Al-Shalabi

Antepartum Hemorrhage by Dr. Haifa' Hope Group

The lecture seems to be long but it's important and easy one inshalla =)

Antepartum = before delivery.

Antepartum hemorrhage means Vaginal bleeding after age of viability (during the
antenatal period and during labor, but before delivery .

The age of the viability is 24 weeks.

This is a very important topic because blood loss is a major cause of maternal
mortality! And that IS CATASTROPHIC EVENT, it's death of a young healthy
reproductive woman.

Maternal mortality rate

- Maternal mortality is 8 per 100,000 live births in the western communities.

- in Jordan it's 19/100,000 live births.
- in Africa it's 500/ 100,000 live births or even more (due to non reported cases).

and we consider 19 per 100,000 a figure that should be reduced.

now the incidence of APH ,,, is about 4% of all pregnancies .. when we are talking about
APH there are 2 main causes; placenta previa and placental abruption, and the 3 rd group
labeled as unclassified causes which includes :

 50 % marginal separation of the placenta abruption which is premature separation

of the placenta.
 the 2nd is passage of show during labor (bloody discharge)
local causes like polyps, cervical erosions , malignancies , local trauma
 small % of vasa previa which is not maternal bleeding
 unknown causes

So Let's start with;

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 Antepartum Hemorrhage by Dr. Haifa' Hope Group

Placenta Previa:
Placenta previa is an obstetric complication in which the placenta is inserted partially or wholly in the
lower uterine segment. It is a leading cause of antepartum haemorrhage,

In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. In a
normal pregnancy the placenta does not overlie. If the placenta does overlie the lower segment, as is the
case with placenta previa, it may shear off and a small section may bleed. Wiki
Diagnosis of placenta previa is made after 28 weeks .

 Incidence 1/250 deliveries.

 20-30% of APH.

 Characteristic of PP : Majority of cases present as painless vaginal bleeding. Very

important point because clinically it's considered the main difference between
Placenta Previa and placental abruption .

 20% of patients complain of bleeding and abdominal pain (the cause of this pain:
placenta previa is a risk factor for preterm labor,, and labor means uterine
contractions (uterine muscle ischemia = pain).

 Incidental discovery: used to be very small % but nowadays it's being common
incidentally diagnosis early in pregnancy. Mainly late in the 2nd trimester!

o Note these 2 pictures showing fetus in cephalic presentation – longitudinal lie

with normally situated placenta in the upper uterine segment by the left
picture.
o While the one in the right represents abnormal implantation of the placenta in
the lower uterine segment.

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What is difference between upper & lower uterine segment ??

- Muscle content, During pregnancy each muscle cell is getting longer and larger
and arranged in an interrelating pattern , after delivery of the fetus, the uterus
will be contracted and retracted (shortened),after the contraction subsided,
retraction remains, this results in what's called living suture or natural ligature
that closes blood vessels perpendicularly.
The lower uterine segment is thin, less contractile opposes very thick musculature
in the upper segment.

- Blood supply (higher in the upper segment). Poor blood supply in the LUS, now
as placenta is the organ that transfer oxygen and nutrients for the baby, it will
compensate this by getting wider and thinner, and normally after delivery of the
placenta, the natural mechanisms will close the vessels to stop bleeding,, but in
case of placenta previa, it may need manual digital try to deliver it, not retracting
LUS >> loss of physiological ligature >> more bleeding . so it increases the risk for
postpartum hemorrhage not only for APH.

Predisposing factors

Multiparity , but may happen in primigravida

Increased maternal age

Previous placenta previa, recurrence rate 4-8%

Multiple gestation: here either we have 2 placentea or one large placenta which will
go to the LUS (by gravity).

Previous cesarean section (placenta comes over the scar of previous C/S (in the LUS
which is common type of uterine incisions >> further replacement of the muscle by
fibrous tissue which increases the risk for placenta accrete, increta and percreta – a
very serious pregnancy conditions.

Uterine anomalies. Like Fibroid occupying the fundus..etc

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The lower segment is a potential state which is formed after 28 weeks gestational age, after
that it gets wider and thinner.

Classifications into Major vs minor and others into different grades

Minor in other classifications equals low grade 1 and grade 2 anterior = low lying placenta,
in which only the margin of placenta is reaching the lower uterine segment, and major
includes grade 2 posterior, grade 3 (partially covers the internal os ) and grade 4 which is
called centralis or complete placenta previa (total internal os covering).

The more major the degree, the more serious the condition is, and more bleeding is to be
happened.

Minor

- Grade I, Low lying placenta (neither reaching nor partially covering the cervical os,
mostly stable pregnancy, vaginal delivery is possible.
- Grade II anterior, marginal.

Major = incompatible for vaginal delivery.

