Antepartum Antepartum Haemorrhage (APH)Haemorrhage (APH)

Nadir khan AurakzaiNadir khan AurakzaiBatch ‘’M’’Batch ‘’M’’

08-23108-231Ayub Medical College, AbbottabadAyub Medical College, Abbottabad

ContentsContents

• Definition• Importance• Causes• Management of APH• Prognosis

Bleeding In

Pregnancy

Bleeding in early

Pregnancy

Antepartum

haemorrhage (APH)

Post partum Haemorrhag

e (PPH)

Antepartum Antepartum HaemorrhageHaemorrhage

• Antepartum haemorrhage (APH,prepartum hemorrhage) is bleeding from the vagina during pregnancy from twenty four weeks of gestational age to term.

• Epidemiology Affects 3-5% of all pregnancies 3 times more common in multiparous than primiparous women

ImportanceImportance• Obstetric emergency• Attention should be sought

immediately• If left untreated can lead to death of

the mother and/or foetus• Can leads to DVT• Management reduce the risk of

premature delivery and maternal/perinatal morbidity/mortality

CausesCauses

• 1: Placental causes:• A. Placental abruption• B. Placenta previa• C. Vasa previa

• 2: Causes in genital tract:• A. Labour• B: rupture of uterus• C. Trauma• D. Infection (cervicitis & vulvovginitis)• E. Tumours

• 3: Bleeding disorders

• A. Congenital (von willebrand’s disease)

• B. Acquired ( DIC)

Placenta praeviaPlacenta praevia

• Definition Insertion of the placenta, partially or

fully, in the lower segment of the uterus

EtiologyEtiology• No definitive cause• Endometrial factors:

– A scarred endometrium– Curettage for several times – Abnormal uterus

• Placental factors– Large plcenta– Abnormal formation of the placenta

Risk factors for Placenta Risk factors for Placenta praeviapraevia

• Multiparity• Advanced maternal age• Prior LSCS or other uterine surgery• Prior placenta praevia• Uterine structural anomaly

Degrees of Placenta praeviaDegrees of Placenta praevia

Classification of degrees Classification of degrees of Placenta praeviaof Placenta praevia

• Four grades:– Type I ( Low lying): Placenta encroaches

lower segment but does not reach the internal os

– Type II (Marginal placenta previa): Reaches internal os but does not cover it

– Type III (Partial Placenta previa): Covers part of the internal os

– Type IV (Complete): Completely covers the os, even when the cervix is dilated

Placenta praevia-Placenta praevia- Clinical Clinical FeaturesFeatures

• Recurrent painless vaginal bleeding (not always)• Abdominal findings Uterus is soft, relaxed and non tender Contraction may be palpated Presenting part is usually high Abnormal presentations • Maternal cardiovascular compromise• Foetal condition satisfactory until severe

maternal compromise• Vaginal examination- should not be done

InvestigationInvestigation• 1: For Localization of placenta:• Ultrasound:• Abdominal ultrasound can easily diagnose

placenta previa with an accuracy of 93-97%.

• Transvaginal ultrasound is safe and is more accurate than transabdominal ultrasound in locating the placenta

• 2: Haematological Investigations:• A. Complete blood picture.• B. Blood grouping. C:Renal profile

Placenta praevia-Placenta praevia-ComplicationsComplications

Maternal • Major hemorrhage, shock, and death• Renal tubular necrosis and acute renal failure• Post partum haemorrhage• Morbid adherence of Placenta : placenta accreta

complicates approximately 10% of placenta praevia cases

• Anaemia in chronic haemorrhage• Disseminated intravascular coagulopathy (DIC)

Placenta praevia-Placenta praevia-Complications cont….Complications cont….

Foetal• IUD• Hypoxic ischemic encephalopathy• Cerebral paulsy• Placental abruption• Premature labour

Placental abruptionPlacental abruption

• Definition Premature separation of a normally situated placenta in a viable foetus • Placental abruption should be

considered in any pregnant woman with abdominal pain with or without PV bleeding, as mild cases may not be clinically obvious

EtiologyEtiologyRisk factors1.Increased age and parity2.Vascular diseases: preeclampsia, maternal

hypertension, renal disease,SLE3.Mechanical factors: Trauma, intercourse Sudden decompression

of uterus Polyhydroamnios Multiple pregnancy 4. Smoking, cocaine use, 5.Premature rupture of membranes

PathologyPathology• Main changes Hemorrhage into the decidua basalis →

decidua splits → decidural hematoma → separation, compression, destruction of the placenta adjacent to it

• Types of abruption 1. Revealed abruption 2. Concealed abruption 3. Mixed type

Revealed abruptionConcealed abruption

Diagnosis-Clinical Diagnosis-Clinical FeaturesFeatures

•Vaginal bleeding associate with persistent abdominal pain • Tenderness on the uterus• “Woody” hard uterus• Change of foetal heart rate• Features of hypovolemic shock

