Bleeding in Antepartum

early
Pregnancy hemorrhage
Bleeding
(APH)
In
Pregnancy

Post partum
Haemorrhage
(PPH)
 ANTEPARTUM HAEMORRHAGE

Definition

Antepartum hemorrhage (APH, prepartum hemorrhage) is

bleeding from or into the genital tract, occurring from 24+0
weeks of pregnancy and prior to the birth of the baby

(RCOG 2011)
Epidemiology

Affects 3-5% of all pregnancies

1/5th of preterm babies born in association of APH
occurs in 2.8/1000 singleton pregnancies & 3.9/1000 twin pregnancies

This definition of gestational age is based on the UK professional guidance for viability
cut-off point of 24 weeks
 IMPORTANCE

Obstetric emergency

Attention should be sought immediately

If left untreated can lead to death of the mother &/or fetus

Management reduce the risk of premature delivery & maternal/

perinatal morbidity/mortality
 CAUSES

Placental abruption - Most common pathological cause (1/100)

Placenta previa - Second most common pathological cause (1/200)

Vasa previa- Often difficult to diagnose, frequently leads to fetal demise

(1/2000-3000)

Uterine rupture - (<1% in scarred uterus)

 CAUSES CONT.…

Bleeding from the lower genital

tract Cervical bleeding – Cervicitis
Cervical neoplasm
Cervical polyp
Cervical ectropion
Vaginal bleeding - Trauma
Neoplasm
Vulval varices
Infection

Inherited bleeding problems - Very rare, 1 in 10,000 women

Unexplained - No definite cause is diagnosed in about 40% of APH

 BLEEDING THAT MAY BE CONFUSED WITH VAGINAL BLEEDING

GI bleed - Hemorrhoids, inflammatory bowel disease, etc.

Urinary tract bleed – UTI, etc.

 COMPLICATIONS OF APH

Maternal complications Fetal complications

•Anaemia •Fetal hypoxia
•Infection •Fetal growth restriction
•Maternal shock •Prematurity (iatrogenic & spontaneous)

•Renal tubular necrosis •Fetal death

•Consumptive coagulopathy
•Postpartum haemorrhage
•Prolonged hospital stay
•Psychological sequelae
•Complications of blood transfusion
 PLACENTA PREVIA

Definition
Insertion of the placenta, partially or completely, in the
lower segment of the uterus
 RISK FACTORS FOR PLACENTA
PREVIA

Previous placenta previa (adjusted OR 9.7) Rasmussen 2000

Previous Caesarean section (RR 2.6, 95% CI 2.3, 3.0) Ananth 1997
•One previous Caesarean section OR 2.2 (95% CI 1.4, 3.4) Hendricks1999
•Two previous Caesarean sections OR 4.1 (95% CI 1.9, 8.8)
•Three previous Caesarean sections OR 22.4 (95% CI 6.4, 78.3)

Previous termination of pregnancy

Multiparity

Advanced maternal age (>40 years)

Multiple pregnancy
 CONT.…

Deficient endometrium due to presence or history of:

•Uterine scar
•Endometritis
•Manual removal of placenta
•Curettage
•Submucous fibroid

Assisted conception

Smoking

(RCOG2011)
 DEGREES OF PLACENTA PREVIA

Four types:
Type I: Placenta encroaches
lower segment but does not reach
the internal os
Type II: Reaches internal os but
does not cover it
Type III: Covers part of the internal
os
Type IV: Completely covers the os,
even when the cervix is dilated
 PLACENTA PREVIA- CLINICAL FEATURES

Recurrent painless vaginal bleeding (not always)

Abdominal findings
Uterus- soft, relaxed, non tender & proportionate to POG
Contraction may be palpated
Abnormal presentations
High floating head in cephalic presentation
Maternal cardiovascular compromise
Fetal condition satisfactory until severe maternal compromise
Vulval inspection- presence of bleeding, character of blood
Vaginal examination- should not be done
 INVESTIGATION

Diagnosis by ultrasound scan (USS) showing placenta coming in to

lower segment

Transvaginal ultrasound (TVS) is safe & is more accurate than

transabdominal ultrasound (TAS) in locating placenta

Leading edge within 2 cm from internal os or completely covering internal

os is incompatible with normal vaginal delivery

Transperineal (TPS)

Colour Doppler flow study

MRI
 CONFIRMATION OF DIAGNOSIS

Localisation of placenta Clinical

Transabdominal By internal examination (double
ultrasonography set up)
Transvaginal ultrasonography Direct visualization during CS
Transperineal Examination of placenta
ultrasonography following delivery
Colour doppler flow study
MRI
 PLACENTA PREVIA- COMPLICATIONS

Maternal

Major hemorrhage, shock & death

Anemia in chronic hemorrhage
Morbid adherence of Placenta : placenta accreta complicates approximately 10%
of placenta previa cases
Sensitization of mother for fetal blood in Rh (-)
patients Post partum hemorrhage
Renal tubular necrosis & acute renal failure
 PLACENTA PREVIA- COMPLICATIONS CONT….

