DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY[LTMMC]

ANTEPARTUM
HEMORRHAGE (APH)
Presented By the Residents of DR.APB unit.
Under the guidance of DR.AMARJEET
BAVA(HOU)
 ANTEPARTUM
HEMORRHAGE

INTRODUTION CAUSES OF APH

 Any bleeding from 1. Placenta previa (30-

genital tract beyond the 40%)
period of viability i.e
beyond 28 wk. 2. Abruptio placentae
(30%)
3. Vasa previa
 Incidence: 2-5% of
pregnancies. 4.Preterm labor (show)
5.Rupture of uterus
 Associated with poor 6. Local causes: Cervical
fetal and maternal polyp, cervicitis,carcinoma
outcome. 7. Unknown causes
 ANTEPARTU
Placenta Abruptio M
previa placenta
HEMORRHA
GE:

1.Placenta
previa

2.Abrutio
placenta.

Revealed
abruption Concealed
abruption
PLACENTA PREVIA:
 Placenta is in lower uterine segment .( usually placenta is in upper
uterine segment ).
 Incidence is in 1/300 pregnancies.
 Placenta previa is classified based on the location of the placenta in
relation to the internal cervical os. The classification is crucial for
management and delivery planning.
 Uterine contractions or cervical changes and formation of lower uterine
segment as gestational age advances causes shearing of inelastic
placental attachment site .This opens the venous sinuses leading to
bleeding from intervillous spaces.

CLINICAL SIGNIFICANCE:
 Placenta previa is a leading cause of painless third-trimester bleeding.
 Diagnosis is confirmed by ultrasound (preferably transvaginal ultrasound
for accuracy).
 Management depends on gestational age, severity of bleeding, and fetal
well-being.
 Cesarean section is usually required for complete placenta previa
1. Traditional Classification
a) Complete (Total) Placenta Previa: The placenta completely
covers the internal os.
b) Partial Placenta Previa: The placenta partially covers the
internal os.
c) Marginal Placenta Previa: The placenta reaches the edge of
the internal os but does not cover it.
d) Low-lying Placenta: The placenta is implanted in the lower
uterine segment within 2 cm of the os but does not reach it.
2. Modern Classification (FIGO, RCOG Guidelines)
 a) Major Placenta Previa: Includes complete (total)
and partial placenta previa.
 b) Minor Placenta Previa: Includes marginal placenta
previa and low-lying placenta.
 The classification helps determine the risk of bleeding
and the need for cesarean section..
 CLINICAL FEATURES OF
RISK FACTORS FOR PP:
PP:
 Past history of placenta
previa. High risk factors for
Placenta previa
 Previous C-section scar
 Placenta
 Increase number of LSCS
 Placental size and
 ART/IVF
abnormality (big
 Twins pregnancy placenta)
 Placenta succenturiate  Race (asian women)

 Placenta bilobate  Presence of uterine scar

 Smoking  Various pregnancies

(multiple pregnancies)
 Hysterotomy/Myomectomy
 Infertility treatment
 Increase maternal age and
 Age (>35 y/o risk
parity
increased 4 times)
 Raised alpha fetoprotein
CLINICAL FEATURES OF PP:
 Occur after 24-28 wk
 There is painless, bright red
(fresh) bleeding
 History of recurrent
bleeding associated with
small warning hemorrhage
 P/A examination:

uterus is relaxed ,soft, and

nontender. Fetal parts easily
palpable. Fundal height
corresponds to age of
gestation. Fetal heart sounds
easily heard. +/-
malpresentation
 P/V examination:

contraindicated
 GENERAL CONSIDERATIONS
1. Obtain blood samples for complete blood count and blood type
and cross matching

2. Institute complete bed rest

3. If the patient and placenta previa is experiencing ACTIVE

BLEEDING, continuously monitor her blood pressure, pulse rate,
respiration, central venous pressure, intake and output, and amount
of vaginal bleeding as well as the fetal heart rate and rhythm.

4. If the patient is Rh-negative and not sensitized, administer Rh (D)

immune globulin (RhoGAM) after every bleeding episode.

