1. Antepartum Haemorrhage
Saad Bin Zafar
Mahmood

2. Definition
 Hemorrhage from the vagina after the
24th week of gestation till end of
pregnancy
 Blood loss of greater than 300mls
 Incidence : 3-5% of all pregnancies

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

4. Abruptio Placentae
 Premature separation of the placenta.
 Pathophysiology of placental
abruption:
◦ Bleeding into the decidua basalis layer
◦ Hematoma forms causing further
placental separation
◦ Fetal blood supply is further compromised
◦ Complication - Couvelaire Uterus
(Retroplacental blood goes into the peritoneal cavity)

5. Classification
 Clinical classification
 Class 0 - Asymptomatic
 Class 1 - Mild (represents
approximately 48% of all cases)
 Class 2 - Moderate (represents
approximately 27% of all cases)
 Class 3 - Severe (represents
approximately 24% of all cases)

6. Placental abruption: types
 Placental abruption can be broadly
classified into two types:
◦ Revealed
◦ Concealed
◦ Mixed

7. Presentation
 Symptoms
◦ Vaginal bleeding - 80%
◦ Abdominal or back pain and uterine
tenderness - 70%
◦ Fetal distress - 60%
◦ Abnormal uterine contractions
(eg, hypertonic, high frequency) - 35%
◦ Idiopathic premature labor - 25%
◦ Fetal death – 15%

8. Presentation
 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 hypertonus
◦ Shock
◦ Absence of fetal heart sounds
◦ Increased fundal height (due to hematoma)

9. Risk factors of Abruptio
Placentae
◦ Maternal hypertension
◦ Maternal trauma
◦ Cigarette smoking
◦ Alcohol consumption
◦ Cocaine use
◦ Short umbilical cord
◦ Maternal age <20 or >35 years
◦ Low socioeconomic status
◦ Elevated second trimester maternal serum
alpha-fetoprotein (associated with up to a 10-
fold increased risk of abruption)
◦ Previous placental abruption

10. Investigations
 Laboratory studies
◦ CBC
◦ PT & APTT
◦ Fibrinogen levels
◦ BUN / creatinine
 Imaging studies
◦ Transvaginal ultrasonography
◦ Transabdominal ultrasonography

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

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

13. Placenta praevia
 Implantation of placenta over the internal
cervical os and therefore in front of the
presenting part
 Pathophysiology
◦ Delay in implantation of blastocyst so that it
occurs in the lower part of uterus
◦ In third trimester isthmus of uterus thins to form
lower uterine segment
◦ Placental attachment is disrupted as the area
gradually thins in preparation of the onset of
labor
◦ This leads to bleeding from the venus sinuses

14. Placenta previa: types
 Complete placenta previa
 Partial placenta previa
 Marginal placenta previa (placenta
approaching the border of os)

15. Grading of placenta previa:
 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.
 Grade IV – The placenta covers and entirely
surrounds the internal os

16. Presentation
 Symptoms
◦ Painless vaginal bleeding
◦ Bleeding stops spontaneously and recurs
with labor
◦ Malpresentation (Breech, transverse lie)
 Physical Exam
◦ Digital exam is contraindicated
◦ Uterus is soft and non tender
◦ Concurrent contractions with bleeding are
present

17. Placenta previa : Risk factors
 Previous placenta previa.
 Multiple pregnancies- due to the
placenta occupying a large surface
area.
 Cigarette smoking
 Increased maternal age
 Uterine scar (previous caesarean
section)
 Endometritis

18. Investigations
 Laboratory studies
◦ CBC
◦ PT & APTT
 Imaging studies
◦ Transvaginal ultrasonography
◦ Transabdominal ultrasonography

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

20. Differential Diagnosis
Abruptio Placentae Placenta Previa
Labour with bloody show Abruptio Placentae
Vasa previa Cervicitis
Vaginal trauma Premature rupture of membranes
Vaginitis Vaginitis
Preterm labour Preterm labour

21. Non Placental causes of APH

22. Vasa previa:
 Vasa previa is a condition when fetal
vessels traverse the fetal membranes over
the internal 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.

23. Management of Antepartum
Hemorrhage

24. Initial management
 Assessing the airways:
 Assessing the breathing:
 Assessing the circulation
 Cannula inserted for
◦ Drug adminstration
◦ Blood sampling
◦ IV fluid adminstration

25. Placenta previa
 If uncomplicated pregnancy no need of
intervention
 Vitamins and Iron supplements should be
taken
 If minimal bleeding expected management
may be continued
 If needed tocolytics may be considered to
administer antenatal steroids
 Before the delivery the following should be
consulted
◦ Obstetric anesthesiologist
◦ Interventional radiologist
◦ General surgeon
◦ Urologist

26. Placenta previa
 If placental edge is more than 2cm from
internal cervial os trial of labour can be
offered.
 If the distance is less than 2cm cesarian
section is done although an SVD can be
done
 Delivery is mostly done at 36-37 weeks
of gestation
 Low transverse uterine incision is used
 If the patient is at risk of invasive
placentation than informed consent
should be taken for cesarian
hysterectomy

27. Abruptio placentae
 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

28. Types of tocolytics
Types of Tocolytics
B2 agonist
Calcium channel blockers
Oxytocin antagonist – Atosiban
NSAIDs

29. Uterine rupture-management
 It is an emergency
 Laprotomy is urgently done
 Uterine rupture can be an antepartum
or postpartum event

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

31. 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 Uterine pain ?? Inflamed cervix or
show distressed fetus mucopurulent
discharge
Routine Suspect Vasa
No pain or pain only Pain between Probable cervical
Evaluation 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 Cesarean if fetal Consider urgent
SVD if fetal death
delivery if in labour distress lapartomy