnormal placenta

placentae • Low socio-economic status
• Hypertension • Smoking
• Multiparity • Trauma (e.g., ECV)
• Maternal age ≥ 35 years • Polyhydramnios
• Multiple pregnancy • Short cord
• PROM
• Uterine anomaly

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 Classification of Abruptio Placenta

• Based on temporal nature of the abruption : acute versus chronic

• Based on clinical presentation : overt/revealed(80%) versus
concealed(bleeding is not visible)
• Based on severity: Mild , Moderate and Sever
• Based on anatomical location(U/S): subchorionic, retroplacental and
preplacental

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Severity based classification

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Based on anatomical location

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 Clinical Manifestations
• An acute, overt abruption typically presents with vaginal bleeding,
abdominal pain, and uterine contractions.
• As it worsens uterine tenderness, NRFHR and fetal death
• The amount of vaginal bleeding correlates poorly with the extent of
placental separation and its potential for fetal compromise
• In fact, concealed abruption occurs in 10-20% of cases
• Chronic abruption may be insidious in its presentation and is often
associated with ischemic placental disease (oligohydramnios, FGR, PTL,
PPROM, and preeclampsia)

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 Diagnosis
• Placental abruption is primarily a clinical diagnosis that is supported
by radiographic, laboratory and pathologic studies
• Vaginal bleeding(>80%): menstrual-like (dark)
• Abdominal pain(>50%)
• Uterine contraction or tenderness
• NRFHR or absent fetal heart beat

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 Cont…
Investigation
• CBC
• Blood group and Rh
• Coagulation profile: Platelet count, PT, PTT, fibrinogen or bedside
clotting and bleeding tests
• Ultrasound: Fetal assessment, retroplacental clot and for exclusion of
placenta previa
• Identified less than 2% of cases

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 Management
• Management of placental abruption depends on the severity,
gestational age and maternal-fetal status
• Considered to be an obstetric emergency
• Resuscitate and stabilize on arrival and admit the patient
• Mild abruptions may be managed expectantly in the hospital till
term
• Expectant management: <37 weeks
• Induction or augmentation or operative delivery if fetal or maternal
decompensation
• Women presenting at ≥ 37weeks should undergo delivery
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Complications
Maternal complication
• Hypovolemic shock
• Consumptive coagulopathy
• AKI
Fetal complication
• IUGR
• Oligohydramnios
• Hypoxemia
• Prematurity
• IUFD
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 2.Placenta previa
• The presence of placental tissue over or adjacent to the cervical os
• Encountered in 0.5 percent or 1 case per 200 deliveries
• Fatal in 0.03% of cases

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 RISK FACTORS

• Scarred uterus: previous uterine surgery (CS, myomectomy), uterine

curettage
• Previous history of placenta previa
• Large placenta: multiple pregnancy, diabetes, smoking, syphilis, Rh
incompatibility
• High parity and advanced maternal age

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Classification

• Totalis
• Partialis
• Marginalis
• Low lying

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 Cont…
• Recent revised classification of placenta previa consists of two
variations:
1. True placenta previa, in which the internal cervical os is covered partially
or completely by placental tissue
2. Low-lying placenta, in which the placenta lies within 2 cm of the cervical
os but does not cover it

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 Clinical Course
• PAINLESS, CAUSELESS, BRIGHT RED Vaginal bleeding
• Hypovolemia
• Anemia
• Malpresentation
• Floating presenting part

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Diagnosis
• Painless third-trimester bleeding was a common presentation for
placenta previa in the past
• Placenta previa are now detected antenatally with ultrasound before
the onset of significant bleeding
• Transabdominal (95%) and transvaginal (100%) ultrasound provide the best
means for diagnosing placenta previa
• More than 90% of the cases of placenta previa diagnosed in the
midtrimester resolve by term

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 Complications
Maternal
Fetal / Neonatal
Blood loss & shock • ↑PNMR from prematurity
Adherent placenta (placenta acreta,
increta and percreta) • ↑risk of fetal anomalies ( 5x)
Longer hospital stay • IUGR (20% Vs 5%)
Post partum hemorrhage • Birth trauma ( malpresentation)
Recurrence rate — 4 to 8 percent • Neonatal anemia

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 Management
• Resuscitate and stabilize on arrival and admit the patient.
• Assess maternal and fetal wellbeing
• Avoid vaginal examination
• Expectant :preterm (<37wks),mild bleeding with no bleeding for a
week, steroid, follow maternal and fetal condition
• Delivery :term, in labor, fetal distress, severe hemorrhage, IUFD,
lethal congenital malformation
• Route of delivery
• Vaginal: low lying, no or mild bleeding, no fetal distress
• Operative: fetomaternal distress, all types of previa, CPD
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Expectant management

Maternal Fetal
• Vital signs every 4 – 6 hrs • Ascertain GA
• Watch for Vaginal bleeding & onset of
labor
• Kick chart
• Serial HCT • FHR 4-6 hrs.
• Iron supplementation • BPP 2x/week
• Avoid douching • Growth monitoring
• Decrease mobility
• If there is no P/previa speculum
• Steroid therapy
examination after 48hrs of last episode to
R/o local causes
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 3.Vasa Previa
• Vasa previa is defined as the presence of fetal vessels over the cervical os.
• Refers to vessels that traverse the membranes in the lower uterine segment
in advance of the fetal head
• Typically, these fetal vessels lack protection fromWharton jelly
(velamentous cord insertion)
• Rupture of these vessels can occur with or without rupture of the
membranes and result in fetal exsanguination

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• Diagnosis
• In rare cases, pulsating fetal vessels may be palpable in the membranes that
overlie the cervical os during labor or with the acute onset of vaginal bleeding
.

• Vasa previa is often diagnosed antenatally by ultrasound with color and pulsed
Doppler mapping.
• Confirmation = Apt test and Kleihauer-Betke tests

• Management
• Same to placenta previa
• Mode of delivery must be by C/S at 36wks

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E ND

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