CH03

Second Edition of the ALARM International Program Syllabus
CHAPTER 3
HEMORRHAGE IN PREGNANCY: ANTEPARTUM and POSTPARTUM
3.1 Antepartum Hemorrhae
!earn"n O#$e%t"&e':
Recite the incidence of antepartum hemorrhage
List the etiology of antepartum hemorrhage
Distinguish the differences in the diagnosis of Placentea Previa and Abruptio Placentea
Apply the principles of fetal and maternal stabilization in the management of antepartum hemorrhage
A 25-year-old G3 woman presents to the maternity unit with vaginal bleeding. Fetal heart rate is 140 per minute
and her blood pressure is 110!0 and her "# is $5minute. Funal height is 2$ %m. &he has been given nothing. 'hat
are the possible diagnosis(
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)))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))
"ow would you distinguish between the diagnosis(
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3.1.1 Definition
Antepartum hemorrhage is vaginal bleeding from 20 weeks to term !n the non"pregnant state# the uterus receives
appro$imately %& of cardiac output# whereas in the third trimester it receives appro$imately 20& 'terine bleeding
in the third trimester can be massive and can result in a hemodynamically unstable patient
Antepartum hemorrhage occurs in 2& to (& of all pregnancies )he appro$imate proportion of various causes is*
Placentae praevia 20& % in 200 pregnancies
Abruptio placentae +0& % in %00 pregnancies
'nclassified ,(&
Lower genital tract lesion (&
-ther
Placentae praevia and abruptio account for slightly more than half of the cases of antepartum hemorrhage and are
two leading causes of perinatal morbidity and mortality in the third trimester
1) Placentae Praevia
Definition
Localization of the placentae near# partially or completely over the cervical os A total praevia entirely covers the
os# a partial praevia partially covers the cervical os and a marginal praevia is near enough to the os to cause potential
risk of hemorrhage during cervical effacement and dilatation Placentae accreta is a risk in any patient with
placentae praevia )his is especially true in those women with previous uterine surgery and an anterior placentae
praevia Accreta may occur in up to %0& of women with placentae praevia
ALARM INTERNATIONAL * Chapter 3 - Hemorrhage in Pregnancy * 49
Incidence
!ncidence of placentae praevia is 0(& to 0.& of all pregnancies !n early pregnancy# a low"lying placentae will be
found in appro$imately ,0& of patients but will persist in only 0(& of the total cases at term Risk factors include
prior placentae praevia# first pregnancy subse/uent to any uterine surgery# multiple gestation# uterine malformation#
multiparity# advanced maternal age and smoking
2) Abruptio Placentae
Definition
An Abruptio placenta is the premature separation of the placentae from the uterine wall
Incidence
!ncidence of placentae abruptio is %& to 2& of all pregnancies )his incidence rises significantly in a patient with a
previous history of abruptio placentae
Risk factors for an abruptio placentae include a prior abruption in a previous pregnancy# maternal hypertension
0gestational or pree$isting1# abdominal trauma# maternal smoking 02% ppd1# multiparity# advanced maternal age 02,(
years1# drug and alcohol use# uterine malformation# and a short umbilical cord !n addition# abruptio can be
associated with a sudden decompression 3ost abruptions are idiopathic
3.1.2 Diagnosis and Management of Placentae Praevia and Abruptio Placentae
1) Diagnosis
% 4istory and physical e$am 5linical differences will give the first clues to the diagnosis
Avoid a pelvic exam until placentae praevia has been ruled out.
2 6peculum e$am is performed to assess the cervi$ for dilatation or any lesion !f available# an ultrasound should
be done prior to a spe%ulum e*am to +irst rule out pla%entae praevia.
, 'ltrasound is the definitive diagnostic test for placentae praevia Abruptio may be seen on a ultrasound but a
negative ultrasound does not rule out abruptio
+ Auscultation will assist in the assessment of fetal status
Electronic fetal monitoring (EM) and ultrasound !ill furt"er evaluate t"e fetal assessment.
