Antepartum Haemorrhage

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Antepartum Haemorrhage

• Dr. Abdalla H. Elsadig
• MD

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Definition

• Bleeding from the genital tract in pregnancy
  between 20 to 24 weeks gestation and the onset
  of labour.
• It affects 4 of all pregnancies.
• It is associated with increased risks of fetal
  and maternal morbidity and mortality.

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causes

• Placenta praevia.
• Placental abruption.
• Local causes
• - cervical ectropion/cervical trauma.
• - local infection of the cervix/vagina.
• - cervical polyps/cervical cancer.
• Undetermined origin.
• Rare cause torn from vasa paevia (fetal origin).

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Placenta praevia

• Definition
• a placenta that partially or wholly situated
  in the lower uterine segment. Its incidence is
  0.4 to 0.8 of pregnancies.
• Lower uterine segment
• it forms after 28 weeks gestation and it has
  3 definitions
• Is that part of the uterus which measures about 5
  cm from the internal os (metric definition used
  in U/S).
• Is that part of the uterus which stretches and
  dilates in labour (physiological definition
  occurs in labour).
• Is that part of the uterus which lies below the
  level at which the visceral peritoneum is
  reflected on the dome of the bladder from being
  ultimately adherent to the upper uterine segment
  (anatomical definition used in caesarean section).

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Placenta praevia

• Grades
• Grade 1 the placental edge is in the lower
  uterine segment but does not reach the internal
  os (low implantation).
• Grade 2 the placental edge reaches the internal
  os but does not cover it.
• Grade 3 the placenta covers the internal os when
  it is close and is asymmetrically situated
  (partial).
• Grade 4 the placenta covers the internal os and
  is centrally situated (complete)
• Grade 2 the placenta could be situated
  anteriorly or posteriorly.

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Implantation of the placenta at or near the
cervix. 
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Placenta praevia

• Predisposing factors
• Older multiparous women. Women gt 40 years have
  9-fold greater risks than women lt 20 years of
  age.
• Multiple pregnancy.
• Previous caesarean section. The risk increases
  with increasing numbers of C/S
• Smoking.
• Associations
• Fetal abnormality (double in placenta praevia).
• IUGR (multiple bleeds).
• Placental abruption (co-exist in 10 of placenta
  praevia).

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Placenta praevia

• Clinical presentation
• Bleeding usually mild but it could be severe
  recurrent, painless and causeless.
• Soft uterus.
• Normal fetal heart rate (unless there is severe
  bleeding or associated abruption).
• High presenting part.
• Fetal malpresentation (breech/transverse/oblique).
  
• Vaginal examination is contraindicated.

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Placenta praevia

• Diagnosis
• Clinical presentation.
• U/S Transvaginal is better than transabdominal
  the woman does not need full bladder and can
  determine the placental edge in posterior PP.
• - 5 of low lying placenta can be diagnosed at
  16-18 weeks but only 0.5 have PP at delivery.
• - in the second trimester, if the placenta
  covers the internal os with an overlap gt 2.5 cm
  and the placental edge is thick placenta praevia
  will persist.
• MRI expensive.
• Examination in the theatre if no facilities or
  in doubt.

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Complications of Placenta praevia

• Preterm delivery and its complications.
• Preterm premature rupture of membranes.
• IUGR (repeated bleeding).
• Malpresentation breech, oblique, transverse.
• Fetal abnormalities (double in PP).
• ? number of C/S.
• Morbid placentae placenta acreta(80), increta
  and percreta.
• Postpartum haemorrhage lower segment not
  contract and retract, morbid placenta, C/S.

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Management of Placenta Praevia

• Asymptomatic and minor bleeding
• Admission (minor). Asymptomatic PP admitted at 36
  weeks.
• CBC, cross matching and preparation of blood.
• Coagulation profile.
• Maternal and fetal monitoring.
• Correction of anaemia.
• Anti-D if the mother is rhesus negative.
• Tocolytic safe, gain 13 days, other than
  B-agonist to be used.
• Corticosteroids 48 hours before delivery ( at 38
  weeks).
• Vaginal delivery placenta 4.5 cm from the
  internal os, low head, no bleeding. Consider
  examination in theatre if in doubt .
• C/S (of choice) grade 4, 3, placenta within 2 cm
  of the internal os, high head, bleeding, presence
  of added factors.

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Placenta Abruption

• Definition
• bleeding following premature separation of a
  normally situated
• Incidence 5 of pregnancies.
• Grades
• Asymptomatic retroplacental clot seen after
  placental delivery.
• Mild vaginal bleeding (revealed) uterine
  tenderness visible retroplacental clot after
  placental delivery.
• revealed bleeding enough placental separation
  producing fetal compromise and visible
  retroplacental clot after placental delivery.
• revealed bleeding with maternal signs (uterine
  tetany, hypovolaemia, abdominal pain) and late
  stage fetal compromise or fetal death. 30 of
  these women will develop DIC.

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Extensive retroplacental clot removed from
maternal placental surface in a case of abruption
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Predisposing factors of Placenta Abruption

• Hypertension PET (24), chronic hypertension (
  9-fold).
• Fetal abnormality ? maternal serum
  a-fetoprotein, ? recurrence of abruption. ?? poor
  placentation (? adhesiveness).
• Thrombophilias factor V leiden, prothrombin
  gene, protein C S deficiency, antiphospholipid
  syndrome homocysteinaemia.
• Trauma ECV, cordocentesis, road traffic
  accidents.
• Rupture membranes rapid decompression in
  polyhydramnios.
• Folic acid deficiency.
• Chorioamnionitis.
• Previous abruption 6 times to recur.
• Multiple pregnancy.
• Smoking.

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Diagnosis of Placenta Abruption

• Clinical presentation
• Bleeding revealed/concealed, so clinical picture
  is important.
• Pain on the uterus and this increases in
  severity.
• Signs of shock (hypovolaemia) fainting and
  collapse.
• Hard tender uterus ( uterine tetany).
• Difficult to palpate the fetal parts and to hear
  the fetal heart.
• The diagnosis is clinical.
• U/S is to
• Confirm fetal viability, assess fetal growth
  normality, measure liquor, do umbilical artery
  Doppler velocities.
• Exclude placenta praevia.

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Complications of Antepartum haemorrhage

• Premature delivery.
• Fetal distress and death
• Haemorrhagic shock.
• Acute renal failure acute tubular or cortical
  necrosis.
• DIC (release of tissue thromboplastin)
• Uterine atony (Couvelaire uterus).
• PPH.

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Management of Placenta Abruption

• Principle of management
• Early delivery (50 of abruption present in
  labour).
• Adequate blood transfusion.
• Adequate analgesia.
• Detailed maternal and fetal monitoring.
• Coagulation profile (30 develop DIC).
• C/S distressed baby, severe bleeding, alive baby
  not in advanced labour. Perinatal mortality
  rate is 15-20.
• Vaginal delivery very low gestation, dead baby,
  cervix is fully dilated (Ventouse delivery).
• Conservative small abruption, well mother and
  fetus, if the gestational age lt 34, give
  steroids.

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Management of Placenta Abruption

• Conservative Time taken to achieve delivery
  depends on
• rate of the bleeding.
• The rate of change in the clotting studies.
• The clinical condition of the mother and fetus.
• CTG twice/day.
• Serial U/S and umbilical artery Doppler
  waveform.
• No conservative after 38 weeks gestation.
• Anti-D if the mother is rhesus positive.
• Anticipate PPH.
• In cases of previous CS, discuss hysterectomy.

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thanks