Complication of Complication of Placental Placental abruptionabruption

Maternal • Disseminated intravascular coagulopathy• Hypovolemic shock• Amnionic fluid embolism• Renal tubular necrosis and acute renal

failure• Post partum haemorrhage• Maternal death

Complication of Complication of Placental Placental abruptionabruption

Feotal• Premature labour• IUGR in chronic abruption• Hypoxic ischemic encepalopathy and

cerebral paulsy• Foetal death

InvestigationsInvestigations• 1: Diagnostic investigations:• Ultrasonography Mainly to exclude placenta praevia Can detect Retroplacental hematoma Feotal viability Most of the time findings will be negative Negative findings do not exclude placental abruption• 2: Laboratory investigations1. Investigation for Consumptive coagulopathy – Platelet

count/BT/CT/PT/INR & APTT2. Liver and Renal function tests

Vasa praeviaVasa praevia

• Foetal blood vessels from the placenta or umbilical cord cross the internal os beneath the baby

• Rupture of membranes leads to damage of the foetal vesseles leading to exsanguination and death

• High foetal mortality (50-75%)

Vasa praeviaVasa praevia

Risk factorsRisk factors

• Eccentric (velamentous) cord insertion

• Bilobed or succenturiate lobe of placenta

• Multiple gestation• Placenta praevia• In vitro fertilization (IVF) pregnancies• History of uterine surgery or D & C

Eccentric (velamentous) cord insertion

Diagnosis - Vasa praeviaDiagnosis - Vasa praevia1.Moderate vaginal bleeding + feotal distress2.Vessels may be palpable through dilated

cervix3.Vessels may be visible on ultrasound

(Transvaginal colour Doppler ultrasound)• Difficult to distinguish from abruption• Can look for feotal Hb (Kleihauer-Betke test)

or nucleated RBC’s in shed blood• Tachycardia or bradycardia in CTG

Management of APH

Management of APH Management of APH • Admit to hospital for assessment and management• May need resuscitation measures if shocked or severe bleeding

Airway, breathing and circulation

Senior staff must be involved –Consultant

obstetrician and consultant anaesthetist,

neonatalogist

Two wide bore canula

Take blood for Grouping & FBC , coagulation

profile,Liver & renal function

•

•

• Severe bleeding or fetal distress: urgent delivery of baby irrespective of gestational age

Management of APH Management of APH

• Volume should be replaced by

Crystalloid / colloid until blood is available

• Severe bleeding or feotal distress: Urgent delivery of baby irrespective of gestational age

Management of APH Management of APH cont… cont… History

• Obtain a history if patient’s condition allow including: • Colour and consistency of bleeding • Quantity and rate of blood loss • Precipitating factors i.e. Sexual intercourse, Vaginal examination • Degree of pain, site and type • Placental location-review ultrasound report if available • Ascertain foetal movements • Ascertain blood group

Management of APH Management of APH cont…cont…Examination

• Assess maternal and foetal well-being Pallor, record temperature, pulse and BP • Perform abdominal examination Note areas of tenderness and hypertonicity Determine gestational age of foetus,

presentation and position, auscultate foetal heart• No vaginal examination should be attempted at

least until a placenta praevia is excluded• Do speculum examination to assess cervix / bleeding

and exclude local lesions  

Management of APH Management of APH cont…cont…

Investigations• Arrange urgent ultrasound scan• Foetal monitoring Continuos electronic foetal

monitoring is indicated

Further management of Further management of APHAPH

• Further management will depend on Cause of the APH Extent of bleeding Presence of feotal distress Gestational age and feotal

maturity

Placenta praevia - Placenta praevia - ManagementManagement

1.Near term / Term• Delivery is considered Types I and II - May be able to deliver vaginally

Types III and IV - Will require

caesarean section by senior

obstetrician

Placenta praevia – Placenta praevia – Management cont…Management cont…

2.Early in pregnancy• Continuation of pregnancy better if possible

• Need bed rest• Educate patient regarding condition and risk• 3 pint of crossed matched blood should be

available till delivery• Foetal well being and growth should be

monitored• Medications may be given to prevent premature

labour- Nifidipine, Atosiban

Placental abruption – Placental abruption – Management ctdManagement ctd

• Small abruption Conservative management

depending on gestational age Careful monitoring of feotal

condition

Placental abruption - Placental abruption - managementmanagement

• Moderate or severe placental abruption:• Restore blood loss• Ideally measure central venous pressure (CVP)

and adjust transfusion accordingly• Prevent coagulopathy• Monitor urinary output • Delivery 1.Caesarean section 2.Vaginal If coagulopathy present If feotus is not compromised If feotus is dead

Vasa Previa Vasa Previa managementmanagement

• Urgent delivery Most of the time urgent LSCS• Neonatologist involvement• Aggressive resuscitation of the baby

with blood transfusion following delivery

Prognosis of APHPrognosis of APH

• Feotus may die from hypoxia during heavy bleeding

• Perinatal mortality more than 50 per 1000 even with tertiary care facilities

• High rates of maternal mortality