LECTURE NOTES ON

ANTEPARTUM AND
POSTPARTUM
HEMORRHAGES
TESHALE W.(MD)

Late pregnancy
complications
Preterm labor
Premature rupture of membranes(PROM)
Post term pregnancy
Rh-isoimmunization
Intrauterine growth restriction(IUGR)
Large/small for gestational age fetus(LGA/SGA)
Antepartum/postpartum hemorrhages
Pregnancy induced hypertension(PIH)
Poly/oligohydramnios
Gestational diabetes mellitus(GDM)

ANTEPARTUM HEMORRHAGE

Definition
Bleeding per vagina after the 28th wk of GA
Common causes:
Placental abruption
Placenta prevea

Less common causes:

Vasa prevea
Circumvallate
Local causes
Cervicitis
Cervical cancer etc

Placental abruption
Premature separation of a normally implanted

placenta
Prevalence-1% of all pregnancies
Blood loss is both maternal and fetal
Bleeding may be is concealed or revealed
Concealed hge- 20% of cases
Detachment may be complete
Complications often severe

Revealed hge- 80% of cases

Marginal separation

Causes of abruption:
Maternal hypertension-commonest
Maternal abdominal trauma
Multiple gestation
Cigarette smoking
Cocaine use
Other risk factors:
PROM
Delivery of first twin
Retroplacental leiomayoma

Amniocentesis through the placental

Old maternal age
Short umbilical cord
History of abruption
Idiopathic

Clinical features:
Dark and nonclotting vaginal bleeding-80%
Abdominal or back pain and uterine tenderness70%
Fetal distress

Abnormal uterine contraction

Hypertetanic, high frequency
Premature onset of labor
Fetal death
Poor BPP
Stony hard or board like uterus
Increasing fundal height

Diagnosis:
Mainly clinical
U/S- not reliable-high false negative rate

Medical challenges:
Classic presentation of abruption esp. with
posterior implantation may be absent
Failure to consider placental abruption in
preterm labor
Absence of vaginal bleeding doesnt exclude
placental abruption
DIC may occur even if clotting factors are
initially are within reference ranges
Normal U/S findings do not exclude placental
abruption

Grading of abruption:
Based on clinical and laboratory finding
Grade 0:
Asymptomatic
Retrospective diagnosis
Clot on a delivered placenta

Grade I:
50% of all cases
<500 ml blood loss or < 25% separation
Mild uterine irritability

Stable maternal V/S and FHB

Usually point tenderness
Reassuring BPP
Mild anemia
Normal fibrinogen and platelet count

Grade II(moderate):
30% of cases
500-1000cc of blood loss and 25-50% separation
Highly irritable and tender uterus
Deranged maternal V/S and FHB
Hardly palpable fetal parts

Non reassuring BPP

Fibrinogen level <150mg/dl
Thrombocytopenia <100,000/mm

Grade III(severe):
25% of all cases
>1000cc of blood loss and >50% separation
Highly irritable and tender uterus
Severe lower abdominal pain
Deranged maternal V/S(shock) and FHB
Hardly palpable fetal parts

Severe anemia(<5mg/dl)
Nonreassuring BPP
Fibrinogen level <150mg/dl
Platelet count <100,000/mm

Maternal complications:
Hemorrhagic shock
Coagulopathy/DIC
Couvelaires uterus
Uterine rupture
PPH
Sheehans syndrome-infertility

Fetal complications:
Perinatal asphyxia
Anemia
IUGR
Prematurity
Fetal distress and death

Management of
abruption
All hospital admissions

(IV fluids and blood transfusions)

Options of management-expectant vs.
aggressive
Decision is based on:
Maternal and fetal conditions
Extent of bleeding
Level of Hb, platelet, and fibrinogen
Bishop score
Presentation, position and station

Vaginal delivery is preferred-either by

induction or spontaneous onset

Section is reserved for emergency cases
Indications for immediate termination:
Term pregnancy at presentation
Continuous vaginal bleeding regardless of
GA
Deteriorating maternal V/S and FHB
despite optimum treatment
Couvelaire's uterus
Coagulopathy/DIC

Expectant management:
Preterm pregnancy with stable maternal V/S
and FHB
No life threatening complication yet developed
Strict follow up of maternal (vaginal bleeding,
V/S) and fetal conditions(FHB, BPP etc.)
Steroids for fetal lung maturity(dexamethasone,
bethamethason)
GA cut point for termination-34wks

Placenta prevea
Placental implantation in the lower uterine

segment within the zone of effacement and

dilatation(not >2cms far from the internal
cervical OS)
Diagnosed after 28th wk of GA
only 20% are complete PP
90% of all are parous women
Prevalence <1% of all pregnancies
Source of bleeding usually maternal
May manifest early as a threatened abortion

Risk factors:
Endometrial scarring in the upper
segment(C/S, myomectomy, curettage ,
repaired rupture, polypectomy)
One prior C/S-0.9%
Two prior C/S-1.7%
3 or more prior C/S-3%

Multiple gestation
Multiparity(0.2% in nulliparous, 5% in

grandmultiparas)

Advanced maternal age

Large placentas such as in GDM
Abnormal forms of placentas such as

succenturiate lobe
Need for increased placental surface area to
compensate for a reduction in uteroplacental
oxygen or nutrient delivery such as in case of:
Maternal smoking
Higher altitude residence
Multiple gestation

Causes of bleeding:
Mechanical separation such as during effacement
and dilatation
Placentitis, PV, PR, coitus
Rupture of veins in the decidual basalis
Abdominal trauma
Associated conditions:
Placenta accreta-in 5-10% of pregnancies with PP
Malpresentation
PROM
IUGR-in up to 16% of pregnancies with PP