5. Administer prescribed IV fluids and blood products.

6. Provide information about 9. Explain that the fetus
labor progress and the survival depends on
condition of the fetus. gestational age and amount
of maternal blood
loss.Request consultation
7. Prepare the patient and her with a neontologist or
family for a possible pediatrician to discuss a
caesarian delivery and the treatment plan with the
birth of a preterm neonate, patient and her family.
and provide thorough
instructions for postpartum
care. 10. Assure the patient that
frequent monitoring and
prompt management greatly
8. If the fetus less than 36 reduce the risk of neonatal
weeks gestation expect to death.
administer an initial dose of
betamethasone: explain that
additional doses may be 11. Encourage the patient
given again in 24 hours and and her family to verbalize
possibly for the next 2 weeks their feelings helps them to
to help mature the neonates develop effective coping
lungs. strategies, and refer them for
counseling, if necessary.
12. Anticipate the need for a 16. Observe for abnormal
referral for home care if the fetal heart rate patterns such
patient bleeding ceases and as loss of variability,
she’s to return home in bed decelerations tachycardia to
rest. identify fetal distress.
13. During the postpartum 17. Position the patient in
period, monitor the patient side lying position and wedge
for signs of early and late for support to maximize
postpartum hemorrhage and placental perfusion.
shock.
18. Assess fetal movement to
evaluate for possible fetal
hypoxia.
14. Monitor VS for elevated
temperature, pulse, and 19. Teach woman to monitor
blood pressure, monitor fetal movement to evaluate
laboratory results for well being
elevated WBC count,
differential shift; check for 20. Administer oxygen as
urine tenderness and ordered to increase
malodorous vaginal discharge oxygenation to mother and
to detect early signs of fetus.
infection resulting from
exposure of placental tissue.
MANAGEMENT OF PLACENTA PREVIA:
1. PP without
bleeding :

Placenta in lower uterine segment during 2nd

trimester without bleeding :
 Advice to avoid : heavy weight lifting ; sexual
intercourse ; moderate to strenuous exercise ; long
standings .
 Advice to immediately report to hospital if there is
contractions or bleeding.
 Repeat ultrasound in 3rd trimester at 32 wk to check for
placenta previa and low laying placenta .
i. If placenta is normally located – ask for routine ANC
follow up
ii. If placenta is abnormally located in LUS – Repeate
TVS at 36 wk .If still placenta is abnormally located ;
plan for elective LSCS at 36-37 wks+6days for
placenta previa and low laying placenta which lies
within 1cm from internal os.
2. BLEEDING PLACENTA PREVIA:

• Maternal resuscitation
• Assessment of time of delivery:

Indications of Active Indications for

management by c-section Expectant management
when:
when :
 mother is hemodynamically
unstable  mother is
 in presence of severe and hemodynamically stable ,
persistent bleeding,  no active bleeding ,
 fetal distress,
 normal CTG,
 >=34wk with significant
blood loss,  <34 wk and no
 gross congenital anomalies significant blood loss,
incompatible with life  congenital anomalies
irrespective of gestational
age on USG .
compatible with life
Expectant management of placenta
previa :
JOHNSONS AND MC CAFFE REGIMEN:

 Admit the patient .

 Give corticosteroid
 Give neuroprotection if <32 wk
 Give Inj anti D if Rh negative pregnancy
 Correction of anemia
 Fetal monitoring
 Termination of pregnancy at 36-37wk+6days.
 No role of cervical cerclage .
 ABRUPTIO PLACENTAE

 Placental abruption is the premature

separation of a normally implanted placenta
before the delivery of the fetus. It is a
significant cause of maternal and fetal
morbidity and mortality.

 +/- Initiating factor

 Rupture of spiral arteries in decidua basalis.

 Blood collection behind placenta .
 This inceases intervillous space pressure
 Follow by more bleeding
 Release of thromboplastin which increases the
risk of disseminated intravascular coagulation.
Pathophysiology of Placental Abruption
 The process of placental abruption begins with uterine
vasospasm followed by relaxation, and subsequent venous
engorgement and arterial rupture (decidual arteries)
 Placental abruption occurs when the maternal vessels tear away
from the placenta, and bleeding occurs between the uterine
lining and the maternal side of the placenta.

 Disruption of the vascular network may occur when the vascular

structures are compromised because of hypertension or
substance use or by conditions that cause stretching of the
uterus.

