ANTEPARTUM

HAEMORRHAGE

Sources :
Textbook of Obstetrics ; D.C Dutta
 Definition
 Causes
 Evaluation
 Management
 Complications
 Definition

Bleeding from the genital tract from 22 weeks

POA until delivery of the fetus

Why 22 weeks POA?

This is because fetus is considered to be
salvageable at this gestation
(WHO= 22 weeks/ 500g or more)

**Lower segment starts to form at 28 weeks

until 34 weeks
CAUSES :
Placental causes (70%)
 Placenta previa 34.5%
 Abruptio placenta 34.5%
 Vasa previa/circumvallate placenta 1%

Unexplained causes (25%)

Extraplacental causes (5%)

 Cervical polyp
 Ca cervix
 Local trauma
 Cervical or vaginal lesion/ infection
 Evaluation
Quick History
Type of bleeding ? Discharge per vagina
POG Past obst history
Fetal movement Blood group
Previous scan
Quick Maternal Assessment
Pulse,BP,Uterine enlargement

Quick Fetal Assesment

USG,CTG
Management
Rx follows into 2 categories
1.MINOR BLEEDING :without compromised
mother and fetus
 USG to rule out PP, Fetal well being

 If no bleeding ascertain cervical causes, Bishop’s

score
 P/S and High vaginal swab

 Investigations: FBC,GXM,BUSE,PT/PTT

Conservative approach
 Bed rest
 Anticipate future bleeding
 Regular fetal well being tests, fetal growth
 Keep 3 pint blood ready
2.SEVERE BLEEDING :Compromised mother and fetus
 Treat as major hemorrhage( altered consciousness
state,SBP< 100mmHg, Pulse >120/min, Blood loss > 1.5L,
Decreased peripheral perfusion
 Activate Red Alert,Call help
 ABC -O2 10L/min
 2 IV 16 G cannula
 Foley’s catheter no 16 G
 30 ml blood investigation (FBC,PP/PTT,BUSE,GXM)
 Commence IV Fluids (NS,HM then blood if available)
 Once hemodynamically stable transfer to HDU
 Bleeding PV > 24 weeks

Placenta previa Abruptio

placenta
Painless bleeding Painful bleeding
Soft uterus Hard uterus
Malpresentation Longitudinal lie
Placenta previa- placenta located at the
lower segment after 20wks of POG
 Placenta Previa
 Risk Factors
 Increased age, parity,
 Previous scar: LSCS, Myomectomy,
 MRP
 Prior placenta previa
 Tobocco use
 Multiple pregnancy
 Previous induced abortion
TREATMENT
Preterm with hemodynamic stable mother
 < 32 POG: Give Dexamethasone 12 mg 12 hrly x 2
doses
 Expectant management: Bed rest TILL TERM

 Fetal well-being and growth tests

 Anticipate bleeding.

 Keep blood kit ready

 Correction and prevention of anemia

 At Term : Deliver depending on type of placenta previa

 If bleeding : recurs or persists,mother is
hemodynamically compromised terminate pregnancy by
LSCS
Term
Delivery either vaginally or LSCS.

Vaginal delivery
LSCS
 Type 1 and Type 2 anterior Type
3,4
 Cephalic presentation Fetal
distress
 Hemodynamically stable
Malpresentation

 Keep blood ready

 Anticipate PPH
 Anticipate adherent placenta
 If LSCS consent for Cesarean Hysterectomy
Abruptio placenta-Premature separation of
normally situated placenta after the period of viability but before
delivery of baby

 REVEALED
 CONCEALED
 MIXED
 Etiology/Risk factors
High risk factors
 Gest Hpt/Pre-eclampsia

 Trauma

 Sudden uterine decompression

 Short cord

 Obstetric procedures like ECV

 Multiple pregnancy

 Polyhydramnios

 High parity
 Management
Trendelenberg position & Oxygen
Obtain immediate Intravenous Access
 Two large bore IV (16-18 gauge)
 Collect blood for investigation
 Initiate Isotonic crystaloid bolus
Call for immediate Obstetric and neonatal support
 ARM and oxytocin/ Induce labor
 Consider Cesarean Section if fetal distress
Vasa previa

 Fetal vessels travel within the

membranes before valementous
insertion
 Crosses internal os
 Fetal distress
 LSCS
 Fetal mortality is > 50%
Vasa previa,circumvallate placenta
 Other causes of APH
 CERVICAL BLEEDING;
 Infectious cause
 Bleeding is controlled by cauterisation

 CERVICAL POLYP
 Self limiting
 Local infection
 Polypectomy
 Histological diagnosis

 BLOODY SHOW
Complications of APH
 Couvelair uterus
 DIVC
 Amniotic fluid
embolism
 Acute renal failure
 PPH
 Hypovolemic shock
 Maternal and fetal
death