Ante partum Hemorrhage

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Dinaol

 Obstetrics is a bloody business

Obstetrics hemorrhage is one of the five leading
cause of Maternal Death
MMR has ed markedly in dev.ed but not dev.ing
countries: Promotion of basic obstetrics care:- hospitalization
- availability of blood products
- improvement in anesthesia care
- prompt surgical intervention

Bleeding during the later half of pregnancy = 3-4%

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Ante Partum

Hemorrhage

Defn. :-

is the occurrence of vaginal bleeding (VB) after 28th

wks of
gestation and before delivery of the fetus
- VB in the 2nd trimester is also a concern = ed
PNMR

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Ethiology

Generally fall into 5-6 categories:-

1.Placenta previa
2.Abruptio placenta
3.Uterine rupture
4.Local causes
5.Unexplained causes
6.Other rare causes
- circumvallate placenta, vasa previa
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A. Placenta Previa(PP)

Definition:- is implantation of the placenta in the LUS, with

the placenta either overlying or reaching the
cervix, usually in advance of the presenting part.

Four types:1.Low lying placenta previa

Type I

2.Marginal placenta previa

Type II

3.Partial placenta previa

Type III

4.Total placenta previa Type IV

Major degree PP= Type III & IV
The degree of PP dep . On cxal dilitn. At the time of dx.
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 Low-lying placenta
(1) to describe an apparent placenta previa
in the second trimester,
(2) the exact relationship of the placenta to
the os has not been determined, or
(3) to describe a placental edge that lies
within 2 to 3 cm of the internal os

associated with an increased risk of

bleeding, although less than with true
placenta previa

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 Incidence of PP: 1 in 200 births

Etiologies of PP:
- the specific cause is not known
- many factors may affect placental implantation
Defective decidual vascularization (ex. Grand
multiparity)
Prior trauma to the endometrium (ex. C/S scar,
curratage, etc)
Placental hypertrophy(ex. DM, Erythroblastosis,
etc)

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Associated factors :-

1. ed maternal age
- 1/1500 = teenagers ; 1/100 = >35yrs.
2. Multyparity
- 1/1500 = nullipara Vs 1/20 = grandmultipara
3. Prior uterine scar
- C/S, D & C, PID, Myomectomy, Metroplasty, etc
= C/S 5 - fold ed incidence
2% with 2 prior C/S
4% with > 2 prior C/S
- risk of TAH ed with repeat C/S for PP (25% Vs
6%)
4. Smoking = hypoxemia Placental hypertrophy
5. Twins = b/c of ed placental surface area.
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 Clinical course and diagnosis

The mean GA at Dx. = 32.5 wks.
PAINLESS, CAUSELESS, BRIGHT RED Vag. bleeding
Why bleeding?
- formation of the LUS detachment of the placenta
- placentitis
- direct trauma coital, PV exam., douching
Can also remain asymptomatic
1st episode usually slight get more sever later on
The GA at 1st episode ass. With perinatal outcome

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 Other clinical findings : Hypovolemia

Anemia
Soft uterus
Malpresentation
Floating presenting part

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Diagnosis
the clinical presentation
- painless Vag. bleeding in 3rd trimester is PP !!!!

Imaging techniques :1. ultrasound

- abdominal Vs Vaginal
2. MRI

Double set up examination

- preparation is needed

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Placental migration
Placental
migration
- it is a misnomer
- placentas that lie close
to but

Not over the

cervical-os, during the 2nd

trimester, are unlikely to
persist at term
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If found at PP at
term
<20wks
2.3%
20-25wks

3.2%

25-30wks

5.2%

>30wks

24%
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 Theories for migration

(1) Development of the LUS relocates
the stationary lower edge of the
placenta away from the os.
LUS 0.5 cm (20 weeks) 5 cm (term).