#epeat ultrasound scanning of a lo!$l%ing placentae seen at routine 1&$2' !ee( ultrasound is not
indicated unless t"ere is recurrent bleeding. #epeat ultrasound scanning of a partial or complete
placentae praevia seen earl% in pregnanc% is recommended after 32 !ee(s gestation even !"en
t"ere "as been no vaginal bleeding up to t"at point
)linical eatures of Abruptio Placentae and Placentae Praevia
Abruptio Placentae Placentae Praevia
3ay be associated with hypertensive disorders#
uterine overdistension# abdominal trauma
Abdominal pain and7or backache
0often unremitting1
'terine tenderness
!ncreased uterine tone
'terine irritability
'sually normal presentation
8etal heart may be absent or non"reassuring
6hock and anaemia out of proportion to
apparent blood loss
3ay have coagulopathy
9o apparent cause
Painless 0unless in labor1
'terus not tender
'terus soft
9o uterine irritability
3alpresentation and7or high presenting part
8etal heart usually normal
6hock and anaemia correspond to apparent blood loss
5oagulopathy very uncommon initially
2) Management
Maternal and etal Assessment
4emodynamic stability must be determined immediately and uterine tone and activity evaluated 8etal health must
be promptly evaluated
*nstable Patient
)he two immediate ob:ectives for those patients actively bleeding and hemodynamically unstable are fluid
replacement and delivery
;hile e$pediting delivery the following management steps occur concomitantly*
% Active fluid resuscitation with &aline or #inger via two large bore 0%<# %.1 intravenous lines
2 !dentify and obtain + units of compatible blood
, 5ontinued fetal surveillance
+. ,-%gen administration for all patients !"o are "%potensive (o-%gen consumption is increased
2'. in pregnanc% and t"e fetus is sensitive to "%po-ia).
A cesarean section will be re/uired if bleeding is due to a partial or complete placentae praevia =aginal delivery#
including o$ytocin augmentation and amniotomy may be considered for an anterior marginal placentae praevia
;ith abruptio placenta and instability of maternal or fetal health# a cesarean section should be performed unless
vaginal delivery is imminent !n every instance# the maternal condition must be as optimal as is possible at the time
of cesarean section
Disseminating intravascular coagulopathy 0D!51 should be ruled out# especially in the case of a dead fetus at the
time of presentation A bedside bleeding test can confirm that diagnosis
If coagulopat"% is present/ correct aggressivel% !it" fres" fro0en plasma or cr%oprecipitate. Al!a%s
consider t"e ris( of infection secondar% to transfusions. As soon as clotting factors "ave been
corrected and volume replacement is ade1uate t"e deliver% s"ould be started.
2table patient
Appropriate attention should be paid to the maternal hemodynamic status
3lood s"ould be dra!n for )3) !it" platelets/ blood t%pe and antibod% screen/ and coagulation studies as
above s"ould be done. A 4lei"auer$3et(e test ma% confirm an abruption and is advisable in all cases of
suspected abruption.
!f bleeding is related to abdominal trauma# the patient should be monitored for at least %2"2+ hours to assess for
evidence of fetal compromise related to abruption or fetal maternal hemorrhage
#" immune globulin s"ould be given to all unsensiti0ed #" negative !omen !it" an% bleeding or
suspected concealed abruptio. 5"e dose ma% be ad6usted b% t"e 4lei"auer$3et(e results. 3'' 7g of
#" immune globulin s"ould be given for ever% 3'cc of fetal blood detected in maternal circulation.
(e1uivalent to 18 cc of pac(ed #3)9s)
5ransfer to a "ig"$ris( centre ma% be indicated if t"e maternal:fetal condition and local resources
!arrant it. ;emod%namic surveillance is necessar% at all times to optimi0e maternal:fetal outcome.
5ocol%tics ma% be considered in mild preterm abruption !"ere t"ere is no fetal compromise.
Prolongation of pregnanc% in t"e presence of significant ongoing bleeding is not advisable.
