1. Antepartum Haemorrhage and Postpartum Haemorrhage
Dr Dalia Juneenath
St 3
02/09/2015

2. Antepartum haemorrhage (APH)
Bleeding in early
Pregnancy
Antepartum haemorrhage (APH)
Bleeding In Pregnancy
Post partum
Haemorrhage (PPH)

3. Antepartum Haemorrhage
Antepartum haemorrhage (APH) is bleeding from or into the genital tract occurring from 24 weeks pregnancy and prior to birth of the baby .
Epidemiology
Affects 3-5% of all pregnancies
3 times more common in multiparous

4. PLACENTAL
Placental Abruption
Placenta Previa
UTERINE
Rupture
Scar dehiscence
LOCAL
Vulval varicosities
Vaginitis
Cervical erosion/Ca/ trauma/polyp
FETAL
Vasa previa

5. Placental abruption Premature separation of a normally
situated placenta in a viable fetus

6. Revealed abruption
Concealed abruption

7. Risk factors Abruption in previous pregnancy Increased age and parity
Fetal growth restriction
Vascular diseases: preeclampsia, maternal hypertension, renal disease,SLE and APS
Mechanical factors: Trauma, intercourse
Sudden decompression of uterus
Polyhydramnios, Multiple pregnancy
6. Smoking, cocaine use,
7. Uterine myoma
8. Premature rupture of membranes/intrauterine infection
9. Maternal thrombophilias

8. Placenta praevia
Insertion of the placenta, partially or fully, in the lower segment of the uterus

9. Risk factors for Placenta praevia
Previous placenta praevia
Previous LSCS or other uterine surgery
Previous termination of pregnancy
Multiparity
Advanced maternal age
Multiple pregnancy
Smoking
Assisted conception

10. Grades of Placenta praevia
Grade I: Placenta encroaches lower segment but does not reach the cervical os
Grade II: Reaches cervical os but does not cover it
Grade III: Covers part of the cervical os
Grade IV: Completely covers the os, even when the cervix is dilated

11. Symptoms Maternal signs Fetal signs USS Pain+/- bleeding FM
Abruption
Praevia
Symptoms
Pain+/- bleeding FM
Painless bleeding- often heavy
Maternal signs
Uterine tenderness +/-contractions
Shock
No Contractions
Fetal signs
Distress/death
Normal lie,+-engaged
Usually normal FH
Abnormal lie, unengaged,
USS
Normally situated placenta
Low lying placenta.

12. Vasa praevia
Fetal blood vessels from the placenta or umbilical cord cross the internal os beneath the baby
High fetal mortality (50-75%)

13. Eccentric (velamentous) cord insertion

14. Rupture of Uterus Risk factors 0.04% of deliveries.
Prior C/S: up to 0.5%
Prior uterine surgery.
Hyperstimulation with oxytocin.
Trauma
Parity > 4
Forceps delivery (especially mid forceps).
Breech version or extraction

15. Rupture of Uterus Uterine scar dehiscence: Uterine rupture:
Fetal membranes remain intact, fetus not extruded intraperitoneally, separation limited to old scar, peritoneum overlying is intact
Usually no fetal distress / maternal Hemorrhage
Uterine rupture:
Separation of scar  extension, rupture of fetal membranes with extrusion
Fetal distress / maternal hemorrhage
Maternal mortality
Fetal mortality = 35%

16. Rupture of Uterus

17. OBSTETRIC HAEMORRHAGE
Management
ASSESSMENT
Delivery
Postpartum
Conservative
?Prevention

18. Management of APH Admit Airway, breathing and circulation
Senior staff must be involved
Two wide bore canula
Bloods for FBC , coagulation profile,Liver & renal function, Group and save/crossmatch
Volume lost replaced by Crystalloid/colloid until blood is available
Severe bleeding or fetal distress: Urgent delivery of baby irrespective of gestational age
Fetal monitoring
Rhesus negative woman- kleihauer test and prophylactic anti-D immunoglobulin
For pre-term delivery when immediate delivery is not necessary, maternal steroids

19. Placental abruption –Management
Small abruption
- Conservative management depending on gestational age
- Careful monitoring of fetal condition
Moderate or severe placental abruption:
- Restore blood loss
- Prevent coagulopathy
- Monitor urinary output
- Delivery
1.Caesarean section
2.Vaginal
If coagulopathy present
If fetus is not compromised
If fetus is dead

20. Placenta praevia - Management
1.Near term / Term- Delivery is considered
Grades I and II - May be able to deliver vaginally
Grades III and IV - LSCS by senior obstetrician
Should anticipate PPH
2.Early in pregnancy
Continuation of pregnancy better if possible
4 pint of crossed matched blood should be
available till delivery
Fetal well being and growth monitored –fbc,CTG,USS

21. Postpartum Hemorrhage

22. Definition
PRIMARY PPH-Blood loss of more than 500 ml within 24 hours of delivery(1000ml –LSCS)
SECONDAY PPH- bleeding after 24 hours and 6 weeks of delivery
Seen in ~5% of deliveries.
PREVENTION
Active Management of Third stage : reduces PPH by 60%

23. Risk Factors …Prenatal Pre-eclampsia Previous postpartum hemorrhage
Previous C/S
Multiple gestation
Multiparity
…Intrapartum
Delivery by LSCS
Prolonged labour
Induction of labour
Operative vaginal delivery
Retained placenta
Episiotomy/Lacerations
Most patients with hemorrhage have none

24. Initial Assessment Identify possible cause of post partum hemorrhage.
Simultaneous evaluation and treatment.
Call for help.
Remember ABCs.
Use O2 4L/min.
two 16g or 14g IVs.
Catheterise

25. ALSO’s 4 Ts Tone (Uterine tone) Tissue (Retained tissue--placenta)
Trauma (Lacerations and uterine rupture)
Thrombin (Bleeding disorders)

26. Management of Uterine Atony
MEDICAL
1. Oxytocin promotes rhythmic contractions.
2. ergometrine
3. Hemabate
SURGICAL
Balloon tamponade
Hemostatic brace suturing(B-Lynch)
Bilateral ligation uterine artery/ Internal Iliac arteries
Selective arterial embolisation
Hysterectomy –sooner than later!

27. Tissue: Retained placenta
Delay of placental delivery > 30 minutes seen in ~ 6% of deliveries.
Prior retained placenta increases risk.
Risk increased with: prior C/S, curettage p-pregnancy, uterine infection, increased parity.
Occasionally succenturiate lobe left behind.

28. Abnormal implantation

29. Trauma (3rd “T”)
Episiotomy
Hematoma
Uterine inversion
Uterine rupture

30. Vulvar hematoma

32. Uterine Rupture When recognized, get help. ABCs. IV fluids.
Surgical correction.

33. Thrombin (4th “T”) Coagulopathies are rare.
Suspect if oozing from puncture sites noted.
Work up with platelets, PT, PTT, fibrinogen level, fibrin split products, and possibly antithrombin III.

34. Secondary PPH Associated with endometritis Treat with antibiotics
Surgical method if heavy/ USS indicative

35. Thank You