1. Antepartum Hemorrhage
Abdulah Al-Tayyem;MD;JBOG
Consultant Ob&Gyn
Urogynaecology
Zarka Govern. Hospital

2. Definition:
APH is bleeding from or within the genital tract after 24 W of gestation.
Causes:
Placenta previa the most common causes
Abruptio placentae
Rupture uterus
Local causes: trauma,infection,tumors.
Vasa previa

3. Placenta previa
Is the implantation of the placenta in the lower uterine segment with different grades of encroachment on the cervix.
Bleeding is: -painless
-causless

5. classification

6. 6

7. APH Per vaginam blood loss >15 ml after 20 weeks’ gestation
5% of all pregnancies
Accounts for % of perinatal mortality 7

8. Severity of bleeding Volume Estimate Percent of circularity volume
Type
500 ml or >
10-15%
compensated ml
15-25%
mild ml
25-35%
moderate ml
35-50%
Severe (shock) 8

9. Abruptio Placentae
Is premature separation of a normally implanted placenta, may be precipitated by a sudden increase in blood pressure or trauma
Fetal parts are difficult to feel.
Feta heart sound may be absent
Sings of hypovolemia
Coagulopathies occur in 30% of cases

10. Diagnosis History: Present obstetric history Symptoms of hypovolemia
Symptoms of pre-eclampsia
Lower abdominal pain or colic
The presence or absence of fetal movements
History of ROM or labour pains
Previous uterine operations
History of sexual intercourse before onset of bleeding
History of trauma or recent surgery

11. Physical examination General examination:-tachycardia,hypotenstion
-sings of shock
-lower limb edema.
Abdominal examination: -abdominal tinderness,or rigidity
-fundable level
-FHS
-consistency of the uterusز
Pelvic examination:
-Don not perform a digital vaginal examination at this stage.
-Inspect the external genitalia and vagina for:
-amount of blood loss
-sings of trauma or infection.

12. Investigations Laboratory investigations: -ABO blood group and Rh type
-Crossmatch at 2 units of blood
-CBC
-Fibrinogen, PTT, PT,CT
-Serume creatinine or BUN
-Urine analysis for protein and RBCs

13. Perform a transvaginal ultrasound scan on all women in whom a low-lying placenta is suspected from their transabdominal anomaly scan (at approximately 20–24 weeks) to reduce the numbers of those for whom follow-up will be needed.
Transvaginal ultrasound is safe in the presence of placenta praevia and is more accurate than transabdominal ultrasound in locating the placenta.

14. Ultrasound Confirm the fetal viability
Localize the site of placenta,and its relation to the cervix
Estimating the gestational age
Detecting the presence of retroplacental hematoma
In case of sever bleeding, do not wait for an US examination .Begin first aid management and the quickly start active management .
Even if the amount of bleeding is mild NEVER perform PV examination until placenta previa has been excluded by US

15. Diagnosis of Antepatrm Hemorrhage
Painless vaginal bleeding after 24w.?
Symptoms and sings:
-shock bleeding may be precipitated by intercourse
-relaxed uterus -normal fetal condition
-fetal presentation not in the pelvis/ lower uterine pole feels empty.
Dg: Placenta previa

16. Vaginal bleeding after 24 w,intermitent,or constant abdominal pain?
Symptoms and sings:
-Shock -tense/tender uterus
-decreased /absent fetal movements.
-fetal distress/absent fetal heart sound.
Dg: Abruptio placentae.
( R/O co-exciting PIH)

17. Bleeding(intra-abdominal and/or vaginal)?
Sever abdominal pain(may decreas after rupture)?
Previous uterine scar?
- shock -abdominal distention/free fluid.
-abnormal uterine contour -tender abdomin
-easily palpable fetal parts -rapid maternal puls
-absent fetal movements and FHS
Dg: Ruptured uterus

18. Mild vaginal bleeding after 24 w(mild)?
Symptoms and sings:
-clinically stable
-fetal assessment showed fetal distress
that can not be explained by the mild bleeding.
Dg : Vasa previa

19. Complications of placenta previa
-shock
-postpartum hemorrhage
Women with placenta previa are at high risk for PPH and placenta accreta/increta;
a common finding is at the site of a previous cesarean section

20. Complications of abruptio placentae
Maternal shock
Fetal death
Uterine atony
Amniotic fluid embolism
Caogulopathy( 30%)
Renal failure
The principal cause of maternal death is renal failure due to prolonged hypotension .
Don not underestimate the amount of the hemorrhage

21. Management General rules: -call for help -keep women NPO
-remember that mother and the neonate
require evaluation and intervention if needed

22. First aid management Insert 2 wide bore cannulae
Blood for CBC,crossmatch
Immediately star iv crystalloid solutions
Provide 100% oxygen via mask
Warm the women
Insert Foley catheter
Monitor blood pressure and pulse/ 5 min
Monitor urine output /hour

23. Indications of when to terminate pregnancy
Women in labour
Bleeding is heavy(evidente or hidden) manifested by shock
Gestational age equals or more 37 w
There is fetal distress
There is IUFD and /or fatal congenital anomalies by US

24. When to use conservative management
Bleeding is light or has stopped AND
The fetus is alive AND
The fetus is premature.
Cases of abruptio placentae which are diagnosed only on US examination, with no clinical finding( no bleeding, no shock, no tender or tonically contracted uterus)

25. In abruptio placentae:
When the clinical diagnosis is clear
Or in the presence of acute fetal distress:…. Do not waste your time for US examination.
US is neither sensitive nor specific diagnosis modality in abruptio placentae

26. Monitoring during hospital say
Check pulse every 3o min/2h, then hourly/6h, then every 4 h.
Perform gentle uterine massage/30 min
APH predispose for PPH
Check for vaginal bleeding
Check urine output/ 2h

27. Conditions that should be met before discharge
No active bleeding
No fever
Open bowel
Stable general condition
Satisfactory urine output
No wound complications

28. - - - - - - + Bleeding + + + C/Section + +
Management of Placenta praevia in a
Pregnancy of viable gestational age - +
Bleeding -
Expectant
management
Fetal distress + +
C/Section
Fetal lung maturity - -
Sono assessment
q 3-4 weeks - +
Placental
migration
Bleeding
Trial of labor - +
Complete
resolution +
Double set-up
Trial of labor
(low-lying only) 28

29. Comparison of presentation of abruption v. praevia v. rupture
Abdominal pain
Yes No
variable
Vaginal bleeding
Old dark
Fresh
DIC
Common
Rare
Fetal distress 29

30. Associated with velamentous insertion of the
Associated with velamentous insertion of the umbilical cord (1% of deliveries)
Bleeding occurs with rupture of the amniotic membranes (the umbilical vessels are only supported by amnion
Bleeding is FETAL (not maternal as with placenta praevia)
Fetal death may occur with trivial symptoms

31. Examination of the placenta showed a velamentous insertion of the umbilical cord and a lacerated fetal vessel as a result of spontaneous rupture of the membranes. In this case, the unprotected fetal vessels passed over the cervical os, a vasa previa. 31 31

32. Comparison of presentation of abruption v. praevia v. rupture
Abdominal pain
Yes No
variable
Vaginal bleeding
Old dark
Fresh
DIC
Common
Rare
Fetal distress