Fetal
Prematurity
Low birth weight
Chronic & acute fetal hypoxia
IUD
Congenital malformation- 3 times more common
 PLACENTAL ABRUPTION

Definition

Premature separation of a normally

situated placenta in a viable fetus

Clinician should have high index of suspicion for diagnosis

 RISK FACTORS FOR PLACENTAL ABRUPTION

The most predictive is abruption in previous pregnancy

A large observational study from Norway reported a 4.4% incidence of recurrent

abruption (adjusted OR 7.8, 95% CI 6.5-9.2).Rasmussen et al 2009

Abruption recurs in 19-25% of women who have had two previous pregnancies
complicated by abruption.(Tikkanen 2010)
 RISK FACTORS FOR PLACENTAL ABRUPTION

Increased age and parity

Vascular diseases: hypertension in pregnancy, renal disease, SLE &

APS

Mechanical factors: Trauma, amniocentesis, sudden decompression of

uterus, polyhydramnios, multiple pregnancy

Smoking, cocaine use

Uterine myoma, septum

Supine hypotension syndrome

 PATHOPHYSIOLOGY

Spasm of vessels in uteroplacental bed (decidual spiral artery) → anoxic

endothelial damage → rupture of vessels & hemorrhage in decidua basalis

→

decidua splits → decidual hematoma (retroplacental) → separation,

compression, destruction of the adjacent placenta

Large retroplacental clot

 TYPES OF ABRUPTION

Concealed abruption

Revealed abruption

Mixed type
 CLASSIFICATION OF PLACENTAL
ABRUPTION

Grade 0- Asymptomatic – small retroplacental clot

Grade 1 (40%) - External vaginal bleeding present. Uterine tenderness and

tetany may be present. NO SIGN OF MATERNAL SHOCK OR FETAL DISTRESS

Grade 2 (45%) - External vaginal bleeding may or may not be present.

NO SIGNS OF MATERNAL SHOCK, BUT FETAL DISTRESS IS PRESENT

Grade 3 (15%) - External bleeding may or may not be present. Marked

uterine tetany, a board-like rigidity on palpation. Persistent abdominal pain,
MATERNAL SHOCK and fetal distress are present. Coagulopathy may become
evident in 30% of cases.
 DIAGNOSIS- CLINICAL FEATURES

Painful vaginal bleeding

Pain- usually continuous

Mild type Severe type

Abruption≤ 1/3 Abruption > 1/3
Vaginal bleeding may Large retroplacental hematoma
be present or absent Vaginal bleeding associated with

persistent abdominal pain

Tenderness on the uterus
“Woody” hard uterus
Change of fetal heart rate –
CTG changes
Features of hypovolemic shock
 COMPLICATIONS OF PLACENTAL ABRUPTION

Maternal

Sensitization of Rh(-) mother for fetal

blood Amnionic fluid embolism Post partum
hemorrhage
Hypovolemic shock
Renal tubular necrosis & acute renal failure
Disseminated intravascular coagulopathy
(DIC) Puerperal sepsis
Sheehan’s syndrome
Maternal death
 COMPLICATIONS OF PLACENTAL
ABRUPTION

Fetal

Prematurity
IUGR in chronic abruption
Hypoxic ischemic encephalopathy
Cerebral palsy
Fetal death
 INVESTIGATIONS

Ultrasonography
Mainly to exclude placenta
previa Can detect
• Retroplacental hematoma
• Fetal viability
Most of the time findings will be negative
Negative findings does not exclude placental abruption

CTG – Sinusoidal pattern, Fetal tachycardia or bradycardia

Laboratory investigations
Investigation for Consumptive coagulopathy – Platelet count/BT/CT/PT/INR &
APTT
Liver and Renal function tests
 VASA PRAEVIA

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

Rupture of membranes lead to damage of the fetal vessels leading to

exsanguination and death

High fetal mortality (50-75%)

 RISK FACTORS OF VASA PREVIA

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
 DIAGNOSIS - VASA PRAEVIA

Moderate vaginal bleeding + fetal distress

Vessels may be palpable through dilated cervix
Vessels may be visible on ultrasound (TV colour Doppler
ultrasound) Difficult to distinguish from abruption
Can look for fetal Hb (Kleihauer-Betke test) or nucleated RBC’s in shed
blood Tachycardia or bradycardia in CTG
Management of APH
 MANAGEMENT OF APH

Advised to report all vaginal bleeding to antenatal care provider

Admit to hospital for clinical assessment & management
Senior staff must be involved – Senior obstetrician, anesthetist,
neonatologist May need resuscitation measures if in shock or severe bleeding
Airway(A), breathing(B) &
circulation(C) Two wide bore cannula
Take blood for Grouping, CBC, coagulation profile, Liver & renal function
Volume should be replaced by Crystalloid /colloid until blood is available
Severe bleeding or fetal distress: Urgent delivery of baby irrespective
of gestational age

MOTHER IS THE PRIORITY IN ABOVE MENTIONED CONDITION

 MANAGEMENT OF APH

What is the role of clinical assessment in women presenting with an APH?