(2) Progressive unidirectional growth

of trophoblastic tissue toward the
fundus within the relatively stationary
uterus (trophotropism) results in
upward migration of the placenta.
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Complications
A) Maternal

Blood loss & shock

Adherent placenta

Transfusion risks

Longer hospital stay

Surgical morbidity

Post partum hemorrhage

Recurrence rate 4 to 8 percent

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B) Fetal / Neonatal
1.ed PNMR from prematurity

2.ed risk of fetal anomalies ( 5x)

3.ed IUGR (20% Vs 5%)

4.Birth trauma ( b/c of malpresentation)

5.Neonatal anemia
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Management

Principles : Admit or Refer all patients to a

hospital
NEVER NEVER NEVER do PV- EXAM
Take Resuscitative measures
Plan further management
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 Resuscitation : Secure IV line ( 1 or 2 IV lines)

Administer fluids depending upon the patient
status
Take blood for BG & RH, HCT
X match at least two units of blood
Transfuse if indicated (HCT < 30%)
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Plan further management

1.Expectant management
-

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no active vaginal bleeding

preterm fetus
hemodynamicaly stable,
no anemia
follow maternal & fetal status

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 Maternal

Fetal

vital signs every 4 6

hrs.
Watch for Vxal
bleeding & onset of
labor
Serial HCT
Iron supplementation
Avoid douching
Decrease mobility

Ascertain GA
Kick chart
FHR 4-6 hrs.
BPP 2x/week
Growth monitoring
Steroid therapy if GA
<34 weeks

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2. Termination of pregnancy

a. term pregnancy
b. labor
c. torrential bleeding
d. IUFD
e. lethal malformation

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Mode of delivery:

1.Vaginal
- type I & type II anterior PP

Determine the Dx. By double set up

examination or by U/S!!!
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2. Cesarean section

- all other major degree PP

- cesarean hysterectomy
- abnormal adherence
- Rh(D)-negative women should receive
Rh(D)-immune globulin if they have
APH if there is bleeding even before
delivery.
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OUTCOME
MMR due to PP has fallen from 25 % to 1
%
- but remains high in developing countries: maternal anemia,
lack of medical resources, and
home births are common.

PNM due to PP has fallen from 60 to 10

percent.
The principal causes for PNM are related to
preterm delivery
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2.Abruptio Placenta(AP)

Definition:- premature separation of the normally implanted

placenta
- also called accidental hemorrhage/ placental
abruption
Types
1. revealed / external
2. Concealed: in most AP
- it might as well be:= partial abruption
= total abruption
= marginal separation

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 Incidence
- 1/75 to 1/225 births ( 0.4 1.3%)
- 1/3rd of all APH
- sever AP that kills the fetus = 1/ 830 ( 0.12%)

Pathogenesis
- It is not clear whether Abruptio placentae results
from a single pathologic event or is the
culmination of a longer-standing disorder of the
fetal-placental interface.
- Likely to involve a chronic pathologic vascular
process at the fetal-placental interface with
abruption as the culmination of a long chain of
events

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 Initially hemorrhage into desidua basalis

decidual hematoma & desidua splits

1.further separation more blood loss shock

and/or
2.compression & destruction of adjacent placenta

Acute placental insufficiency

Fetal demise
-Since Uterus is still distended don't contract and
compress the torn vessels that supply the placental
bed
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Risk factors for AP:-

1.Prior abruption = 4-5%

2.Advanced age and parity = 2.5%
3.Preeclampsia = 5 fold
4.Chronic hypertension = 5 fold
5.Trauma
6.Race and ethnicity = Black Vs Asia
7.PPROM = cause or result
8.Multifetal pregnancy = twin B, 3 fold
9.Cigarette smoking = 2.5 fold
10.Thrombophilias
11.Cocaine use
12.Myoma
13.Folate deficiency
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 Clinical feature
- highly variable depend on the severity & +/- compl.
Vaginal bleeding = dark red, painful (80%)
Uterine tenderness & back pain & abd. Pain (50%)
Uterine hyper tonus ( focal or generalized)
Idiopathic preterm labor
Fetal distress / NRFHRP
ARF
Coagulopathy
- the amount of bleeding does not correlate with the
extent of maternal hemorrhage!!! ( concealed type)
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 The classic symptoms with out vaginal bleeding

concealed hemorrhage (20%)