- Grade II posterior
- Grade III, partial
- Grade IV, central, complete.

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Nowadays we have a better way of defining placenta previa;

Any placenta that is 2 cm or less from the cervical os by U/S is placenta previa that
need to be delivered by cesarean section.

And this is most accurate way in setting the degree of placenta previa.

So 2 cm and below is PLACENTA PREVIA.

Presentation of placenta previa

OTHER THAN accidental discovery are:

- Painless vaginal bleeding, more severe with major degrees.

Uteral placental blood flow reaches 700 ml/ min in pregnancy, 800-1200 in
American schools, and so these patients can lose about 1 L/min! A very
serious problem.

- Recurrent bouts of bleeding may be from early pregnancy.

- Very high incidence of Malpresentation and high presenting part. Breech

presentation, transverse lie, and even in cephalic presentation, the placenta
interferes with normal engagment.

- Uterus is soft and not tender. Clue to differentiate it from abruption.

- Fetus is usually alive and well even if the mother bleeds heavily, unless she is
shocked!

- More serious for mother than fetus. How??

Maternal risks

Maternal mortality 0.1% mainly from hemorrhage.

PPH.
Complications of C/S and general anesthesia (bleeding + hypotensive effect of
anesthetic agents). But spinal or regional anesthesia is associated with low risks.
Sepsis because of C/S.
Air embolism

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DIC, it is not a complication of placenta previa but can result from prolonged
shock and hemo-dilution if I don't correct blood loss early.

Fetal risks
The major risk to the fetus is prematurity. Because of the risk of bleeding by the age
of 30 weeks.

IUGR in 15-20%.

Congenital malformations doubled.

Umblical cord complication (risk of cord prolapsed in case of partialis placenta previa
if there is no presenting part and ruptured membranes.

Malpresentation.

Diagnosis

o Ultrasonography

o Abdominal U/S is accurate in diagnosing 95% of placenta previa and its

grades.
o Vaginal U/S usually for placenta attached to the posterior wall and difficult
to define by abdominal ultrasound (done in hospital).
o Double set up examination is rarely needed in patients not actively
bleeding.

Double setup
Double Set-Up examination : vaginal examination in the theater patients are prepared
for caesarean section. At vaginal examination, placenta praevia is checked for. If
major placenta praevia is confirmed or bleeding occurs then a caesarean section is
performed immediately.

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What if you don’t have U/S?

How to take decision of delivery mode by differentiating it from abruption?

Never depend on clinical picture in differentiating between the 2 conditions

because it's suggestive not diagnostic and that mean you may see patients
without classical symptoms, so follow the double setup procedures.

This is U/S view shows Grade 4 Placenta previa, the grayish part that
totally covers the cervical os.

Again here the placenta is reaching the cervix and partially covering it so it's grade 3 but
still major placenta previa! And I can measure the distance between its lower edge and
the cervical opening. I can say this is 2 or 3 cm away from the os…etc

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If placenta previa is present or suspected, DO NOT PERFORM VAGINAL

EXAMINATION, especially in acutely bleeding lady. Why?
because palpation can cause local placental separation and precipitate more
hemorrhage.

Management
 Proper assessment of maternal condition and resuscitation (any patient
admitted with bleeding should receive two canulas, until determining if she
needs fluid replacement or blood transfusion to establish her circulation, if she
needs resuscitation the first thing that I should start with is crystalloid solution
- we don't use colloid- we use FFP to avoid Hemodilution*, and blood
transfusion by packed RBC. this is the most important step.

Hemodilution
Increase in the fluid content of blood, resulting in diminution of the
concentration of formed elements (RBCs and other blood elements.

 In severe bleeding, resuscitation is not enough and emergency cesarean delivery is

needed irrespective of gestational age, 26,30 ,35…etc. (Mother's life is my aim).

 If bleeding (either mild or heavy) is after 36-37 weeks, again deliver her. For cases of
mild bleeding I will plan delivery to the next day but not more because no benefit
from waiting and the next amount of bleeding will be even heavier and might lead to
maternal mortality.

If bleeding is not heavy and in early pregnancy (prematurity), we try to reach fetal maturity
(36-38 weeks) without risking maternal health. So any time she encounters severe bleeding
you have to deliver her by C/S.

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Expectant management should be followed if haemorrhage is not severe and pregnancy has
not reached 36-37 weeks. Postpone delivery until 37 weeks unless earlier intervention is
indicated for fetal or maternal reasons.

