University of Mosul�College of Medicine

Lecture:4

Subject/year : Antepartum haemorrhage 2022-2023

Lecturer: Dr. Saja Al-Jawady

Department: Gynecology & obstetrics

Date:

​

The AIM of this lecture is

To understand

• incidence of antepartum hemorrhage (APH)
• Types , risk factors of APH
• Predisposing factors
• management before and during labour

• Intended learning outcomes:

• By the end of this lecture the student will be able to:
• Identify APH regarding types , causes and first aid .
• Remember its incidence and predisposing factors
• Characterize findings in placenta previa
• Apply these informations in management of this emergency life – threatening condition .

​

Heading 1:

Dfinition

• Antepartum haemorrhage (APH) is usually defined as bleeding from the birth canal after the 24th week of pregnancy
• It can occur at any time before delivery of the baby

​

• *bleeding following the birth of the baby is postpartum haemorrhage.
• *Bleeding before 24 completed weeks of pregnancy is miscarriage

Heading 2�Aetiology

Heading 3

​

• Maternal complications
• 1-Anaemia
• 2-Infection
• 3-Maternal shock
• 4-Renal tubular necrosis
• 5-Consumptive coagulopathy
• 6-Postpartum haemorrhage
• 7-Prolonged hospital stay
• 8-Psychological squeals
• 9-Complications of blood transfusion

fetal complications

• 1- Fetal hypoxia
• 2-Small for gestational age and fetal growth restriction
• 3-Prematurity (iatrogenic and spontaneous)
• 4- Fetal death

​

Heading 4

APH assessment

Initial assessment

Rapid assessment of maternal

and fetal condition is a vital

first step as it may prove to be

an obstetric emergency

Include

-history

-maternal assessment

-fetal assessment

Heading 5

HISTORY

A basic clinical history should establish:

• Gestational age.

• Amount of bleeding (but don’t forget concealed abruption).

• Associated or initiating factors .

• Abdominal pain.

• Fetal movement

• Previous episodes of vaginal bleeding in this pregnancy.

• Leakage of fluid vaginally.

• Previous uterine surgery (including CS).

• Smoking and use of illegal drugs (especially cocaine).

• Blood group and rhesus status (will she need anti-D?).

• Previous obstetric history (placental abruption/intrauterine growth restriction (IUGR), placenta praevia).

• Position of placenta, if known from previous scan.

​

​

Heading 6

Maternal assessment

This should include:

• BP.

• Pulse.

• Other signs of haemodynamic compromise (e.g. peripheral

vasoconstriction or central cyanosis).

• Uterine palpation for size, tenderness, fetal lie, presenting part (if it is engaged,) it is not a placenta praevia

Fetal assessment

• Establish whether a fetal heart can be heard.

​

• Ensure that it is fetal and not maternal (remember, the mother may be very tachycardic).
• If fetal heart is heard and gestation is estimated to be 26wks or more, FHR monitoring should be commenced

Heading 7

Investigations

1-Complete blood count2-Blood group and Rh

3-Cross match- depending on the estimated blood loss

4-Coagulation studies – if a coagulopathy is suspected or blood loss is massive. Low fibrinogen, increase D-dimer, prolong prothrombin time and APTT, and low

platlates suggest DIC, usually following abruption

5-CTG- commenced as early as possible to ascertain fetal well being fetal well being and monitor uterine activity

6-Ultrasound – requested urgently if the placental site is unclear , to look for placenta preavia

Heading 8

Management of APH

-Including history , assessment and investigations then ;

-Hospital admission for clinical assessment and management

-Resuscitation measure if shock present or severe bleeding

-Air ways. Breathing, oxygen mask. Circulation, insert two I.V lines using 2 large bore cannula .

-Insert folye’s catheter.

-Sample blood for investigations.

-Cross match of at least 4 pints blood.

-Check vital signs ( PR, RR, temperature, and blood pressure) and kept patient on chart observation .

​

Heading 9

-Volume should be replaced by crystalloid, /colloid until blood available

-Sever bleeding urgent delivery.

-Advised to report all vaginal bleeding in antenatal care provider.

-Team work – senior obstetriacian , anasthetist, neonatologist.

​

Heading 10

PLACENTA PREVIA

defined as placenta located partly

or completely in lower uterine segment.

​

Incidence 4\1000

Heading 11

CLASSIFICATION

-Grade I placental edge in the lower segment but not reaching the internal os.

-Grade II placental edge reaching the os but not covering it.

-Grade III placenta cover the os but not symmetrically ( incompletely ).

-Grade IV placenta covers the os symmetrically (completely ).

I & II are minor

II&IV are major

​

Heading 12

RISK FACTORS

1. Previous uterine surgery ; Caeserean section , myomectomy and curettage

2.previous history of placenta previa.

3.Multi-parity.

4.Increase maternal age

5. Multiple pregnancy.

6.Smoking.

7.Submucous fibroid.

8.Assisted reproduction

Heading 13

CLINICAL PICTURE

Painless ,Causeless ,Recurrent bleeding after 24 weeks.

1*General examination

-Pallor ,if present, will be proportionate to the amount of bleeding

. 2*Abdominal examination

-Uterus is soft and not tender.

-Size of uterus usually correspond to gestational age

-May be malpresentation –

-if cephalic presentation non engagement head

-Supra pubic fullness

-Fetal heart sounds usually are normal

Heading 14

Expectant management Indications:

-No active bleeding.

-Hemodynamically stable.

-Gestational age < 37.

-Assuring fetal condition.

-No major fetal anomaly on US

This includes

-Hospitalization

-Correction of anaemia with blood transfusion if necessary.

-Blood should always to be kept in bank.

-Antenatal steroids to promote fetal lung maturity.

-Anti D if patient Rh negative.

-If uterine contractions present- tocolysis can be given to prolong pregnancy.

​

Heading 15

Active management

To terminate pregnancy irrespective to gestational age.

Indications:

-If active bleeding is present.

-Hemodynamically unstable.

-Gestational age >37 weeks.

-Patient in labour.

-Fetal distress present /FHR absent.

-USG shows fetal anomaly or dead fetus

Heading 16

Mode of delivery

In case of grade I & II placenta previa, anterior with no or mild vaginal bleeding

vaginal delivery can be tried.

​

If the bleeding is severe or the placenta previa was grade III & IV caesarean section should be done by the hand of most senior obstetrician

To summarize:

• APH is one of maternal complications
• APH can be dangerous for mother and fetus
• Many predisposing factors for APH
• Life saving procedures are mandatory
• Placenta previa has causes , types and different mode of management .

Lets check our knowlege

MCQ

Q- The causes of placenta previa are EXCEPT:

a-multi-parity

b-previous placenta previa

c-hypertension

d-multiple pregnancy

e-smoking

​

References and recommended further readings:

Obstetrics by Ten Teachers, 19E - Kenny, Louise, Baker, Philip N.

Dewhurst's Textbook of Obstetrics and Gynaecology,Eighth Edition- D.

Keith Edmonds

UNICEF-Sd-Neonatal-Guidelines-report-2018

The end