ANTEPARTUM HAEMORRHAGE

DEFINITION:
Bleeding from the genital tract after the

28th week of pregnancy but before the

birth of the baby.

ANTEPARTUM HAEMORRHAGE
EPIDEMIOLOGY:

Overall incidence of 3-5%.

3X more common in multiparous women.

CAUSES OF APH
PLACENTAL BLEEDING EXTRA-PLACENTAL BLEEDING

PLACENTA PRAEVIA ABRUPTIO PLACENTAE

CERVICAL POLYPS

CARCINOMA OF CERVIX

LOCAL TRAUMA

VULVAL VARICOSE VEINS

CAUSES OF ANTEPARTUM HAEMORRHAGE

1)

Placenta Praevia

2) 3)

Abruptio Placentae Indeterminate

PLACENTA PRAEVIA
DEFINITION: The implantation of placenta over or near the internal os of the cervix.

T2 + T3 4 main types

CLASSIFICATI ON

A-ANTERIOR WALL OF UTERUS B-POSTERIOR WALL OF UTERUS

TYPE 4
4

TYPE 3
3A 3B 2B

TYPE 2
2A 1A

TYPE 1
1B

MAJOR

MINOR

AETIOLOG Y
UNKNOWN! However some theories are postulated regarding this:
1. 2. 3.

DROPPING DOWN THEORY

PERSISTENCE OF CHORIONIC THEORY

DEFECTIVE DECIDUA

4.

BIG SURFACE AREA OF PLACENTA

HIGH RISK FACTORS

Multiparity

Advanced maternal age ( 35)

Previous Caesarean delivery Previous abortion Previous curettage Scarring of the uterus Smoking

PRESENTATIO N

SUDDEN VAGINAL BLEEDING IN T3.

SYMPTOMS: Painless and causeless recurrent vaginal bleeding. May be precipated by coitus Bright red Warning Haemorrhages May/May not have contractions simultaneously with the bleeding SIGNS: Vital signs degree of haemorrhage General condition of anaemia proportional to visible blood loss

GENERAL FEATURES

Features of shock and degree of anaemia proportional to amt. of blood loss. Pulse and BP - hypotensive and tachycardic if in shock

SPECIFIC FEATURES
ABDOMINAL:

Non-tender Symphysiofundal height usually corresponds with period of gestation Lie of fetus = Unstable or Normal Presenting part high above pelvic brim Fetal Heart Sound usually present

VULVA:

Bleeding stil occurring or has ceased Character of blood NB:VAGINAL EXAMINATION IS DANGEROUS SINCE IT MAY PRECIPITATE HEAVY BLEEDING.

DIAGNOSI S

CLINICAL: Internal Examination - double set up examination. Direct visualization during Caesarian Section. Examination of Placenta following Vaginal Delivery.

LOCALIZATION OF THE PLACENTA:(CONFIRMATION) Transabdominal Ultrasound Transvaginal Ultrasound Translabial Ultrasound Transperineal Ultrasound MRI

PREVENTIO N

Adequate Antenatal Care Antenatal diagnosis of Low Lying Placenta at 20 weeks with routine USS.Repeat at 34 weeks for confirmation.

Do Not ignore Warning Haemorrhages

ADMISSION TO HOSPITAL
ALL APH CASES MUST BE ADMITTED AND MANAGED AT A TERTIARY HEALTH CARE UNIT WITH FACILITIES FOR:

Ultrasound Scan Blood transfusions Emergency Caesarian Sections Neonatal intensive care unit

EMERGENCY MANAGEMENT

IV line with a wide bore cannula Isotonic fluids until blood available Blood tests: Group & Cross Match, CBC (Hb) KLEIHAUER-BETKE test (Anti D given if Rh -)

FORMULATION OF TREATMENT
DEPENDS UPON :

DURATION OF PREGNANCY FETAL AND MATERNAL STATUS EXTENT OF HAEMORRHAGE

EXPECTANT TREATMENT
Prerequisites: 1. Availability of Cross Matched Blood for transfusion 2. Facilities for Caesarian Section 3. Maternal Anemia Corrected Selection: Hb>10g/dl Gestational period less than 38 weeks Active Vaginal bleed absent Fetal well being shown by ultrasound

CONDUC T

Patient under constant supervision

Bedrest
Routine blood investigations Blood loss monitored by sanitary pad count Fetal surveillance by ultrasound 2-3 week intervals Supplementary haematinics Use of tocolysis (MgSo4)

INDICATIONS: 1. Bleeding at or after 38 weeks 2. Patient is in labour 3. Patient is in an exsanguinated state at time of admission 4. Bleeding continues with moderate degree 5. Baby is dead or congenitally deformed CONDUCT: Caesarian Section-USS evidence of placenta preavia where placental edge is 2cm from internal os. Vaginal Delivery-considered where placental edge is 2-3cm from internal cervical os

