Obstetric Medicine

Antepartum Hemorrhage
Antepartum hemorrhage (APH) is usually define 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 hemorrhage.
*Bleeding before 24 completed weeks of pregnancy is miscarriage
Epidemiology
It affects 3-5% of all pregnancies
Up to 20% of very preterm babies are born in association with APH, which explains the
association between APH and cerebral palsy.
Etiology
1-Placental causes:
*Placental abruption
*placenta previa
*vasa previa
*marginal placental bleeding.
2-Local causes:
*Cervical causes (friable, ectropion)
*genital tract trauma, infection, varicosities
*rupture uterus (scarred uterus)
3-Inherited bleeding problems, DIC
4-unexplained
Complications of APH
Maternal complications
1-Anaemia
2-Infection
3-Maternal shock
4-Renal tubular necrosis
5-Consumptive coagulopathy
6-Postpartum hemorrhage

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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
Antepartum hemorrhage 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
History
A basic clinical history should establish:
• Gestational age.
• Amount of bleeding (but do not 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.

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Maternal assessment
This should include:
• BP.
• Pulse.
• Other signs of hemodynamic 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 monitor ing should
be commenced

Investigations of APH
1-Complete blood count
2-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 platelets suggest DIC, usually
following abruption
5-Kleihauer test- particularly important for Rh-negative women to determine the dose of anti-D
required. The result of test is not immediate, however, to help in initial management.
6-CTG- commenced as early as possible to ascertain fetal well-being fetal well-being and monitor
uterine activity
7-Ultrasound – requested urgently if the placental site is unclear, to look for placenta preavia.
In case of abruption ultrasound help to exclude placenta preavia
8-High vaginal swab and cervical swab should be sent if an infective cause of bleeding is
suspected.

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Management of APH
Including history, assessment and investigations then:
• Hospital admission for clinical assessment and management
• Resuscitation measure if shock present or severe bleeding
• Airways, breathing, oxygen mask. Circulation, insert two I.V lines using 2 large bore
cannula.
• Insert Foley’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.
• 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 obstetrician, anesthetist, neonatologist.
Placenta praevia
Defined as placenta located partly or completely in lower uterine segment.
Incidence 4\1000
CLASSIFICATION (GRADES)
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).
II & I are minor
III&IV are major

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Risk factors for placenta previa
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
CLINICAL PICTURE
Symptoms
Painless
Causeless
Recurrent bleeding after 24 weeks.
Signs
*General examination
-Pallor, if present, will be proportionate to the amount of bleeding.
-Depend on severity of bleeding ± anaemia
*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
Management of placenta previa
After first aid, Cannulas, assessment with lifesaving procedures including IV fluids and
preparation of 4 pints of blood
Ultra sound for localization of placenta either trans abdominal or transvaginal.
In transvaginal scan, the probe inserted within vagina without touching the cervix.
Per vaginal examination can done only in theatre and everything ready for cesarean section.

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Expectant management
Goal is to prolong pregnancy to term without putting mother life at risk.
Indications:
-No active bleeding.
-Hemodynamically stable.
-Gestational age < 37.
-Assuring fetal condition.
-No major fetal anomaly on US
Expectant management 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.
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.
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

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Complications of placenta previa
1-maternal complications
• Major hemorrhage, shock and even death.
• Anemia.
• Morbid adherent placenta: placenta accreta, increta, percreta.
• RH sensitization.
• PPH
• Renal tubular necrosis and acute renal failure.
2-Fetal complications
• Fetal prematurity
• Low birth weight
• Chronic and acute fetal hypoxia
• IUD