Antepartum Haemorrhage

Introduction
Defined – any bleeding from the genital tract
after 24 week. (by convention)

Complicates 2 – 5% of all pregnancies

Causes
• Placenta Praevia 31%
• Abruptio Placenta 22%
• Others 47% (trauma to vaginal/vulva, cervicitis,
tumours,etc)
 Management
• Condition unpredictable, and can deteriorate
any time
• Should be in a hospital with adequate facilities
for transfusion, delievery by emergency C-
section and neonatal resuscitation +/-
neonatal intensive care.
• Divided into initial and specific
 Initial Management …History
• Acertain any initiating factors eg trauma
• Amount / Character of bleeding
• Association of abdominal pain / contraction
• History of ruptured membranes / previous
bleed
• Gestational age
• Foetal movements
• Knowledge of placenta
Initial Management …Physical Examination

Primary Assessment of Mother (does the

mother needs to be tilted?)
• Airway
• Breathing (RR)
• Circulation (BP, PR, clinical evidence of shock – restlessness, cold /
clammy extremities, poor skin perfusion)
• Disability / Neurological Condition (abdomen- uterine size,
tenderness, contraction, number of foetuses, viability, presentation)
• Exposure for other full assessment (perineal assessment,
speculum examination, vaginal examination if placenta is not low
lying)
 Initial Management …and Treatment
• I/V line – at least 16 G
• Bloods – FBC, Group and save (or crossmatched if
still bleeding or severe), Kleihauer, Coagulation
profile, urea/electrolytes, LFT
• Initial fluid resuscitation – colloids, crystalloids, O
negative bloods
• Ultrasound – exclude placenta praevia, abruption
(major), viability / presentation of foetus
• CTG if foetus viable
• Steroids (Betamethasone) for foetal lung maturarity
 Initial Management
Review situation for secondary / specific management.
Hospitalisation till 24 hours after bleeding has stopped may be
needed. Consider antiD

Following categories may occur

• Bleeding stopped
• Bleeding continues but mild/moderate and not life threatening
• Bleeding continues and severe and life threatening -> needs
immediate delivery
• Foetal distress, irrespective of bleeding pattern ->needs
immediate delivery?
• Foetus is dead
 Placenta Praevia
• Situation where placenta is sited partially or
wholly in the lower segment
• Types of grading

4 3 2 1
 Placenta Praevia
By ultrasound, if leading edge of placenta is
• Between 2 – 5 cm from internal os – Type 1
• Less than 2 cm from internal os – Type 2
• Covering internal os – Type ¾

Aetiology unknown but is associated with

advancing maternal age / parity, previous C-
section, smoking and previous placenta praevia
 Placenta Praevia
• Maternal risks – APH /PPH leading to maternal
mortality/morbiddity, post partum sepsis,
anaesthetic/surgical complications, placenta
accreta (15%), hysterectomy, recurrence

• Foetal risks – preterm births, intra-uterine

growth restriction, malpresentaion, umbilical
cord complications, foetal death
Placenta Praevia …Clinical Presentation
• Characteristically presents as painless
unprovoked per vaginal bleeding. Occassionally,
post coital bleeding
• Persistent foetal malpresentation
• Failure of foetal engagement in maternal pelvis
• Incidental finding on anomaly scan – need to
repeat at 34 weeks
• NEVER do digital examination!!!
 Placenta Praevia … Investigation and
treatment
• Ultrasound

• MRI

• General Management

• Specific management
Delivery depends on type of placenta praevia
Placenta Previa … Mode of delivery
If no other complicating feature(s)

• Type 1 and Type 2 anterior – vaginal delivery

• Type 2 posterior and Type 3 /4 – C-section
 Abruptio Placenta
• Defined as premature separation of placenta
• 2 types – revealed (65 – 80%) and concealed (20 –
35%)
• Aetiology – unknown (majority), trauma (ECV?),
sudden decompression (ROM in polyhydramnios /
multiple pregnancy), advancing maternal parity(Not
age), smoking, pre-eclampsia
• Recurrence rate between
8 – 16%
Abruptio Placenta … Maternal Risks
• Mortality – 1% from shock, DIVC, renal failure
• Recurrence
• Post partum Haemorrhage – couvalaire uterus
• Foeto-maternal haemorrhage – rhesus
sensitisation?
• Mortality/Morbidity associated with C-section
 Abruptio Placenta …Foetal Risks
• Perinatal mortality- 50% stilbirth rate
• Intra-uterine growth restriction – up to 80%
• Association with Congenital malformation ( 2
– 3 X background risk)
• Preterm deliveries
• Abnormal neonatal haematology / coagulation
 Abruptio Placenta …Diagnosis
• Maternal per vaginal bleeding
• Abdominal pain – not so in posterior sited placenta
• Uterine contractions / tenderness – woody uterus
• Signs of CVS compromise
• Increasing abdominal girth / uterine fundal height
• Foetal distress / death
• USS – not useful unless large abruptio
 Abruptio Placenta …management
• Depends on severity, associated
complications, condition of mother, and of
foetus and gestational age
• Severity of abruptio – mild (Grade 1 –
unrecognised, diagnosed after delivery);
moderate (Grade 2 – classical signs of abruptio
with alive foetus); severe (Grade 3 –dead
foetus and coagu;opathy present)
 Abruptio Placenta …management
• Expectant management
• Aimed at prolonging pregnancy for improved
foetal maturity and survival
• Only for mild abruptio, and gestational age
<34 weeks
 Abruptio Placenta …management
• Immediate delivery –depends on severity and
whether the foetus is still alive.
• If foetal death – aim for vaginal delivery
• If foetus alive – vaginal delivery or C-section
depends on maternal and foetal condition
• Need to consider complications such as
haemorrhagic shock, DIVC, postpartum
haemorrhage, organ failures in mother.