- how?
Placental margins remain adherent to uterine wall
Membranes retain their attachment during marginal
separation = sts. Invade amniotic cavity = PORT
WINE
Fetal head obstructs egress of blood through cervix
= blood may extravasate into the myometrium

Couvelaire uterus ( Apoplexy)

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Grades of AP
SSx

II

III

bleeding

slight

Mild- mod

Mod-sever

PR

normal

+/- elevated

elevated

BP

normal

maintained

shock

Ux irritabilit

Uly.present

irritable

Tetanic/pain

FHRP

normal

distress

Death

Fibrinogen

normal

150-250

<150

Separation

<25%

25-50%

>50%

Blood loss

<1L

1-3L

>3L

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 Diagnosis: primarily clinical, supported by: Ultrasonography

- appearance depend on time of scanning
= acute hemorrhage hyper / isoechoec
= resolving hematoma hypoechoec (1 week)
-- sonolucent (2 weeks)
- most imp. Is to R/O placenta previa!!!
Laboratory tests
- none is diagnostic
- Fib.Digrad.Products & thrombomoduline levels
- fibrinogen level, platelet count
Pathologic examination
-after delivery, cloat or depression
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 Differential diagnosis for AP:-

Placenta previa in labor(b/c

pain,bleeding)
Uterine rupture(b/c pain, bleeding)
Sepsis / DIC
Scar dehiscence (b/c pain, bleeding)
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Management
Principles : Admit or Refer all patients to a
hospital
NEVER do PV- EXAM unless PP is R/O
Take Resuscitative measures
Plan further management dep on GA
& severity
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A) Mild AP ( grade I)

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Expectant Mx. If preterm

- secure IV-line
- hct, BG & RH, X-match blood
- platelet, PT, aPPT, fibrinogen, FDP, bed side
tests
- continuous FHR monitoring (CTG)
- follow maternal hemodynamic status
= V/S q 15, OUP q 1hr., bleeding, S-hct, labor,
coagulopathy, uterine tenderness
- steroid therapy
= terminate if any deterioration in mother or
fetus or term
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B. Moderate or sever AP (type II / III)

No place for expectant Mx.
Restore the blood volume
- correct anemia
- correct acid base imbalance
- prevent or correct coagulopathy
- monitor the renal function
- continuous FHR monitoring

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Mode of delivery
A) Vaginal

Dep. on cervical status, maternal & fetal

condition

Rule out PP by U/S or double set up examination

Amniotomy

Induction / augmentation

IU-Pressure monitoring

Internal electronic FHR monitoring

Frequent V/S monitoring

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B. Cesarean section
Indication:Uncontrolled hemorrhage
Protracted labor suspected
Fetal distress
No coagulopathy
Other obstetric indications
- avoid regional anesthesia in
hypotension and DIC
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 Complications:Maternal

Hypovolemic shock = MOD = death!!!

Acute renal failure
DIC
PPH
Surgical morbidity

Fetal / Neonatal

Prematurity
IUGR
PNM
Future neurological sequelle

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Vasa previa
Vasa previa refers to vessels that
traverse the membranes in the lower
uterine segment in advance of the
fetal head.
Rupture of these vessels can occur
with or without rupture of the
membranes and result in fetal
exsanguination.

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 Diagnosis
vaginal bleeding that occurs upon rupture
of the membranes.
The concomitant finding of fetal heart
rate abnormalities, particularly a
sinusoidal pattern.
Confirmation = Apt, Kleihauer-Betke tests,
Management = immediate abdominal
delivery.
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3. Local Causes
Causes:
Trauma to cx, vx before delivery
Leech infestation
Cervicitis
Diagnosis:
Speculum exam after PP is R/O
Management:
Manage the local cause

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4. Idiopathic
The commonest cause of APH
Bleeding may not be heavy
Even if no identified cause, MM and PMR is high
Therefore termination of pregnancy at term, do
not wait for spontaneous labor.

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Thank You

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