<asa Praevia
)his rare condition occurs in % in (000 pregnancies !n this condition# vessels in the membranes run across the
cervi$ in front of the presenting part
Diagnosis is difficult to make !n the presence of fetal bradycardia with minimal painless vaginal bleeding# often at
the time of rupture of the membranes# this diagnosis should be entertained -ccasionally# the vessels may be felt on
digital e$am prior to rupture of the membranes ;right>s stain on vaginal blood could suggest the diagnosis
8etal mortality is estimated to be as high as (0& to ?0& !f suspected# an emergency cesarean section should be
performed
3.1.3 2ummar%
@ach unit should develop a standard protocol for the management of antepartum hemorrhage )he life"threatening
nature of placental abruption and placentae praevia for both mother and fetus should be borne in mind# as should the
potential for rapid evolution of these conditions =igorous resuscitation should be undertaken when appropriate
'ltrasound determination of placental location should proceed pelvic e$amination when the situation allows
Appropriate surveillance and active management are re/uired
#eferences*
Aaskett# )8# ,ssential -anagement o+ .bstetri% ,mergen%ies ,rd @dition Aristol* 5linical Press Ltd
%BB% p <+ to ?<
Aenson# 3D# .bstetri%al /earls 8A Davis 5ompany %BB+ p %?? to %.+
6e$ton# 3 0he 5 -inutes 1lini%al 1onsult ;illiams C ;ilkins %BB( p +# ( and p .00# .0%
Rasmussen# 6 et al# 0he ,++e%t on the 2i3elihood o+ Further /regnan%y o+ /la%enta Abruption and the
#ate o+ #e%urran%e# Ar D -bs7Eynaecol %BB? 9ov * %0+ * %2B2"(

3.( Po'tpartum Hemorrhae
!earn"n O#$e%t"&e'=
Define postpartum hemorrhage
Recognize etiologic factors for postpartum hemorrhage
Apply appropriate preventive strategies
@mploy the principles of resuscitation in the management of postpartum hemorrhage
4o you routinely give o*yto%in +ollowing delivery either o+ the anterior shoulder o+ the newborn5 or a+ter delivery o+
the pla%enta( 'hy do you use o*yto%in(
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6ou have 7ust delivered a 38 wee3 twin pregnan%y per vagina. 0he third stage is %ompli%ated by postpartum
hemorrhage unresponsive to uterine massage and the use o+ o*yto%in. 'hat would your ne*t management steps be(
3.2.1 Definition and Etiolog%
1) Definition
)raditionally# the definition of postpartum hemorrhage has been blood loss in e$cess of (00 cc in vaginal
deliveries and in e$cess of %#000 cc in abdominal deliveries 8or clinical purposes# any blood loss that has the
potential to produce hemodynamic instability should be considered a postpartum hemorrhage )he amount of
blood loss re/uired to cause hemodynamic instability will depend on the pre"e$isting condition of the woman
4emodynamic compromise is more likely to occur in conditions such as anemia 0eg iron deficiency#
thalassemia1 or volume contracted states 0eg dehydration# gestational hypertension with proteinuria1
2) Etiolog%
!t may be helpful to think of the causes of PP4 in terms of the four )>s*
5one " uterine atony
5rauma " uterine# cervical or vaginal in:ury
5issue " retained placenta or clots
5hrombin " pre"e$isting or ac/uired coagulopathy
)he most common and important cause of PP4 is uterine atony )he primary mechanism of immediate hemostasis
following delivery is myometrial contraction causing occlusion of uterine blood vessels# the so"called Gliving
ligatures> of the uterus
#is( actors for PP;
)he risk factors for postpartum hemorrhage can be related to antepartum# intrapartum and postpartum factors
Antepartum #is( actors
Placental abruption especially if concealed or accompanied by fetal demise
Placenta previa
Eestational hypertension with proteinuria
-verdistended uterus 0eg twins# macrosomia# polyhydramnios# uterine abnormality1
Previous PP4
Pre"e$isting maternal disorder of hemostasis 0eg !)P1
Intrapartum #is( actors
-perative delivery " cesarean or assisted vaginal delivery
Prolonged labor
-bstructed labor
Rapid labor
!nduction7augmentation
5horioamnionitis
6houlder dystocia
!nternal podalic version and breech e$traction of second twin
Ac/uired maternal disorder of hemostasis 0eg 4@LLP# D!51
Postpartum #is( actors
-bstetrical lacerations7episiotomy
Retained placenta
'terine rupture
'terine inversion
Ac/uired maternal disorder of hemostasis 0eg D!51
3.2.2 Prevention and Management
1) Prevention

Active vs E-pectant Management of t"e 5"ird 2tage
PPH ) *++ m! n,(1+-
PPH ) 1+++ m! n,(1+-
Materna. H# / 01 n,1003
1.ood tran'2u'"on
n,((03
Therapeut"% o45to%"n
n,((03
Nau'ea n,63*
+.1 1 1+
Odd' Rat"o 70*8 Con2"den%e Inter&a.9
Out%ome 'u#$e%t'
E.#ourne :R; CCPC
Spr"n 100*.
