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Definition

Antepartum haemorrhage (APH) is bleeding from the genital tract after the age of viability and before the onset of labour.

The age of viability is 24weeks in developed countries and 28 weeks in developing countries.

APH is an obstetric emergency and one of the leading causes of antepartum hospitalization, maternal and perinatal morbidity and mortality, and operative intervention.

Incidence

The incidence of APH is 3 percent in developed countries.

Classification

Classified based on etiology into placental causes and local causes.

Placental causes
1. Placenta praevia
2. Abruptio placentae
3. Vasa Previa

Local causes

  1. Cervicitis
  2. Cervical ectropion
  3. Cervical polyp
  4. Cervical erosion
  5. Cervical carcinoma
  6. Vaginal trauma
  7. Vaginal infection

NOTE: When the above causes have been ruled out, some authors classify this as “Haemorrhage of undetermined origin”.

Placenta praevia

Placenta praevia is defined as a placenta that has implanted into the lower segment of the uterus. Bleeding in placenta praevia is from maternal circulation and is more likely to lead to maternal death.

Incidence of placenta praevia

Incidence is about 1% in some western countries.

Etiology of placenta praevia

The cause of placenta previa is unknown, however, some factors have been associated with its occurrence.

Risk factors for placenta praevia

Risk Factors for placenta praevia
1.  Multiple gestation

2.  previous Cesarean section/ uterine damage

3.  structural uterine anomaly

4.  large  placental surface

 

 5. uterine fibroid

6. advanced age

7. high parity

8. Assisted conception

NOTE: Women with a history of previous caesarean section, have a risk of placenta implantation and invasion on the previous scar. This results in morbidly adherent placenta of which there are three types;
1. Placenta accreta: the placenta is abnormally adherent to the uterine wall.
2. Placenta increta: the placenta is abnormally invading into the uterine wall.
3. Placenta percreta: the placenta is invading through the uterine wall.

 

Classification of placenta Praevia

Major:  the placenta covers the internal cervical os.
Minor: the placenta is sited within the lower segment of the uterus, but does not cover the cervical os.
This has replaced the older I–IV classification system.

Class Extent
Type 1 The placenta encroaches on the lower uterine segment but does not reach the internal os.
Type 2 The placenta reaches the internal os but does not cover it.
Type 3 The placenta covers the internal os but ceases to do so as the cervix dilates.
Type 4 The placenta completely covers the internal OS even with cervical dilatation.

 

Clinical history

Patients present with history of painless vaginal bleeding which may be provoked or spontaneous and usually recurrent in the third trimester.

Clinical examination findings

  1. Signs of anaemia e pallor.
  2. Signs of hypovolemic shock ( hypertension and tachycardia
  3. abdominal examination: Soft, non-tender abdomen, Malpresentation/Abnormal lie.
  4. Fetal heart sound is usually present
  5. Avoid vaginal examination

Investigations

  1. Packed cell volume
  2. Clotting profile
  3. Group and crossmatch 6 units of blood
  4. ultrasound (check fetal size, presentation, amniotic fl uid, placental position and morphology).
    Transabdominal USS is the simple and safest while transvaginal ultrasonography has substantially improved diagnostic accuracy
  5. MRI is more accurate
  6. Examination in theatre( at 38 weeks)

NOTE: At 18 weeks, 5-10% of placentas are low lying. Most ‘migrate’ with development of the lower uterine segment.

Management of placentae praevia

The choice of management is dependent on the degree of bleeding and GA.

Aims of management

  1. Prevent prematurity
  2. Prevent further haemorrhage
  3. Identify anaemia and correct
  4. Institute EXPECTANT or EMERGENCY management

Expectant/Conservative management

This is instituted in patients with minor bleeding before term to allow for further fetal growth and maturation. Also known as MacAfee regime.
Criteria for MacAfee regime

  1. Haemodynamically stable mother.
  2. No fetal distress.
  3. GA less than 36 weeks.
    In the absense of any one these criteria, deliver patient by caeserean section.

Components of MacAfee Regime

  1. Admit patient: on the same plane as the operating theatre.
  2. Correct anaemia: via blood transfusion.
  3. Tocolytics if indicated(Nifedipine, MgSo4)
  4. Corticosteroid to enhance fetal lung maturity: 28 to 34 weeks
  5. Caesarean birth if fetus is thought to be matured (≥37 weeks)

NOTE: MacAfee regimen should be abandoned if there is uncontroled bleeding or evidence of fetal distress.

Emergency management

Involves initial resucitation and delivery by caesarean section irrespective of GA.

Indications for emergency management

  1. Severe intractable haemorrhage ± evidence of shock.
  2. Recurrent bleeding and transfusions.
  3. Fetal distress or demise.

Asymptomatic Placentae previa

Usually discovered incidentally during routine USS and without any prior symptom of vaginal bleeding.
Cases of minor placenta previa can be managed on outpatient basis and should report to the hospital if there is an episode of bleeding. Note that this is reserved for patient who live close to the hospital.
Patient with major placenta previa are admitted at 34 weeks and delivered by caeserean section at 37 weeks.