 The uterus is a muscle and is elastic, whereas the placenta is

less elastic than the uterus. Therefore, when the uterine tissue
stretches suddenly, the placenta remains stable, and the
vascular structure connecting the uterine wall to the placenta
tears away.
 When accumulating blood causes separation of the placenta
from the maternal vascular network, these vital functions of the
placenta are interrupted. If the fetus does not receive enough
oxygen and nutrients, it dies.
 A hematoma forms which may initially be concealed but with
expansion of the hematoma, progressive placental separation
occurs.
 When there has been intravasation of blood into the
myometrium, the uterus becomes purplish in color - The so
called Couvelaire uterus.
 The infiltration of blood between muscle fibers causes a tonic
contraction which makes the uterus “woody hard” and tender.
 The increase in intra-uterine pressure compromises the
placental circulation, adding to the fetal hypoxia which has
already started due to the placental separation.“
Classification Based on Bleeding
Type
CLINICAL SIGNIFICANCE:
 Abruptio placentae is a leading cause of antepartum
hemorrhage.
 Risk factors include hypertension, trauma, smoking, and
prior history of abruption.
 Diagnosis is mostly clinical but can confirmed with
ultrasound.
 Management depends on severity and gestational age,
with immediate delivery often needed in severe cases.
 Risk factors can be thought of in 3 groups: health history,
including behaviors, and unexpected trauma.
 Factors that can be identified during the health history
that increase the risk of placental abruption include
smoking, cocaine use during pregnancy, maternal age
over 35 years, hypertension, and placental abruption in a
prior pregnancy
 Conditions specific to the current pregnancy that may
precipitate placental abruption are multiple gestation
pregnancies, polyhydramnios, preeclampsia, sudden
uterine decompression, and short umbilical cord.
 Finally, trauma to the abdomen, such as a motor vehicle
collision, fall, or violence resulting in a blow to the
abdomen, may lead to placental abruption.
 "Vaginal bleeding occurs in 80% of patients . Bleeding may compromise
fetal and maternal health in a short period of time.
 Uterine activity is a sensitive marker of placental abruption, and in the
absence of vaginal bleeding, should suggest the possibility of an abruption
especially if there is a history of trauma.
 The presenting complaint may be decreased fetal movements, which may
indicate fetal compromise or even fetal death."
 A high index of suspicion may be required to make a diagnosis.
 If the separation is early and near the placental margin, vaginal bleeding
occurs early, the pain is minimal, and the tenderness mild.
 This may be mistaken for a heavy bloody show, and the diagnosis is less
obvious.
 Signs and symptoms of placental separation that is early or near the
placental margin : With severe abruptions signs include heavy vaginal
bleeding, abdominal pain, back pain, anemia, hypovolemia, a tender
“woody hard” uterus, decreased fetal movements and difficulty palpating
fetal parts.
 With a posteriorly situated placenta, back pain initially dominates . If the
patient presents with hypovolemic shock, there may be hypotension,
tachycardia and decreased urine output . The patient may progress from
alert to an obtunded state . Fetal monitoring may reveal a prolonged fetal
bradycardia, repetitive late decelerations on CTG, decreased variability on
CTG, or even a sinusoidal pattern . The uterine fundal height may increase
Conclusion:
 a placental abruption is a major cause of maternal-fetal
morbidity and mortality and is an obstetric emergency . Intense
monitoring is required in the mother and ongoing resuscitation.

Summary:
 Placental abruption is an important cause of antepartum
hemorrhage and is an obstetric emergency . It results in
morbidity and mortality in mother and child Smoking and
cocaine use are modifiable risk factors A high index of suspicion
is sometimes required to make a diagnosis.

 The classic clinical triad for diagnosis is vaginal bleeding, a

tender uterus, and decreased fetal movements. The patient
does not always present with this triad . Appropriate
investigations are essential. This may include: ultrasound and
blood investigations.
 Be aware of CTG changes associated with abruption .
Resuscitation is required and must be ongoing. Patients may
require admission to ICU.

 Vaginal delivery is the preferable route of delivery when the

fetus has demised unless there is an obstetric
contraindication to vaginal birth.

 Cesarean section (C-section) is the preferable route of

delivery in placental abruption with a live fetus, unless the
patient is fully dilated with a low fetal presenting part.

