ANTEPARTUM HAEMORRHAGE is defined as bleeding from the genital tract after 28th week of pregnancy before the onset of labour.

APH is an Obstetric Emergency

One of the causes of obtstetric haemorrhage

It is associated with increased risks of fetal and

maternal morbidity and mortality.

Incidence:2 – 6 %.

Placenta praevia

Placenta abruption

Vasa previa

Incidental causes

Vagina lesions

Cervical lesions

Vulva lesions

Vulva

vulva abrasion

Vagina ◦ Coital laceration

◦ Condyloma acuminata

Cervical ◦ Erosion

◦ Polyps

◦ Carcinoma

◦ Condyloma acuminata

Placenta praevia occurs when the placenta is wholly or partly in the lower uterine segment after 28 weeks of gestation

Its incidence is 0.4 to 0.8% of pregnancies

it forms after 28 week’s gestation and it has 3 definitions

• Is that part of the uterus which measures about 5 cm from the internal os (metric definition used in U/S).

• Is that part of the uterus which stretches and dilates in labour (physiological definition occurs in labour).

• Is that part of the uterus which lies below the level at which the visceral peritoneum is reflected on the dome of the bladder from being ultimately adherent to the upper uterine segment (anatomical definition used in caesarean section

• Grade 1: the placental edge is in the lower uterine segment but does not reach the internal os (low implantation).

• Grade 2: the placental edge reaches the internal os but does not cover it.(Marginal)

• Grade 3: the placenta covers the internal os when it is close and is asymmetrically situated (partial/eccentric).

• Grade 4: the placenta covers the internal os and is centrally situated (complete/concentric)

Multiparity

Increased maternal age

Previous cesarean section

Multiple gestation

Previous myomectomy Previous termination of pregnancy by sharp

currettage Cigarette smoking/cocaine use Uterine fibroids/other uterine abnormalities Uterine anomaly Large placenta

Placenta praevia typically occurs as a result of abnormally low implantation believed to result from abnormal endometrial vascularisation related to atrophy or scarring from prior trauma or inflammation.

The margins of the abnormally implanted placenta are altered as the lower uterine segment thins out in late pregnancy.

Various degrees of placental detachment may develop with ensuing maternal haemorrhage from the intervillous spaces.

In the absence of the decidua basalis, the placenta can attach directly to the myometrium (Accreta), invade the myometrium (Increta),or penetrate it (percreta).

Placenta accreta occurs in ~ 1 in 2500 deliveries and the rate is increased to 10% in women with placenta praevia

Vaginal bleeding ◦ Painless vaginal bleeding, more sever with major

degrees(70-80%) ◦ Recurrent bouts of bleeding may be from early

pregnancy ◦ 10 to 20 percent present with uterine contractions

associated with bleeding. Malpresentation e.g Breech Abnormal lie-Transverse lie, Oblque lie, Unstable lie High presenting part Uterus is soft and not tender Fetus is usually alive and well( may be dead in severe

haemorrhage) More serious for mother than fetus Fewer than 10 percent are incidentally detected by

ultrasound.

History;

Clinical examination: General physical examination and abdominal examination

(NOTE-vaginal examination is contraindicated)

Investigation; ◦ The diagnosis is based upon results of ultrasound

examination. ◦ Routes of ultrasound- (Transabdominal, Transvaginal,

Translabial)

Avoidance of coitus and digital cervical examination.

Counseling to seek immediate medical attention if there is any vaginal bleeding.

Women are also encouraged to avoid vigorous exercise, decrease their daily activity and notify the physician of uterine contractions.

Group and crossmatch 2-4 units of blood.

Serial ultrasound evaluations every two to four weeks to assess placental location and fetal growth.

Large bore IV access & administration of crystalloid.

Type and crossmatch for four(4) units of PRBC.

Transfuse to maintain a Haematocrit of 30% if the patient is actively bleeding.

Maternal pulse and blood pressure every 15 minutes to 1 hour depending upon the degree of blood loss.

The fetal heart rate is continuously monitored.

Quantitative monitoring of vaginal blood loss.

The source of the vaginal blood (maternal versus fetal) is intermittently assessed by either an Apt test or Kleihauer-Betke analysis.

Urine output is evaluated hourly with a Foley catheter & should be at least 30 mL/hour.

Haemoglobin & Haematocrit check.

Serum electrolytes and indices of renal

function. Coagulation profile (fibrinogen, Platelet,

Prothrombin Time & Prothrombin Time kaolin) are checked especially if there is a suspicion of coexistent abruption causing deranged clotting profile.

Tocolysis is not administered to actively bleeding patients.

Cesarean delivery is the delivery route of choice

DELIVERY IS INDICATED IF

◦ There is a nonreassuring fetal heart rate. ◦ Life threatening refractory maternal

hemorrhage. ◦ Depending on the gestational age:

Introduced by Mac Afee at the Royal maternity hospital Belfast

The aim is to prolong the pregnancy to gestational age at which fetal survival is ensured(> or =37weeks)

◦ Full facilities for emergency caesarean section

◦ Obstetric staff 24hrs

◦ Blood transfusion services-Cross-matched blood should be available all the time

◦ Correct anemia

◦ Prophylactic transfusions to maintain the maternal hematocrit above 30 percent in stable asymptomatic patients in anticipation of future blood loss.