Expectant management??
o Keep in hospital. especially in patients with major degree and those who are far away
from hospital.

o Corticosteroids to improve the development of pneumocyte type 2 which are

responsible for surfactant secretion and thus decreasing the incidence of RDS, it is
given in gestational age from 30-34 weeks.

o Correct anemia ? (for example a pregnant lady in her 37 weeks or in labor comes
with 9 g Hb and I confirmed that she has IDA? Then what to do? Give >> oral iron
supplements and it's ok, I will do for her cross matching and see if she will bleed or
not, I don't need to do blood transfusion because it's a serious thing. But in cases of
placenta previa you have to reach Hb to at least 10 by blood transfusion because
they don't have time, they may bleed after 2 hours. Bleeding of an anemic patient
leads mostly to shock.

o One unit of packed RBCs should increase levels of hemoglobin by 1 g

per dL.

o Cross-matched blood should be available all the time for those patients depending
on the situation, sometimes they need 4-6 cross matched units

o Assess fetal well-being by routine checking of growth, daily fetal heart and CTG.

Delivery
 Delivery is by cesarean section. any patient with PP who is bleeding must be
delivered by C/S even if it's marginal.

 Very occasionally ?? fetus with anterior marginal placenta with lower margin >2cm
from the internal os (by USS), in which there is no bleeding and no other indications
for C/S,, may be delivered vaginally.

 Observe for PPH.

 Prophylaxis for Rh isoimmunization with higher doses of anti-D because of more

fetomaternal hemorrhage.
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Other important conditions of the placenta not mentioned by the dr.

The placenta attaches strongly to the myometrium, but does not penetrate it. This
Placenta accreta
form of the condition accounts for around 75% of all cases.

Placenta increta Occurs when the placenta penetrates the myometrium.

The worst form of the condition is when the placenta penetrates the entire
Placenta percreta myometrium to the uterine serosa (invades through entire uterine wall). This variant
can lead to the placenta attaching to other organs such as the rectum or bladder.

***

Placental abruption

Normally the placenta is separated after delivery of the baby, in the 3 rd stage of labor

- Abruption is premature separation of the placenta (before delivery of the fetus either
in antepartum period or during early stages of labor).

- Common, Incidence 0.5-1.5%.

- Very serious problem leads acutely to fetal hypoxia and lately to deprivation of
nutrients and that depends mainly on degree of separation.

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Antepartum Hemorrhage by Dr. Haifa' Hope Group

Predisposing factors
- Hypertension, mostly PET, thrombophilia in pregnancy.

- Previous placental abruption- a major factor- because recurrence rate after one
episode is 8-17%, after two episodes 25%.

- Trauma, mainly blunt trauma of the abdomen, mostly in RTA

- Polyhydramneous by itself doesn't cause abruption but if ROM happened, sudden

drainage of the liquor and contraction of uterus may result in placental separation.

- Premature rupture of membrane PROM; especially if they develop chorioamnionitis.

- Short cord ( cord maintains blood supply and drainage of fetus) so the fetus is having
all his needs thus he is healthy and moving, fetal movement with short cord acts like
traction force to the cord and placenae resulting in increased risk of separation.

- Smoking.

- High parity and low social class. Why? Because unbooked status, common
multiparity, lack of antenatal care and traditional abdominal massage during
pregnancy are predisposing factors to abruptio placenta.

- Idiopathic, represents majority of patients.

Clinical presentation
- Concealed: 25-30% ,no vaginal bleeding, when the separation starts from the
center of placenta, the blood will be collected behind the placenta (between the
placenta and the uterine wall). ‫ يتجمع الدم على شكل تخثر كبير في الرحم‬،‫ غير مكتشف‬،‫مختفي‬
very serious condition, may lead to consumption of coagulation material and
development of DIC.

- Revealed 65-80%: vaginal bleeding, Majority of patients. Note that half of those of
concealed presentation, by time they will reach you with vaginal bleeding.

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You have to keep in mind that vaginal bleeding in abruption does not reflect the
actual amount of bleeding.

- Another classification of abruption depending on the amount of bleeding, maternal

condition and fetal condition is:

1. Mild : Many mild cases left undiagnosed until delivery mainly in cases of marginal
separation of placenta.
2. Moderate.
3. Severe; in complete separation.

Classification BY Grades

Grade 0.
Asymptomatic, small retro-placental clot seen after delivery.

Grade 1.

* External vaginal bleeding.

*Uterine tetany and tenderness may be present.
*No signs of maternal shock.
*No evidence of fetal distress.

So again don't depend on clinical picture alone in diagnosis. Don't say this is abruption and I
can do vaginal exam because even in major separation when the placenta is located in the
posterior wall, abdominal tenderness may be absent.

Grade 2.
o External vaginal bleeding may or may not be present.
o Uterine tenderness and tetany
o No signs of maternal shock.
o Signs of fetal distress present.

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Grade 3.

o External bleeding may or may not be present.(concealed).

o Marked uterine tetany (very tense uterus, fetal parts cannot be felt due to
Couvelaire uterus.

o Persistent abdominal pain.

o Maternal shock.
o Fetal death or distress.
o Coagulopathy in 30% of the cases.