 Notable, serious complications include coagulopathy and

renal failure . Patients may require ICU admission

 .Postpartum hemorrhage may also occur. The doctor in

charge of the patient must be prepared for this and know
how to perform cesarean-hysterectomy if required . Multi-
disciplinary intervention is sometimes required."
VASA PREVIA
 Vasa previa is a rare but serious obstetric condition
where fetal blood vessels cross or run near the
internal cervical os, unprotected by the umbilical cord
or placenta. If these vessels rupture during labor, it
can lead to rapid fetal exsanguination and death.
 CLASSIFICATION OF
VASA PREVIA
A) Type I Vasa Previa:
- Fetal blood vessels run
through the fetal membranes
over the cervix without support
from the placenta or umbilical
cord.
- Commonly associated with
velamentous cord insertion.

B) Type II Vasa Previa:

- Fetal blood vessels connect
lobes of a bilobed or
succenturiate-lobed placenta
and traverse the cervix.
- More commonly seen in multi-
lobed placentas.
C).Type III vasa previa:
Unprotected fetal vessels run over
the cervix, connecting one placental
edge to another, without a
velamentous cord insertion or
accessory lobes.
RISK FACTORS, DIAGNOSIS AND
MANAGEMENT

Risk factors:
- Velamentous cord insertion
- Succenturiate or bilobed
placenta
- In vitro fertilization (IVF)
pregnancies
- Placenta previa or low-lying
placenta
- Multiple gestations
DIAGNOSIS OF VASA PREVIA
 Vasa previa is primarily diagnosed antenatally using ultrasound with
color Doppler. In emergency cases, it may be suspected intrapartum
based on clinical findings of vaginal bleeding and fetal distress.

 Antenatal Diagnosis (Gold Standard):

• Transvaginal Ultrasound with Color Doppler (Best modality)

Identifies fetal vessels crossing or near the internal cervical os.
Confirms that these vessels are not protected by Wharton’s jelly
(suggesting velamentous insertion or placenta with succenturiate
lobes).
• Transabdominal Ultrasound
May initially detect abnormal placental vessel positioning but is less
sensitive than transvaginal ultrasound.
• MRI (Rarely used)
Helpful in cases where ultrasound findings are inconclusive.
• At the time of mid-trimester
ultrasonography, the
placental location and the
relationship between the
placenta and internal cervical
os should be evaluated.’• It is
also recommend that
theplacental cord insertion
site be documented when
technically possible.
Management of Pregnancy with Prenatal
Diagnosis of Vasa Previa
Early diagnosis of vasa previa allows for planned antenatal monitoring and
scheduled cesarean delivery to prevent fetal exsanguination and stillbirth.

Antenatal Management
 Hospitalization at 30–32 weeks (AJOG & SMFM guidelines) for close
monitoring.
 Serial fetal surveillance with NST or BPP starting at hospitalization.
 Antenatal corticosteroids (betamethasone 12 mg IM, 2 doses 24 hours
apart) at 28-32 weeks to enhance fetal lung maturity.

Timing and Mode of Delivery

Elective Cesarean Section
• Scheduled at 34–37 weeks (preferably before labor or membrane rupture).
• Earlier delivery (before 34 weeks) if there are signs of labor, membrane
rupture, or fetal distress.
Emergency Cesarean Section Indications
• Preterm labor
• Preterm premature rupture of membranes (PPROM)
• Non-reassuring fetal status.

Because of the speed at which total exsanguination can occur ,delivery should not
be delayed while trying to confirm the diagnosis.
•Especially if of fetal compromise on CTG
•The ultimate management goal of confirmed vasa praevia should be to deliver
before rupture of membranes while minimising the impact of iatrogenic
prematurity.
 LOCAL CAUSES OF APH

1. Cervical Causes: 3. Other Genital Tract Causes:

 Cervical ectropion (erosion) • Vulvar varicosities
 Cervicitis (infectious or inflammatory) • Vulvovaginal hematoma
• Rupture of a uterine scar (e.g.,
 Cervical polyp
previous cesarean scar rupture)
 Cervical carcinoma
 Cervical trauma (e.g., post-coital 4. Other Rare Causes:
bleeding, cervical laceration) • Uterine rupture
• Infections such as herpes
2. Vaginal Causes: simplex virus (HSV) causing
 Vaginitis (infection, inflammation)
ulceration and bleeding
 Vaginal varices (especially in
multiparous women)
 Trauma (sexual intercourse,
instrumentation, or physical injury)
 Vaginal carcinoma