DEFINITIVE TREATMENT

COMPLICATIO NS
MATERNAL: DURING PREGNANCYShock Malpresentation Premature Labour DURING LABOUREarly rupture or membrane Cord prolapse Slow dilatation Intraparum haemorrhage Postpartum haemorrhage Retained placenta FETAL: Low birth weight Asphyxia IUGR Congenital malformation Fetal anemia Rh isoimmunization PUERPERIUM: Sepsis is increased due to Increased operative interference Placental site near to vagina Anemia and devitalized state of patient

CAUSES OF ANTEPARTUM HAEMORRHAGE

1)

Placenta Praevia

2) 3)

Abruptio Placentae Indeterminate

2) Abruptio Placentae
Defintion: Separation before delivery of a normally sited placenta i.e. one in the upper uterine segment

BIRTHS = 30,987
DEATHS = 860 Perinatal mortality rate = 27.7/1000 births
NUMBER OF PERINATAL DEATHS

391
LEADING CAUSES OF EARLY NEONATAL DEATHS: 1) Respiratory Distress Syndrome 2) Birth asphyxia 3) Sepsis

469
LEADING CAUSES OF FETAL DEATHS: 1) Hypertensive disorders of pregnancy 2) Abruptio Placentae 3) Diabetes Mellitus 4) Intrapartum fetal distress 5) Congenital anomalies

RISK FACTORS
MATERNAL: Age Parity Hypertensive STRUCTURAL: Sudden uterine decompression Uterine abnormalities

disorders of pregnancy
Cigarette smoking Cocaine use Serum AFP Thrombophilias

PPROM
Retroplacental leiomyoma Short umbilical cord EXTERNAL: Physical trauma Cephalic Version

PATHOPHYSIOLOGY
Vasospasm of the uterine vessels

Rupture of arterioles in decidua basalis

Blood beneath decidua basalis

Dissection under placenta

Degree of separation extends Myometrial muscles to the serosa Amniotic cavity Cervix in the vagina

Uterus contracts and appears bruised, purplish and mottled (Couvelaire uterus)

VARIETIES
Concealed / Internal Revealed / External

Mixed

SYMPTOMS

Abdominal Pain:

Onset = sudden Nature = constant (not contractile) Intensity = progressively becomes worse Spreads

Vaginal bleeding (depends on variety)

Weakness collapse

GENERAL FEATURES
Tachycardia Low-volume pulse BP = normal or slightly elevated (If mild) Shock (If severe separation occurred)

Signs of DIC (bleeding, blood clots, bruising, bp decreased)

SPECIFIC FEATURES
UTERUS:
-Tender

- Hard (Woody hard consistency)

FETUS: - Parts difficult to palpate - Heart inaudible

STRUCTURAL CLASSIFICATION
ABRUPTIO PLACENTAE

EXTENT OF SEPARATION

LOCATION OF SEPARATION

PARTIAL

COMPLETE

MARGINAL

CENTRAL

S T R U C T U R A L

C L A S S I F I C A T I O N

CLINICAL CLASSIFICATION

Class 0 - Asymptomatic Class 1 - Mild (48%)

Class 2 - Moderate (27%)

Class 3 - Severe (24%)
ing incidence: 1 2 3 0

CLASS 0 Diagnosis made retrospec tively by finding an organized blood clot or a depressed area on a delivered placenta

CLASS 1 (mild) No vaginal bleeding to mild vaginal bleeding Normal maternal BP and heart rate

CLASS 2 (moderate)

CLASS 3 (severe)

No vaginal bleeding to No vaginal bleeding moderate vaginal to heavy vaginal bleeding bleeding Maternal tachycardia with orthostatic changes in BP and heart rate Moderate to severe uterine tenderness with possible tetanic contractions Hypofibrinogenemia (ie, 50-250 mg/dL) Maternal shock

Slightly tender uterus

Very painful tetanic uterus

No coagulopathy

Coagulopathy

Hypofibrinogenemia (ie, < 150 mg/dL)

Fetal death

No fetal distress

Fetal distress

DIAGNOSIS

Moderate or severe: evident

Mild: Clinical Dx +/- Ultrasonography Difficult to differentiate placenta praevia and abruptio placentae

DIAGNOSIS OF EXCLUSION
SPECULUM: No local causes

ULTRASONOGRAPHY: Requires great deal of operator skill Presence of retroplacental clots Failure to show placenta praevia

DIFFERENTIALS

Blunt Abdominal Trauma Acute Appendicitis DIC Ovarian Cysts Ovarian Torsion Placenta Previa Delivery Ectopic Pregnancy Preeclampsia Shock: Haemorrhagic/ Hypovolemic Vaginitis

COMPLICATIONS
MATERNAL: DIC FETAL: Anoxia

Renal failure
Postpartum Haemorrhage Hypertension

Death

MANAGEMENT
MILD < 38/40: -No deterioration of clinical condition + Resolution of symptoms Conservative Mx 38/40: - Expedite delivery Route = Vaginal Induction of Labour = Amniotomy + Syntocinon Infusion CTG MODERATE OR SEVERE Maintain blood volume Expedite delivery Prevent DIC: Adequate transfusion of whole blood Treating DIC: Adequate transfusion of whole blood + cryoprecipitate + fresh frozen plasma OR packed red cells + platelets + fresh frozen plasma