◦ Steroids

Assess fetal well-being :Fetal growth, amniotic fluid volume, and placental location are evaluated sonographically every two to four weeks.

Tocolysis may be safely utilized if contractions are present and delivery is not otherwise mandated by the maternal or fetal condition

Prophylaxis for Rh isoimmunization

Scheduled abdominal delivery is suggested at 37weeks or upon confirmation of pulmonary maturity.

Abdominal delivery.

Two to four units of Packed RBC should be available for the delivery.

Appropriate surgical instruments for performance of a cesarean hysterectomy should also be available since there is a 5 to 10 percent risk of placenta accreta.

The surgeon should try to avoid disrupting the placenta when entering the uterus.

If the placenta is encountered upon opening the uterus then it is necessery to cut through the placental tissue to deliver the fetus.

Outpatient Managaement

Women who are well motivated.

Women with placenta previa if bleeding has stopped for more than one week.

There are no other pregnancy complications, such as fetal growth restriction

Live in an area easily accessible to the hospital.

Patient have good communication

Patient have good transportation means

Have an adult companion available 24 hours a day who can immediately transport the woman to the hospital if there is light bleeding or call an ambulance for severe bleeding.

Be reliable and able to maintain bed rest at home.

Understand the risks entailed by outpatient management.

The maternal and perinatal mortality rates in pregnancies complicated by placenta previa have been reduced over the past few decades because of:

The introduction of conservative obstetrical management.

The liberal use of cesarean rather than vaginal delivery.

Improved neonatal care.

FETAL – prematurity, increased risk of neonatal admission, fetal anaemia, still birth, perinatal asphyxia

MATERNAL- anaemia, increased risk of instrumental delivery, increased risk of hospital admissions.

It is the premature separation of a normally sited placenta from its site of implantation before delivery of the fetus.

It is an obstetrics emergency.

Associated with maternal and perinatal morbidity and mortality

It occurs 1 in 200 deliveries

Incidence of 1% (0.5-1.5%)

It tends to recur in 8.8% of patients

THE AETIOLOGY IS UNKNOWN Hypertensive disorders. Trauma Multiparity Preterm ruptured membranes. Multiple gestation. Short umbilical cord Polyhydramnios. Smoking Cocaine use.

Prior abruption. recurrence rate after one episode 8-17%, after two episodes 25%

Uterine fibroid.

Thrombophilia.

Maternal age of 35 years or older

Predisposition for Male fetal sex

low social class

Vagina bleeding ◦ Vaginal bleeding is present in 80% of patients

diagnosed with placental abruptions.

◦ Bleeding may be significant enough to jeopardize both fetal and maternal health in a relatively short period.

◦ Remember that 20% of abruptions are associated with a concealed hemorrhage and the absence of vaginal bleeding does not exclude a diagnosis of abruptio placentae.

Abdominal pain, discomfort and backache in 65% of cases

High frequency contractions. Uterine hypertonus.

Uterine tenderness. Uterus may be woody hard and tender rendering fetal parts difficult to palpate or impalpable

High incidence of fetal distress and fetal death. Fetus is dead in 25-35% of cases at admission (perinatal mortality 4.4-67%)

Normal lie and presentation

Shock: Shock is an outstanding feature of the concealed type of placental abruption. The patient may be unconscious when brought to the hospital and show all the signs and symptoms of acute blood loss like a thin thready pulse, low blood pressure, cold, clammy arms and legs etc.

There are three types of placenta abruption

Concealed type

Revealed

Mixed

The grading of Abruptio placenta according to SHER and STUTLAND (1985)

GRADE CLINICAL FEATURES

I Not recognised clinically before delivery

II The classical signs of abruption are usually present but the fetus is still alive though may be in distress.

III Severe :the fetus is dead. (a) No coagulopathy (b) coagulopathy

The diagnosis is primarily clinical, but may be supported by radiologic, laboratory, or pathologic findings.(HX and PE)

It is generally obvious in severe cases.

mild cases may pose diagnostic difficulty until a retroplacental clot is identified after delivery.

ultrasonography may be helpful in a few doubtful (mild) cases

FBC (PCV PLT)

ultrasound

Coagulation profile

◦ Clotting time, platelet count,

◦ fibrinolysin test, fibrinogen estimation, and FDP (Fibrinogen degradation products)

Acid base status (PH, blood gas analysis

•Blood urea and electrolytes

•Urinalysis

Blood grouping and cross matching

Rhesus typing

This depends on

Severity

Associated complications

State of the patient

State of the fetus

The gestational age

Resuscitation 1. IV access wide bore canulla (size 16 , 14) 2. Urgent Packed Cell Volume 3. Coagulation profile studies 4. Correction of blood loss(crystalloid, Fresh

Frozen Plasma, fresh whole blood) 5. Catheterize for hourly urinary out put

monitoring 6. Oxygen 7. Continuous fetal monitoring

Specific measures

–Immediate delivery –?Expectant management –Management of complications

Depends on the severity of the abruption,

and the state of the fetus (dead or alive)

DEAD FETUS ◦ Aim at vagina delivery

◦ Needs adequate resuscitation

◦ ARM plus or minus oxytocin (with oxytocin, close monitoring to avoid over stimulation and uterine rupture).