To establish whether urgent intervention is required to manage maternal

or fetal compromise

The process of TRIAGE includes –

•history taking to assess coexisting symptoms such as

pain •an assessment of the extent of vaginal bleeding
•cardiovascular condition of mother •assessment of fetal
well-being
 MANAGEMENT OF APH CONT…

History

Obtain history if no maternal compromise –

Colour and consistency of bleeding

Quantity & 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 fetal movements
Ascertain blood group
Previous cervical smear history if available
 MANAGEMENT OF APH CONT…

Examination
To assess amount & cause of APH

Assess maternal & fetal well-being

Pallor, record temperature, pulse &
BP Perform abdominal examination
• Note areas of tenderness & hypertonicity
• Determine gestational age of fetus, presentation
• & position, auscultate fetal heart
No vaginal examination should be attempted at least until placenta previa
is excluded
Do speculum examination to assess cervix / bleeding & exclude local lesions
 MANAGEMENT OF APH CONT…

Investigations

Arrange urgent ultrasound scan

Does not exclude abruption
Glantz and colleagues reported the sensitivity, specificity,
and positive and negative predictive values of
ultrasonography for placental abruption to be 24%, 96%,
88%, and 53%, respectively. Glantz C et al 2002

Fetal monitoring
Continuous electronic fetal monitoring indicated
where knowledge of fetal condition influence timing &
mode of delivery
 MANAGEMENT OF APH CONT…

Rhesus negative woman should have a Kleihauer test

& be given prophylactic anti-D immunoglobulin

For preterm delivery between 24+0 & 34+6 weeks POG, antenatal
corticosteroids - to promote fetal lung maturity (RCOG 2011)
• Betamethasone
• Dexamethasone
 MANAGEMENT OF APH CONT…

Role of tocolytic therapy in women presenting with APH having uterine

activity –

• preterm needing transfer to hospital with NICU facility

• incomplete course of corticosteroids

Calcium antagonist (Nifedipine) best avoided with cases of maternal hypotension

Drug of choice should have fewest maternal cardiovascular side

effects (RCOG 2011)
 FURTHER MANAGEMENT OF APH

Depend on -
Cause of APH
Extent of bleeding
Presence of fetal distress
Gestational age & fetal maturity
 PLACENTA PRAEVIA - MANAGEMENT
Near term / Term
Delivery is considered
Type Ia, Ib & IIa - May be able to deliver vaginally
Type IIb, III and IV - Will require caesarean section by senior
obstetrician

Should anticipate PPH

Pregnancy below 34 weeks POG
Continuation of pregnancy better if possible
• Need bed rest
• Educate patient regarding condition & risk
• cross matched blood should be reserved till delivery
• Fetal well being & growth should be monitored –BPP,CTG,USS
• Medications may be given to prevent premature labor- Nifedipine, Atosiban
 PLACENTAL ABRUPTION – MANAGEMENT

Small abruption
Conservative management depending on gestational age
Careful monitoring of fetal condition
Moderate or severe placental abruption
•Restore blood loss
•Ideally measure central venous pressure (CVP) & adjust transfusion accordingly
•Prevent coagulopathy
•Monitor urinary output
•Delivery
1.Caesarean section
2.Vaginal- If coagulopathy present
If fetus is not compromised
If fetus is dead
 VASA PREVIA MANAGEMENT

•Urgent delivery
•Most of the time urgent LSCS
•Neonatologist involvement
•Aggressive resuscitation of the baby with blood transfusion following
delivery
 POINTS TO REMEMBER

Women presenting with APH before 37+0 weeks POG, where there is no
maternal or fetal compromise & bleeding has settled, there is no evidence
to support elective premature delivery of fetus

Following an episode of major APH that has settled or recurrent unexplained

APH it is reasonable to arrange delivery of the fetus after 37+0 weeks POG

If presenting after 37+0 weeks it is important to establish if the bleeding is

an APH or blood stained „show‟; if the blood is streaked through mucus it is
unlikely to require active intervention

in the event of major APH, IOL with aim of achieving vaginal delivery should be
considered in order to avoid adverse consequences potentially associated with
a further APH
 PROGNOSIS OF APH

Fetus may die from hypoxia during heavy bleeding

Perinatal mortality more than 50 per 1000 even with tertiary care
facilities
High rates of maternal mortality