Antepartum haemorrhage This is bleeding from the genital tract of a

pregnant woman at any time from the 28th week of gestation to the birth of the baby (end of the second stage of labour)

It is one of the major causes of maternal and fetal morbidity and mortality

Causes of antepartum haemorrhage

Classification Obstetric Non-obstetric causesObstetric causes Placenta praeviaHaemorrhage from separation of a placenta that is attached in an abnormal position on the lower uterine segment Abruptio placentaHaemorrhage from separation of a placenta that is attached in a normal position on the upper uterine segmentIndeterminate causes Haemorrhge from the “marginal sinus” Placenta vera

Placenta previa (types and classification)Types (just descriptive) Type 1: placenta attached onto upper segment but its lower margins

encroach onto the lower segment (Lateral) Type 2: Placenta attached onto lower segment but lower margins do not reach

the internal cervical os (Marginal) Type 3: (Central, acentric)Placenta extends to partially cover the internal cervical os (does not

cover os when cervix is fully dilated Type 4: (Total, centric)Placenta covers the internal os when cervix is fully dilated Type 1 and 2 are referred to as minor: Type 3 and 4 are major

Placenta previa: associated factors and clinical presentation

Associated factors High parity and Grand-multiparity Multiple gestations Prior caesarian section or uterine operationsClinical presentation Recurrent painless bleeding, may be post-coital Initial episodes of haemorrhage usually minor May have history of recurrent threatened abortion Unstable lie Malpresentations (especially breech) Abnormal lie , (Transverse or oblique lie)

Placenta previa (diagnosis)Diagnosis High index of suspicion from history of recurrent painless

haemorrhage; often subtle or “spotting”; rarely heavy. Signs of :-Malpresentations; abnormal lie-Unstable lie, -Lateral displacement of the fetal head (or pole)-Persistent failure of the fetal head to engage (stays “high”)- Abdomen may be difficult to palpate due to anterior placenta previa. Investigations : ultrasound scan for placental localization Vaginal examination is absolutely contraindicated

Placenta previa (management)Management depends on: amount of blood lost, gestation age, Grade of placenta previaAt any gestation age, with severe haemorrhage: resuscitate the patientCheck BP, Pulse; correct anaemia; transfuse Terminate the pregnancy by caesarean sectionClose to term, with severe haehorrhage: (Resuscitate patient) Do EUA- Major previa present, do emergency C/S

No or minor previa, ARM in theatre, augment labour, Monitor labour.

Placenta previa (management) Minor haemorrhage before term: Aim at Conservative management of pt ADMIT Patient with 24-hr available facilities for

t/fusion and surgery Confirm diagnosis Resuscitate Correct anaemia and Book blood- Do speculum exam to rule out local lesions once

bleeding has stopped,

Placenta previa (management) Be on the look out for any hemorrhage If minor previa confirmed, no further bleed: Do EUA

at 37 weeks. If minor previa diagnosed, rupture membranes, (ARM), Augment labor,

- aim at vaginal delivery for type 1 and 2 anterior placenta;

- Active Management of the 3rd stage of labor. If major previa is confirmed, no further bleed,

Do elective C/S at (term) 37 completed weeks If severe haemorrhage occurs at any time,

stop conservative mngt, Do emergency C/S

Placenta previa: complications Anaemia Post-partum haemorrhageLower segment does not contract effectively Morbidly-adherent placentaMay be partial, local or diffuse Fetal complications

Abruptio placenta

Associated factors Smoking excessively Folic acid deficiency Pre-eclampsia Trauma Sudden decompression of the uterus after fetal

membrane rupture High parity

Abruptio placenta (clinical features)Clinical features Sudden onset Severe abdominal pain, may be associated with labor Fetal distress, fetal death Inaudible fetal heart due to uterine muscle spasm Fainting, collapse; patient be very sick or even toxic in

appearance Usually associated pre-eclampsia or hypertension Haemorrhage may be concealed, revealed or mixed in

type Tends to recur in subsequent pregnancy

Abruptio placenta-DiagnosisHistory: A high index of suspicion from history of sudden

onset of abdominal pain (severe, diffuse, constant) with variable amount of haemorrhage

Clinical signs: pt may be in shock in severe cases, or may be apparently normal.

Signs: Look for pallor, hypotension (severe cases), hypertension, uterus tense and tender, abdominal tenderness; fetal demise

Confirm diagnosis by :Ultrasound scan: 1 to rule out placenta praevia

2 for retroplacental clot

Abruptio placenta- mngt

Depends on fetal viability and whether bleeding continues

Fetus viable, any gestation age: emergency c/s Fetal death confirmed on ultrasonography, no

continuing bleeding: do EUA to rule out placenta previa. If no previa, do ARM, augment labour, AIM for vaginal delivery

Abruptio placenta- mngt (cont’d)Any gestation age, fetus dead, continuing severe bleeding: Resuscitate pt, correct volume deficit , aim for CVP of 10 cm of

water Correct anaemia, preferably with fresh blood products check for and correct coagulopathy, (Do full blood count, assay fibrinogen levels, do clot retraction tests) deliver by c/s if coagulopathy corrected or absentVaginal delivery is a much safer and preferred option for delivery in

case fetus is dead (not viable) Confirm fetal death by ultrasonography, not fetoscope (due to uterine spasm which may make fetal heart inaudible)

Abruptio placenta- complications Hypovolaemic shock. This may lead to acute

renal failure and renal shut down (both cortical and tubular necrosis)

Fetal distress and fetal death Postpartum haemorrhage DIC

Indeterminate causes of APH

May be due to: 1 Bleeding from margins of the placenta (from the

“marginal sinus)2 Placenta vera (bleeding from the rupture of fetal

vessels as they course thru the membranesAssociated with Placental abnormalities like: succenturate lobe, velamentous insertion of the cord, placenta membranaceaous

Indeterminate causes of APH Bleeding usually mild Blood loss is fetal in origin so fetal demise is very

common Diagnosis can be made by ultrasound in a few cases,

where the position of the cord may be localized. When in doubt, manage as placenta previaConfirm fetal origin of blood loss with the Kleihauer-

Betke test (to test for fetal blood cells)If fetus is alive, manage as placenta previa. If fetus is dead, manage as abruptio placentaWhen in doubt, manage as placenta previa

Antepartum haemorrhage: Non-obstetric causes

Local lesions in the genital tract

Cervical- cervical cancer- Cervical erosions- Cervical ectropion- Trichomoniasis- Vulvovaginitis of any

cause