This document discusses antepartum hemorrhage (APH), or bleeding from the female genital tract between 20-28 weeks of pregnancy until delivery. It defines the different types of APH such as simple or complicated, and describes the main causes - placenta previa, abruptio placentae, and vasa previa. Risk factors, signs and symptoms, investigations, and management are outlined for each condition. Complications for both mother and baby are also noted. The key is to assess the ABCs, monitor the fetus, provide supportive care or intervention as needed depending on the etiology and severity of bleeding.

1. ANTEPARTUM
HEMORRHAGE
House Surgeon WYO

2. • Bleeding from female genital tract after the 24th week of
pregnancy before the birth of the baby (some define from 20th
week and some up to 28th week )
WHO
• “ Bleeding from the female genital tract anytime after fetal viability
but before delivery”
• Incidence : 3-5% of all pregnancies
3 times more common in multiparous than nuliparous women .

3. Antepartum Hemorrhage: Types
• Simple:
• Local
• Vagina – Trauma
• Cervical – Infection or tumor
- Blood dyscrasias
• Thrombocytopenia
• Anticoagulants
• Complicated:
• Abruptio Placentae
• Placental praevia
• Vasa Praevia

4. Placenta - Physiology and function
. Fetus entirely dependent on placenta
until birth.
. Maternal and fetal blood kept separate
by placental barrier.
. Protects the infant from infection and
harmful substances.
. Acts as endocrine organ - makes
hormones to maintain pregnancy.
. Made of 12-20 cotyledons.
. Fetal blood transported to placenta via
two umbilical arteries.

5. . Umbilical arteries get smaller and
become arterioles then villi.
. Villi suspended in pools of
maternal blood in the lacunae.
. Fetal blood returns to fetus via
umbilical vein.

6. ABRUPTIO PLACENTA
NORMAL PLACENTA
PLACENTA ACCRETA
PLACENTA
PREVIA

7. Placenta praevia
Abnormally implanted placenta placed totally
or partially in the lower segment of the uterus,
rather than in the fundus.
When the cervix begins to dilate and efface the
placenta separates, allowing
bleeding form the open vessels.

8. Placenta praevia: types
• Complete placenta praevia
• Partial placenta praevia
• Marginal placenta praevia (placenta approaching the border
of os )

9. Grading of placenta praevia:
• Grade I – The placenta is in the lower segment, but the
lower edge does not reach the internal os.
• Grade II – The lower edge of the low-lying placenta
reaches, but does not cover the internal os.
• Grade III – The placenta covers the internal os but not
cover when os is dilated
• Grade IV – The placenta covers and entirely surrounds the
internal os even though os is fully dilated.

10. TYPES OF PLACENTA PREVIA
LOW LYING MARGINAL
TOTAL
PARTIAL

11. Placenta praevia : Risk factors
• Previous placenta praevia.
• Multiple pregnancies- due to the placenta occupying a
large surface area.
• Mutiparity
• Cigarette smoking
• Increased maternal age
• Endometritis
• Previous caesarean section

12. Presentation
Symptoms
• Sudden, Painless ,Causeless recurrent vaginal bleeding (color
Bright Red )
• No history of trauma to abdomen
• Triggering factors may be present (e.g. Bleeding post coitus )
• Anemia symptoms which is proportionate visible blood loss
(Tiredness, lassitude, weakness, dyspnoea, palpatation , pallor )
• Fetal distress but more dangerous for mother
• In excessive blood loss >>> symptoms of shock ( faintness ,
tachycardia , hypotension , sweating ,cold & clammy
extremities, oliguria, syncope

13. Physical Exam
• Digital exam is contraindicated
• Breech presentation or unstable lie or high presenting part
• Soft and relaxed, non tender uterus which is proportionate to
gestational age
• Concurrent contractions with bleeding are present

14. Investigations
• Laboratory studies
• CBC
• PT & APTT
• Imaging studies
• Transvaginal ultrasonography
• Transabdominal ultrasonography

15. Cervix
Placenta
Uterus
A PLACENTA WHICH HAS IMPLANTED OVER THE OS

16. Midwifery Actions-Woman presents with painless bleeding
• Calm attitude
• Inform Obstetric staff
• T, P, BP
• CTG
• Palpation
• NO Vaginal Examination until location of placenta has been
confirmed by ultrasound
• Take history of amount of blood loss, explore possible causes.
• Establish venous access
• Take blood for Group & Matching, Full blood count, clotting IV
fluids as prescribed

17. Midwifery Actions
• Consider anxieties of woman in hospital with other children to care
for
• Possible visit to the neonatal unit
• Include in discussions surrounding expectant birth date of the baby

18. Management
• Assessing the airways, breathing, circulation
• Cannula inserted for Drug administration ,Blood sampling ,IV fluid
administration
• In the absences of heavy vaginal bleeding , not in labour( B4 37 wk )
and bleeding stop spontaneously >>> Expectant Management
• Ensure blood available
• Monitor for anemia
• Vitamins and Iron supplements should be taken
• Anti D if Rh Neg
• Steroids for fetal lung development

19. • If uncomplicated pregnancy no need of intervention
• If needed tocolytics may be considered to administer
antenatal steroids
• Types of Tocolytics(anti-contraction medications or labour
represents )
B2 agonist
Calcium channel blockers
Oxytocin antagonist – Atosiban
NSAIDs
Before the delivery the following should be consulted
• Obstetric anesthesiologist
• Interventional radiologist
• General surgeon
• Urologist

20. • Termination of Expectant Management when fetus is mature or
dead or not compatible for life & mother is in danger ( heavy
vaginal bleeding )
Normal spontaneous Vaginal delivery ????
OR
Elective LSCS????