◦ Delivery should be effected within 6 hrs.

If bleeding continues and progress of labour is slow, deliver by C/S.

Note that C/S is risky in the presence of DIC. If there is not much blood available to resuscitate the patient adequately then early recourse to C/S may be justifiable

CS or vaginal delivery. CS offers better chances of survival for the baby. If vaginal

delivery is aimed at, then there is the need for continuous fetal electronic monitoring and this may be considered if labour is well advanced.

This is not advisable if there are no sophisticated fetomaternal monitoring gadgets.

•Fetal distress – immediate Caesarean Section

This may be regarded as contoversial by some authorities

This may be done for very mild cases in which the fetus is immature.

Such cases may develop mild localized tenderness over the uterus.

The ultrasound scan identifies a small retroplacental clot. ◦ Admit patient ◦ Pain relief ◦ Continuous electronic fetal heart rate monitoring (if

available)

Repeated USS for first few hours to monitor rate of progression of retroplacental clot.

Monitor fetus subsequently by –Daily fetal kick counts

–Twice weekly Cardiotocography –Twice weekly ultrasound scan

If abruption progresses, deliver as soon as possible. If abruption does not progress, continue expectant management till 37 weeks

gestational age and deliver.

MATERNAL Hypovolemia. Disseminated Intravascular Coagulopathy. Renal failure. Death. PostPartum Haemorrhage

FETAL Asphyxia

Prematurity

Intra Uterine Growth Restriction

IntraUterine Fetal Death

INTRODUCTION

RISK FACTORS

PATHOPHYSIOLOGY

CLINICAL FEATURES

MANAGEMENT

COMPLICATIONS

Is an obstetric complication defined as "fetal vessels crossing or running in close proximity to the inner cervical os. These vessels course within the membranes (unsupported by the umbilical cord or placental tissue) and are at risk of rupture when the supporting membranes rupture.

Vasa” is the plural of “Vas” which comes from Latin word denoting a vessel or a dish (thus the word “vase”).

“Previa” is a combination of two words: “pre” (or “prae”) meaning before, and “via” meaning way. “Previa” in medicine, usually refers to anything obstructing the passage in childbirth.

Literally therefore, vasa previa means “vessels in the way, before the baby”.

Rare - 1 in 3000

Fetal mortality 33-100%, if not diagnosed prenatally

Placenta praevia

Bilobed or Succenturiate placenta

Velamentous insertion of cord

Multiple pregnancies

Invitrofertilized pregnancies

1% - singleton pregnancies, 10% - twin pregnancies, higher in early pregnancy & spontaneous abortion.

Umbilical cord usually inserts on placental mass - 99% cases.

Velamentous - cord inserted on chorioamniotic membrane.

Variable amount of cord unprotected by Wharton’s jelly.

Vasa praevia coexisting in 6% singleton pregnancies with velamentous insertion.

Asymptomatic

sudden onset of painless bleeding in 2nd or 3rd trimester

Artificial/sudden Rupture of Membrane.

Heavy or small amount of bleeding. No sign or symptom of Placenta praevia or abruption.

IUGR/ Congenital malformation

Maternal risk: bleeding

ANTENATAL

An avoidable tragedy.

Changing ultrasound protocol for checking placental cord connection.

Can be diagnosed as early as 16 weeks .

All suspected cases should be checked for vasa praevia

The classic triad of the vasa praevia is

membrane rupture,

painless vaginal bleeding

fetal bradycardia.

This is rarely confirmed before delivery but may be suspected when antenatal sono-gram with color-flow Doppler reveals a vessel crossing the membranes over the internal cervical os.

The diagnosis is usually confirmed after delivery on examination of the placenta and fetal membranes

Most often the fetus is already dead when the diagnosis is made; because the blood loss (say 300ml) constitutes a major bulk of blood volume of the fetus (80-100ml/kg i.e. 300ml approx for a 3kg fetus)[].

If fetus is alive a caesarean section should be done immediately.

Although vasa previa can be recognized in grey-scale as linear structures in front of the inner os, the diagnosis is considerably simpler by putting a flash of color Doppler (color or power) , over the cervix.

Arterial flow but also venous flow can be recognized. Although some have obtained the diagnosis by perineal(trans-labial) scan , a transvaginal image is clearly superior to an abdominal scan. Some have also advocated the use of 3D.

digital palpation of a vasa previa

Amnioscopy

Apt

similar tests (fetal blood detection), and palpation have mostly a historical significance.

MRI has been suggested too

This is usually a diagnosis of exclusion after the major causes must have been ruled out.

It is essentially due to any bleeding from the structures of the lower genital tract – vulva, vagina and cervix.

Management is essentially to treat the underlying cause.

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