MANAGEMENT
BLOOD INVESTIGATIONS: CBC PT, PTT Group & Cross-match (Reserve 4 units of fresh whole blood)

Fibrinogen, U&Es
Kleihauer-Betke test

MANAGEMENT
VE + AMNIOTOMY:
1) Induce/ accelerate labour 2) Decrease intra-uterine pressure reduce uterine tension 3) Internal fetal heart rate monitoring

MANAGEMENT
MOST CRITICAL TIME for patient = during 3rd stage of labour

IV Syntocinon with birth of anterior shoulder Continue with a HIGH-DOSE SYNTOCINON INFUSION: Couvelaire uterus contracts + retracts poorly during postpartum period postpartum haemorrhage

CAUSES OF ANTEPARTUM HAEMORRHAGE

1)

Placenta Praevia

2) 3)

Abruptio Placentae Indeterminate

AETIOLOGY
Vasa Previa Bloody show Trauma Uterine rupture Marginal sinus rupture

CAUSES TO RULE OUT

EXTRAPLACENTAL: GI bleeds Urinary tract bleeds

LOWER GENITAL TRACT: Vulval varicose veins Vaginal lacerations Vulvovaginal infections Cervical polyp Cervicitis Cervical carcinoma.

1) VASA PREVIA
Definition: An obstetric complication whereby fetal vessels cross or run in close proximity to the internal cervical os or lower uterine segment and are at increased risk for rupture due to lack of supporting membranes, rupture of membranes, labour and advance of fetal head.
If rupture occurs, bleeding from feto-maternal circulation and fetal exsanguination occurs

ASSOCIATED CONDITIONS

vilamentous cord insertion low lying placenta bi-lobed or multi-lobed placenta succenturiate lobed placenta multiple pregnancies pregnancies resulting from IVF

DIAGNOSIS

Triad = membrane rupture, painless vaginal bleeding, fetal bradycardia/ heart rate abnormalities

US with colour flow Doppler vessel crossing the membranes over the internal cervical os The kleihauer betke or apt test fetal Hb
Fetal blood loss condition deadly (95%)

MANAGEMENT

The international vasa previa foundation recommends PELVIC REST Hospitalization in the T3 (30-32 weeks) risk of rupture Delivery by C-section at 35 weeks highest survival rate with VP

Immediate blood transfusion and aggressive resuscitation of the infant in the event of a rupture
Steroids promote lung maturity

2) BLOODY SHOW
Definition: Passage of a small amount of blood or blood tinged mucus through the vagina. It occurs just before the onset of labour or in early labour as cervical changes free mucus and blood occupied in the cervical glands or os.

3) UTERINE RUPTURE
Definition: Breach in the integrity of the myometrial wall
UTERINE RUPTURE

COMPLETE Spillage into the peritoneal cavity or broad ligament

INCOMPLETE
Peritoneum is still intact

RISK FACTORS

previous uterine incisions high parity abnormal fetal presentation uterine overdistension-fetal enlargement eg hydrocephalus, macrosomnia

delivery complications eg. Forceps delivery, breech extraction

PRESENTATION
Initially subtle Old caesarean scar dehiscence Sudden fetal heart decelerations abdominal pain PV bleed diaphragmatic irritation loss of fetal station hypovolemic shock cessation of uterine contractions

Haemorrhage + Infection fetal death and maternal morbidity

MANAGEMENT

stabilize maternal hemodynamics

emergency laparotomy with Caesarean delivery to repair defect of hysterectomy

antibiotics

INFECTIONS

Cervicitis STIs (Chlamydia, gonorrhea, syphilis) IUDs allergic reactions to spermicides or condoms bleeding. To stop the bleeding treat underlying cause ie. Role of antibiotics in infections.

Vulvovaginal infections: STIs, allergies to tampons

CERVICAL POLYPS
Definition: Benign tumour of cervical canal commonly associated with inflammation of the cervix but uncommon in pregnancy.

Can be seen during pelvic examination. Biopsy determines nature of the cells. Management: controlling symptoms of anaemia from bleeding.

CERVICAL CANCER

rare cause of APH Staging must be determined and decision must be made on whether to continue with the pregnancy. If pregnancy continues, C-section is done when the fetus is able to survive outside the womb and then treatment is started right away.

VULVAR VARICOSE VEINS

PRESENTATION

Most are asymptomatic

Symptoms: - anxiety - pain - heaviness - discomfort during walking - dyspareunia - pruritus - thrombosis - bleeding
Normally resolves after pregnancy.

REFERENCES

Textbook of Obstetrics, 1988. Published by Lexicon Trinidad Ltd., 3rd Edition, Trinidad. 2008.

Obstetrics by Ten Teachers, 2006. Published by Hodder Arnold, 19th Edition, London. 2011.
An Audit of Perinatal Mortality, West Indian Med J 2001 Sep;50(3):243-4, Bassaw B, Roopnarinesingh, Sirjusingh A.