)AAL@ H Active management of the third stage of labor is advocated
)he management of third stage includes*
% Administer o$ytocin# but never before the delivery of the anterior shoulder 0-$ytocin %0 ' !3 or ( ' != push
or %0"20 '7L != at %00"%(0 mL7h into an e$isting !=1 )here is no evidence that administration of o$ytocin
prior to delivery of the placenta will cause retained placenta -n the contrary# the evidence shows that active
management of the third stage reduces the incidence of retained placenta
2 After delivery of the baby# clamp and divide the cord and take the cord samples including blood gases
!mmediately p
, alpate the uterine fundus and confirm the uterus is contracted
, Ieep tension on the cord pulling gently while applying counter"traction on the uterus with the other hand
Eentle digital e$am along the cord will determine whether the placenta is at the cervi$ Pulling hard on the cord
may cause the cord to avulse or cause uterine inversion " an acute obstetrical emergency
+ !f the placenta has not delivered after %( minutes# infuse o$ytocin at 20 units7L of 6aline or Ringers
( ;hen the placenta is delivered# first assess the fundus and ensure that it is well contracted and that there is no
ongoing significant bleeding )hen inspect the placenta for completeness 9ote any abnormalities that may
indicate retained products 0eg vessels crossing the membranes with no attached succenturate lobe or missing
cotyledon1
< 5onsider the need for an o$ytocin infusion after delivery of the placenta
? !nspect the lower genital tract after all deliveries
. )he cervi$ and upper vagina should be inspected following all operative vaginal deliveries Place + fingers in
the vagina and depress the posterior vaginal wall )he anterior lip of the cervi$ will come into view !f
necessary# grasp this with the ring forceps and pull upwards to bring the entire cervi$ into view or Gwalk
around> the cervi$ with ring forceps Push the cervi$ up into the vaginal vault to inspect the whole vagina for
lacerations
2) Management of PP;
% D,>?5 ,#@E5 A,*# A3)9sBBBBBBBBBB
)alk to and observe your patient
3onitor vital signs
Remember that compensatory responses to blood loss in these patients are e$cellent and may give
caregivers a false sense of security
5ommence at least one large bore != 0%< gauge or larger1
Run a saline drip wide open
,btain a )3)/ C$matc" and possibl% do coagulation studies
@E5 ;EDP " 5onsider the need for additional personnel to manage the resuscitation
" 9otify the lab of potential need for massive transfusion support
2 Assess the fundus 0concurrently with step J%1
!f boggy# proceed to bimanual massage )he uterus is massaged between a hand in the vagina
against the cervi$ and a hand on the fundus )he uterus may be e$plored at this stage to rule
out retained products# uterine inversion or uterine rupture if analgesia allows @$perience in
uterine e$ploration and manual removal of the placenta may be gained at the time of any
caesarean section
, @mptying the bladder may help with assessment and subse/uent manoeuvres in the management of PP4
+ !f the uterus is still boggy proceed with further pharmacologic intervention
( units of o$ytocin != bolus
-$ytocin 20 units7L in normal 6aline or Ringers solution initially wide open
%0 units o$ytocin directly into the uterus if no != access
( !f the uterus is still boggy and the uterus has not been e$plored# this must be done now in order to rule out
retained clots or products# uterine rupture or inversion
< !f bogginess or hemorrhage continues# consider
a1 @rgot 02( mg !3 or 0%2( mg != 0ma$imum of / ( minutes1
- ma$imum cumulative dose of %2( mg
- may inhibit subse/uent e$ploration of the uterus due to tetanic contraction
- hypertension is a relative contraindication
-
b1 3isoprostol 05ytotec1 is currently being studied for prophyla$is and therapy
- !s absorved effectively from rectal# oral or vaginal mucosa