Vasa prevea and velamentous umbilical cord insertion

Congenital anomalies
Amniotic fluid embolism(AFE)

Clinical manifestations:
Sudden, bright-red, painless vaginal bleeding is the
hallmark of PP- in 70-80% of cases of PP.
No abdominal pain or tenderness unless there is
uterine contraction which is rare(10-20% of cases)
About 10% of women term with out bleeding
Most episodes of bleeding begin after 28 th wk of GA
but spotting may also occur in the 1st and 2nd TMs

Diagnosis:
Clinical
TVU/S and TAU/S-95% diagnostic
Double set up examination
Based on U/S:
Complete PP

Placenta completely

Partial PP:
Placental edge partially covers the internal cervical
OS

Marginal PP:
Placental edge is adjacent to the internal OS
Low-lying PP:

Placental edge lies within 2-3cm of the internal OS

Complications:
Premature labor
Hemorrhagic shock
Fetal distress and death
Malpresentation
Amniotic fluid embolism
Infection

Management of placenta prevea

All hospital admissions-IV fluid and transfusion
Management may be is expectant or aggressive
No use of uterotonics such as oxytocin

Vaginal delivery may be allowed in anterior lying PP

Decision is based on:
Gestation age
Maternal and fetal condition
Amount of blood loss
Presentation, position and station of the fetus
Cervical status(Bishop score)

Indications for immediate termination:

Term pregnancies at presentation
Continuous vaginal bleeding regardless of the
GA
Deteriorating maternal V/S and FHB despite
optimum treatment
Congenital anomaly of the fetus which is
incompatible with life

Expectant management:
Preterm pregnancy with stable maternal and
fetal conditions
No life threatening complications yet developed
Strict follow up of maternal(vaginal bleeding,
V/S) and fetal(BPP, FHB) conditions
Avoiding precipitants of bleeding such as
exercise, PV, PR, coitus-strict bed rest
Steroids for fetal lung maturity
GA cut point for termination

NB:
PV is absolutely contraindicated in a pregnant
mother presenting with vaginal bleeding after
28th wk of GA until PP is ruled out by abdominal
U/S

Vasa prevea
The fetal blood vessels, unsupported by either

the umbilical cord or placental tissue traverse

the fetal membranes across the lower uterine
segment b/n the fetus and the cervix
Bleeding is almost exclusively fetal
Fetal mortality rate-almost 100%
Associated with placental anomalies such as
Circumvallate placenta

Five top causes of maternal

mortality in Ethiopia
Hemorrhage
Pregnancy induced hypertension(PIH)
Abortion
Infection

Postpartum
hemorrhage
Defined as:
Vaginal bleeding post delivery in excess of:
500cc in vaginal delivery
1000cc in C/S delivery

If there is 10% loss of total blood volume

If patients hemodynamic status is deranged to

the extent of requiring transfusion regardless of

the amount of blood loss
Total blood loss about 1% of patients body
weight

About 50% of mothers bleed up to 500cc during

vaginal delivery and 1000cc during C/S delivery

with no adverse effect
Actual measured blood loss during
uncomplicated vaginal delivery averages to
700cc
But blood loss often may be underestimated
But for severely anemic women even loss as
little as 200cc may be fatal
Nevertheless the criterion >500cc is acceptable

Bleeding may occur before, during and after

delivery of the placenta

Prevalence-10%
Major contributor of the top five causes of
maternal mortality in our country
Classification based on time of occurrence:
Primary(early) PPH
Within the first 24hrs postpartum
Uterine atony
Retained products of placenta and membranes(RPC)

Uterine incision extension

Genital tract laceration
Uterine rupture
Acute uterine inversion
Cervical prolapse
Coagulation disturbances

Secondary(late) PPH:
24hrs to 6wks postpartum
Retained products of placenta and membranes(RPC)
Uterine sub involution
Chronic uterine inversion

Placental polyp
Coagulation disturbances
Endometritis
Myomatous uterus
Choriocarcinoma

The 4Ts causing PPH-pneumonic

Tone, tissue, trauma and thrombosis
Evidence of uterine atony(uterine laxation)
Over distended(boggy) uterus
Progressive uterine size increament
Continuous vaginal bleeding
Absence of genital tract laceration

Most PPH cases occur in the third stage of

labor
Failure to actively manage the third stage of
labor(failure to institute ATSM)
Physiologic vs. active management of the
third stage
Signs of placental separation in ATSM
Lengthening of the umbilical cord
Gush of blood per vagina
Uterus becomes globular and firmer

Management of PPH
Anticipation of PPH-b/c 75% PPH is unpredictable
Anticipation of PPH 2to uterine atony such as in:
Prolonged labor
Multiparity
Prolonged oxytocin stimulation(induction and
augmentation)
Pregnancy induced hypertension
Previous history of PPH
Placental abruption
choriamnionitis

Polyhydramnios
Macrosomia
Myomatous uterus etc

Prevention of anticipated PPH

Keep IV line open
Avoid injudicious use of uterotonics
Institute ATSM properly
Inform the most senior person around
Prepare X-matched blood

Approach to the patient:

Team management
Call help
First person-arrest bleeding
Second person-opens IV line
Third person-collects blood for Hb and X-match
Fourth person-compresses the abdominal aorta

Intervention to arrest bleeding:

Uterine massage
Bimanual uterine compression
Administration of uterotonic drugs
Deflating the bladder
Compressing the abdominal aorta
If the above intervention fails to stop the bleeding:
Curettage for any RPC
Uterine artery ligation
Hysterectomy
Uterine artery embolization
B-Lynch suture

END