Complications of Placenta Praevia

Divided into maternal and fetal

Maternal Fetal
1.  APH

2.  Malpresentation

3.  Placenta accreta

4.  Shock/ hypovolaemia

5.  PPH

6.  Puerperal sepsis

7.  Death

 1.  Prematurity

2.  IUGR

3.  IUFD

4.  RDS

5.  Anaemia

 

 

Abruptio Placentae

This can be defined as bleeding from a normally sited placenta (upper uterine segment) as a result of partial or total seperation of the placentae. Bleeding is from both maternal and fetal circulation, however the fetus is more at risk.

Etiology of Abruptio Placentae

The cause if unknown but there are associated factors

Risk factors for Abruptio placentae

Risk factors for Abruptio placentae
1.  Chronic Hypertension

2.  Severe pre-eclampsia and eclampsia

3.  Direct trauma

4.  High parity

5.  Advanced maternal age

6.  Previous abruptio placentae

 7. Uterine fibroid
8. Polyhydramnios9. Cocaine use

10. Short umbilical cord

11. Chorioamnionitis
12. PROM
13. Cigarette smoking

14.  Increased maternal age

 

Incidence of Abruptio placentae

This occurs in 1 percent of pregnancies.

Classification of Abruptio placentae

Classified into three categories

  1. Revealed type
  2. Concealed type
  3. Mixed type

Revealed type: bleeding is revealed through the vagina

Concealed type:  there’s no obvious bleeding through the vagina. Blood reaches the myometrium causing a woody hard tender uterus called couvelaire uterus

Mixed type: a combination of reviewed and conceived

Clinical history

1. Vaginal bleeding,
2. abdominal discomfort/pain which increases in severity
3. Lack of fetal movement
4. Shock i.e sweating and dizziness,

Clicical examination

  1. Shock i.e pallor, cold clammy extremities, tachycardia and hypotension
  2. Abdomen: tense, tender woody hard uterus more marked in the concealed type. Increasing abdominal girth if the abruption is continuing. Constant pain associated with a uterus that is very hard on palpation is known as a Couvelaire uterus and is due to a large volume of blood within the myometrium.
  3. Fetal parts are difficult to palpate and fetal heart beat may be absent or deranged.
    NOTE: Vaginal examination should only be done when the diagnosis of Abruptio placentae is certain and this would show evidence of bleeding in the revealed and mixed type.

 

Investigation

  1. Urgent PCV
  2. Coagulation profile
    3. Group and crossmatch 6units of blood
  3. Acid base status
  4. Serum EUCr
  5. USS may show retroplacental clots. Negative findings do not exclude abruptio placebtae as USS only shows about 25 percent of abruptions.

 

Diagnosis of Abruptio placentae
Diagnosis of Abruptio placentae is CLINICAL by any of the above presentations or by post-delivery retroplacental clot

 

Management of Abruptio placentae

The choice of management is dependent on the level of haemorrhage and the GA.
NOTE:  blood loss may be far greater than the blood loss seen.

Conservative management:
this is adopted when bleeding is mild, mother is haemodynamically stable, fetal heart is reassuring (assessed by an obstetrician) and GA is less than 36weeks. Patient is put on bed rest with close feto-maternal monitoring. Blood should be transfused to correct anaemia. USS should be done at regular interval to check for fetal growth restriction. Patient should be delivered not later than 38 weeks.

Active Management:
This is the management of choice in moderate to severe haemorrhage. The approach depends on whether the fetus is alive or not.

In both cases

  1. Resuscitate patient using the structured approach of ABC.
  2.  Analgesics ie pethidine is given.
  3. Correct Anaemia.
  4. Caeserean section is indicated if fetus is alive,
  5. vaginal delivery is recommended, in the absense of other contraindications.
  6. Active management of third stage of labour is the rule.
  7. Urine output and coagulation profile should be monitored to quickly identify complications ie oliguria and DIC if they occur.

Complications of Abruptio placentae

  1.  Shock
  2. Perinatal
  3.  PPH
  4. Renal Failure (Renal cortical &Tubular Necrosis)
  5. Maternal death
  6. Preterm delivery
  7. Couvelaire Uterus
  8. IUGR
  9. IUFD

Vasa Praevia

Vasa praevia is present when fetal vessels traverse the fetal membranes over the internal cervical os.
These vessels may be from either a velamentous insertion of the umbilical cord or may be joining an accessory (succenturiate) placental lobe to the main disk of the placenta.

The diagnosis is usually suspected when either spontaneous or artifi cial rupture of the membranes is accompanied by painless fresh vaginal bleeding from rupture of fetal vessels.
Immediate Caeserean section should be done in such cases to avoid fetal exsanguination.
Fetal blood can be confirmed by Kleihauer test or simple alkali denaturation test.

Local causes

Already listed above, local causes may present with scanty or insignificant vaginal bleeding. Management is usually cause specific and treated under dedicated chapters.

Summary

APH is bleeding from the genital tract after the age of viability and before the onset of labour. It is an obstetric emergency.
APH is classified based on etiology into Placental and local causes. Placental causes of APH are potentially fatal and should be managed by an obstetrician.