- =ery effective for the treatment of postpartum hemorrhage unresponsive to o$ytocin and
ergometrine
- Dose .00 to %000 micrograms 0four to five tablets1 rectally
c) ;emabate ()arboprost:18$Met"%l Prostaglandin 2
)
$ 28' ug IM or intram%ometrial
$ ma-imum cumulative dose of 2 mg (& doses)
$ ma% in"ibit subse1uent e-ploration of t"e uterus due to tetanic contraction
ast"ma is a relative contraindication
? !f the uterus is firm and the bleeding continues
@$plore the lower genital tract
analgesia must be appropriate
good lighting and e$posure is necessary
appropriate surgical repair of vaginal and bleeding cervical lacerations
may temporise with packing
due bleeding time
if bleeding time is abnormal# give whole blood
&. If t"e bleeding continues and is originating from a firm uterus
Evaluate for an ac1uired coagulopat"%
If coagulation is abnormal
correct !it" P/ cr%oprecipitate/ platelets and P#3)9s
If t"e coagulation is normal
prepare for t"e ,#
rule out uterine rupture or inade1uatel% repaired incision
be prepared to ligate or emboli0e t"e uterine:"%pogastric arteries or perform a
"%sterectom%
if surgical e-pertise is unavailable E consider pac(ing/ s"oc( trousers/ stabili0e and transport
*terine Inversion
-ccurs in %72(#000 deliveries
-ften iatrogenic and more common in grand multips
)he placenta appears at the introitus with a mass attached
)he patient may e$perience shock secondary to bradycardia caused by increased vagal tone
Replacement of uterus should be performed promptly without removing the placenta
Replacement is by Klast out# first inK with pressure applied around the leading point
'se e$ploratory laparotomy for replacement if all else fails
*terine #upture
3ost common in patients with prior uterine surgery
Erand multiparas and patients undergoing induction or augmentation are at risk
5ommonly presents as non"reassuring fetal monitoring or unremitting abdominal pain
8ollowing vaginal delivery a defect may be palpated on manual e$ploration
=igorous resuscitation and emergency laporotomy are indicated
Placenta Accreta
3ost common in patients with prior uterine surgery especially with an anterior placenta
Patients with placenta previa and grand multiparas are at risk
5ommonly presents as retained placenta
!f placenta seems adherent at time of attempted manual removal consider placenta accreta and stop
Appropriate resuscitation and consultation are indicated
3.2.3 2ummar%
% Postpartum hemorrhage is an emergency that re/uires a clear understanding of the pathophysiology responsible
2 A clear management plan that ensures ade/uate volume replacement and secures hemostasis must be in place
, Active management of the third stage of labor reduces the incidence and severity of PP4
+ )he importance of the assessment and management of the patient>s AA5>s cannot be overstated
( Resuscitation should be commenced concurrently with other therapeutic manoeuvres and consideration given to
calling in additional personnel to aid in management
#eferences*
Aaskett# )8# ,ssential -anagement o+ .bstetri% ,mergen%ies ,rd @dition Aristol* 5linical Press Ltd
%BB% pp %B<"2%? L selected references from p 2%<
Drifem D# -anagement o+ /rimary /ostpartum "emorrhage 5 Ar D -bstet Eynaecol# %BB? %0+* 2?("?
Rogers# Dane# et al# A%tive 9ersus ,*pe%tant -anagement o+ the 0hird &tage o+ 2abour: 0he
ALARM INTERNATIONAL * Chapter 3 - Hemorrhage in Pregnancy * 5!
"in%hingbroo3e #andomi;ed 1ontrolled 0rial# Lancet# %BB.# ,(%* <B,"B
6-E5 Euidelines
;alley RL# ;ilson DA# Al# A 4ouble-blind /la%ebo 1ontrolled #andomi;ed 0rial o+ -isopostrol and
.*yto%in in the -anagement o+ 0hird &tage o+ 2abor Aritish Dournal of -bstetrics and Eynaecology#
6eptember 2000# =ol %0?# pp%%%%"%%%(

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Second Edition of the ALARM International Program Syllabus

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