Dr.Tarig Mahmoud Ahmed

MD SUDAN

HAIL UNIVERSITY KSA

Antepartum haemorrhage (APH) is any

bleeding occurring in the antenatal

period after 24 weeks to delivery of the

baby..

It complicates 2–5 per cent of

pregnancies.

At term, APH can be difficult to

distinguish from a ‘show’ which is the

release of the cervical mucus in the

early stages of labour.

CAUSES:

Placental causes:

Placental abruption

Placenta praevia

Vasa praevia

Local causes Cervicitis

Cervical ectropion

Cervical carcinoma

Vaginal trauma

Vaginal infection

Placenta praevia is defined as a

placenta that has implanted into the

lower segment of the uterus.

It is now classified as either major, in

which the placenta is covering the

internal cervical os, or minor, when the

placenta is sited within the lower

segment of the uterus, but does not

cover the cervical os.

Multiple gestation

Previous Caesarean section

Uterine structural anomaly

Assisted conception

Multiparous

The incidence in the UK is approximately 5

per 1000 and is increasing due to the rising

Caesarean section rate and increasing

maternal age.

In women who have had a previous

caesearean section, there is a risk of

placenta implants into, and thus invades,

into the previous scar ‘morbidly adherent

placenta’.

morbidly adherent placenta are three types:

1. Placenta accreta.Placenta is abnormally adherent to the

uterine wall.

2. Placenta increta.Placenta is abnormally invading into the

uterine wall.

3. Placenta percreta.Placenta is invading through the uterine

wall.

Diagnosis:

recurrent painless bleeding in the 3rd

trimester.

On abdominal palpation, the uterus will

be soft and non-tender and the

presenting part will be high.

ultrasoundscans will demonstrate the

abnormal location of the placenta.

A digital examination is contraindicated

as this can precipitate bleeding.

Management:

resuscitated using approach of ABC.

If the bleeding is minor and the fetus

uncompromised, the patient should be

admitted for observation for at least 24

hrs.

Women with major placenta praevia

who have had recurrent bleeding should

be admitted as inpatients from 34

weeks till Caesarean section at 37–38

weeks .

Cases of minor placenta praevia can be

considered for a vaginal delivery if the

placenta is a minimum of 2 cm away from

the cervical os.

There is risk of serious maternal haemo -

rrhage, either as APH or during Caesarean

section when the placental bed may not

contract, or due to morbid adherence.

Time of elective delivery when reaching

37–38 weeks.

A placental abruption is separation of a

normally sited placenta from the

uterine wall.

Has tow Presentation :

revealed with vaginal bleeding (2/3).

concealed, which present as uterine

pain and potentially maternal shock or

fetal distress without obvious

bleeding(1/3).

Risk factors for placental abruption:

Hypertension

Smoking

Trauma to abdomen

Cocaine use

Anticoagulant therapy

Polyhydramnios and multiple gestation

FGR

High parity

sudden decompression of the uterus (e.g.after rupture of the membrane inpolyhydramnios).

Clinical presentation and diagnosis

The classical presentation is that ofabdominal pain, vaginal bleeding anduterine contractions, often close to term orin established labour.

maternal shock and/or collapse.

Abdominal palpation typically reveals atender, tense uterus ‘woody hard’.

The fetus is often difficult to palpate.

fetus may be dead, in distress orunaffected.

The diagnosis is usually made on clinicalgrounds.

Hypovolaemic shock

Disseminated intravascular coagulation

(DIC)

Acute renal failure

Fetomaternal haemorrhage (important for

mothers who are rhesus negative)

Perinatal mortality

FGR (When abruption is chronic or recurrent)

Management:

resuscitated using approach of ABC.

2 14-gauge intravenous lines .

Full blood count and clotting studies.

Test for renal function and liver

function tests.

Cross-match at least 6 units of blood.

Fluid resuscitation intravenously.

Foley catheter into the bladder and

fluid balance chart.

In very severe cases, the fetus will be dead

and vaginal delivery can be accelerated by

artificial rupture of the membranes.

If the fetus is alive, delivery without

compromising the mother’s resuscitation is

urgent and this will usually be by Caesarean

section.

Placenta praevia Vs Placental abruption

pain

abruption - constant

placenta praevia - painless

obstetric shock

abruption - the actual amount of

bleeding may be far in excess of

vaginal loss

placenta praevia - obsetric shock in

proportion to amount of vaginal loss

uterus

abruption - uterus is tender and tense

placenta praevia - uterus is non-tender

fetus

abruption - normal presentation and

lie

placenta praevia - may have abnormal

presentation and/ or lie

fetal heart

abruption - fetal heart distressed/absent

placenta praevia - in general, fetal heart

normal

associated problems:

abruption - may be a complication of pre-

eclampsia, may cause DIC.

placenta praevia - small antepartum

haemorrhage may occur before larger

bleed

Vasa praevia is rupture of fetal

vessels running within the

membranes, often near to the

cervical os and damaged when the

membranes rupture.

it is catastrophic for the fetus as it

is fetal blood that is lost

placenta praevia.

a velamentous placental insertion.

multiple pregnancy.

Management: When vasa previa ruptured

cardiotocograph will rapidly become

abnormal with a fetal tachycardia,followed

by deep deceleration.

If the baby is still alive once the diagnosis

is suspected, the immediate action is

delivery by emergency Caesarean section

Thank you