21. Induction of labour
• Is possible in:
 

22. Possible complications
• Uncontrollable bleeding
• Anaemia
• Infection
• Renal failure due to severe shock
• Hysterectomy
• Sheehan’s syndrome as a result of severe shock
(Damage to the pituitary gland – hypopituitarism)
• Fetal hypoxia
• Premature birth
• Fetal death
• Psychological effects

24. Abruptio Placentae
Separation of the normally
situated placenta from its uterine site
of implantation after 20 weeks gestation,
but before delivery of the placenta.
( Premature separation of the placenta )

25. Placental abruption: types
• Placental abruption can be broadly classified into
two types:
• Revealed
• Concealed
• Mixed

26. Classification
• Placental Grades :
A . Grade 0 - Patient asymptomatic.
Small retroperitoneal clot seen after delivery
B. Grade 1 - Vaginal bleeding,
may have abdominal tenderness or slight uterine
tetany ,mom and baby not in distress.
C. Grade 2 - Uterine tenderness, tetany with or without
evidence of bleeding, baby shows signs of
distress.
D. Grade 3 - Uterine tetany , severe bleeding may not be
visible. Baby is dead.
Mom often has coagulopathy.

27. Placental Abruption

28. Risk factors of Abruptio Placentae
• Trauma (Fall, accident, ECV )
• Grandmutipra , Multiparity , Maternal hypertension
• Sudden decompression of uterus – release of hydramnios
( after delivery of 1 st twin )
• -Polyhydramnios with rapid decompression on membrane rupture
• -cocaine use, tobacco use
• -PPROM
• -short umbilical cord , IUGR
• Anti-coagulant threapy

29. Presentation
• Symptoms
• Vaginal bleeding - 80% ( Red or brown loss PV)
• Abdominal or back pain and uterine tenderness - 70%
• Abnormal uterine contractions (eg hypertonic, high
frequency) - 35%
• Idiopathic premature labor - 25%
• Tense, firm uterus tender to palpate
• Signs of shock
• Reduced or excessive fetal movements
• Fetal distress - 60% or no fetal heart
• Fetal death – 15%

30. • Physical Examination
• Should be done after stabilizing the patient
• Ultrasound should be done first to assess the location
of placenta. Only then should a digital pelvic exam be
conducted
• Profuse bleeding in waves
• Uterine contraction / Uterine hypertonic
• Shock
• Absence of fetal heart sounds
• Increased fundal height (due to hematoma)

31. Investigations
• Laboratory studies
• CBC
• PT & APTT
• Fibrinogen levels
• BUN / creatinine
• Imaging studies
• Transvaginal ultrasonography
• Transabdominal ultrasonography

32. Management
• Stabilize the woman
• T, P, BP
• Full history
• IV access
• Blood for group & hold, Full blood count, Coag & Kleihauer if rh neg
Caesarean Section Expectant Management
• If unstoppable labour • If preterm
• If fetal distress • No profuse haemorrhage
• If life threatening Haemorrhage • Not life threatening
• No fetal distress

33. Management
• Vitamins and Iron supplements should be taken
• Initial management
• Transfusion, correction of coagulopathy and Rh immune
globulin if needed
• Cesarian section preferable mode of delivery
• Vertical incision
• Hysterectomy might be needed if severe blood loss
• Tocolytics may be used in case of preterm delivery only if
• Hemodynamically stable
• No fetal distress
• Preterm fetus may benefit from corticosteroid therapy
• In case of fetal death mode of delivery is SVD

34. Complications of Abruptio placentae - Maternal
Can
lead to
DIC

35. Complications of Abruptio placentae –
Fetal
• Fetal complications include
• Hypoxia or hypoxic-ischemic encephalopathy (HIE)
• growth retardation
• CNS abnormalities
• Intra uterine death.

36. Abruptio Placentae Placenta Previa
Pain Abdominal pain, low back pain Painless unless in labour
Uterus Tender, irritable Nontender, soft (unless contracting)
Not associated with abnormal
Presentation Breech or high presenting part
presentation
Fetal tracing not affected since blood is
Fetus Fetal heart tracing abnormal, atypical
maternal
Shock/anemia out of proportion to Shock/anemia proportionate to blood
Shock
amount of blood seen seen
Imaging U/S cannot rule out U/S sensitive

37. Non Placental causes of APH

38. Non Placental causes of APH

39. Uterine rupture-management
• It is an emergency
• Laparotomy is urgently done
• Uterine rupture can be an antepartum or
postpartum event

40. Vasa praevia
• When vasa praevia is diagnosed antenatally, an
elective Caesarean section should be offered prior
to the onset of labour.
• In cases of vasa praevia, premature delivery is
most likely, therefore, consideration should be
given to administration of corticosteroids at 28 to
32 weeks

41. Antepartum hemorrhage
Massive bleeding
Call for help
Evaluate ABCs
Administer IV fluids
Consider transfusion
Consider CS
History and Physical Examination
Fetal monitoring
Normal Bloody Severely distressed Uterine pain ?? Inflamed cervix or
show fetus mucopurulent
discharge
Suspect Vasa
Routine Evaluation No pain or pain only Pain between Probable cervical
Previa
with contractions. contractions and infection
Non tender fundus tender fundus
Culture and treat as
appropriate
Suspect Placenta
previa
Consider abruptio
placentae Consider uterine
Immediate rupture
ultrasound
examination if Monitor fetus.
available Supportive mother
care
Urgent Cesarean Cesarean delivery if Cesarean if fetal Consider urgent
SVD if fetal death
delivery in labour distress lapartomy

42. THANK U
XO MUCH