"Couvelaire uterus"

Is a phenomenon wherein the retroplacental blood may penetrate through the thickness of
the wall of the uterus into the peritoneal cavity. This may occur after abruptio placentae.

Differential Diagnosis
 Revealed: may present like placenta previa or local causes.

 Concealed: differentials of acute abdominal pain:

Intraperitonial haemorrhage .
Ruptured uterus.
Abdominal pregnancy.
Acute polyhydramnious .
degenerated fibroid or complicated ovarian cyst.
Volvolus & Peritonitis.

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Clinical presentation
- Vaginal bleeding, variable amount, no bleeding in concealed

- Abdominal pain( majority of cases), discomfort and backache in 65% of cases.

- Uterine tetany and tenderness over placental site, more in concealed.

- Normal lie and presentation, like any other pregnancy.

- High incidence of fetal distress and fetal death. Fetus is dead in 25-35% of
cases at admission (perinatal mortality 4.4-67%). Variable statistics depending
on the site of abruption of the selected samples.

- Blood pressure may be normal or elevated (majority of them are originally

hypertensive), protein urea (IUGR present in 80% of cases delivered after 36
weeks of gestation and this indicates evidence of vascular problem occurs in
abruption even if there is no risk factors), Over distended uterus, rigid, difficult
to feel fetal parts and fetal heart may be negative in concealed hemorrhage.

- Evidence of DIC; skin ecchymosis in 13% of cases, bleeding from puncture sites
or hematuria, usually those admitted with fetal death.

Management
- Mild cases no fetal or maternal compromise with early gestational: Conservative .
it may progress into an established abruption so you have to do:

- Admission.

- Blood workout and cross- matching

- Steroids in less than 34 weeks GA.

- Strict observations may change to severe.

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- Twice daily CTG

- Ressuscitation, IV canula ,IV crystalloid

- Cross match blood and FFP.

- Assessment of mother, put fixed catheter, CBC ,KFT (because of early involvement
of the kidney, catheter for urine output measurement Urine for protein,
coagulation profile: (thrombocytopenia is the earliest indicator of DIC ,

 plts count < 100,000 / microL= thrompocytopenia.

 Plts < 50,000 bleeding from any site of injury.

 Plts < 20,000 bleeding from any site.

- Assessment of fetal wellbeing, CTG. If the baby is distressed, aim for immediate
delivery.

- Definitive treatment by delivery, assess for labor,if the cervix is dilated do ARM
(artificial rupture of membrane even if you are planning for C/S, Why?? Because
this will reduce the pressure inside the uterus and separate the clot from the
uterine wall and thus reduces more absorption of coagulation factors from the
circulation. Give syntocinon infusion, and note any fetal distress or deterioration
of maternal condition happened, deliver by C/S.

- DIC management ,DIC is a self limiting process, once you end its cause, the
coagulation profile corrects itself ! Our role is to maintain the patient for the next 2
hours by giving him packed RBC and FFP and platelets if needed.

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- Observe for PPH. Why?? Because of 1- DIC, 2- the uterus will be containing blood>>
risk for uterine atony because it results in Couvelaire uterus, if you do C/S you will
find an organ with blue like a blood clot. Fibrinogen degradation product (byproduct
of DIC can prevent uterine contractions in addition to its action as anticoaugulant.

Observe urine output even after delivery; Early deposition of blood byproducts in the
kidney>> renal hypoxia>> risk of renal tubular or cortical necrosis., Some patients
with severe abruption may end up with chronic renal failure.

***

The left picture shows normal pregnancy, normal site and attachment of the
placenta.

In the right one, part of the placenta is separated from the uterine wall. Once the
clot reaches the margin it will bleed.

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Sometimes there will be tear in the membranes >>> parts of the placenta will
go in >>> ROM>> bloody liquor >> which is one of the urgent cases of
abruption.

Note the two parts of placenta, pale and dark.

About 50% of the placenta is separated (Dark clots

covers half of the placenta.

VASA previa
Is included in APH but it's a fetal bleeding.
Fetal bleeding presented as acute fetal distress after ruptured membranes.

Abnormal placental shape >>> blood vessels running from lobe to another, so during
artificial ROM , cut to these vessels is a possible cause fetal bleeding >> because of
very small intravascular volume of the fetus >> so loss of fetal blood loss more than
10ml has a considerable effect to the baby.

In Acute fetal distress, immediately deliver the baby by C/S and many of them
needs blood transfusion to correct their anemia.

The END =)

Done by: Fatima Al Kasasbeh

"Do not take someone's silence as his pride, perhaps he is busy fighting with his
self." Ali ibn Abi Talib

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