At the end of this tutorial the student will be able to:

Define APH Discuss the etiology and differential

diagnosis of APH Describe the assessment and

management of a woman with APH

Definition and Classification

Definition bleeding from or in to the genital tract, occurring from 22 weeks (>500g) of pregnancy and prior to the birth of the baby.

Classification Placenta praevia

Abruptio placenta

CAUSES OF 763 PREGNANCY-RELATED DEATHS

DUE TO HEMORRHAGE

CAUSES OF HEMORRHAGE NUMBER (%)

Placental abruption 141 (19)

Laceration/uterine rupture 125 (16)

Uterine atony 115 (15)

Coagulopathies 108 (14)

Placenta previa 50 (7)

Uterine bleeding 47 (6)

Placenta accreta/increta/percreta

44 (6)

Retained placenta 32 (4)

Placental: - Placenta praevia - Placenta abruption - Vasa praevia

Local cause: - Cervical polyps - Cervicitis, Vaginitis - Cervical cancer.

(Should be taken after the mother is stable.) Severity of the bleeding

-associated pain with the haemorrhage?

-Continuous pain : Placental abruption.

-Intermittent pain : Labour. Time of onset Triggering factors A/w pain or uterine contractions? Fetal movement

-If it reduced and associated with spontaneous or iatrogenic rupture of the fetal membranes : ruptured vasa praevia

Hx of ruptured membranes Hx cervical smear (date/normal or abnormal)

-Previous cervical smear history possibility of Ca cervix. Symptomatic pregnant women usually present with APH (mostly postcoital) or vaginal discharge.

Previous ultrasound report Risk factors for abruption and placenta praevia should be identified.

General: PULSE & BP Abdomen: The tense, tender or ‘woody’ feel to the

uterus indicates a significant abruption. Painless bleeding, high fetal presenting part –

Placenta praevia - soft, non-tender uterus may suggest a

lower genital tract cause or bleeding from placenta or vasa praevia.

Speculum : -identify cervical dilatation or visualise a

lower genital tract cause.

Digital vaginal examination - Should NOT be done until Placenta

Praevia has been excluded by USG.

Blood test - FBC - Coagulation profile - Cross-match blood Ultrasound Colour doppler Kleihauer test

Fetal monitoring: CTG monitoring

Conservative Management

Admit ( according to RCOG is 28weeks)

Monitor BP & Pulse rate Pad chart -  to monitor progress of

the leaking liquor Minimize the abdominal examination

Monitor fetal well being - Fetal kick chart(daily) - CTG (weekly) - U/S (fortnightly)

Steroid injection (> 24w, <36w) ‐ IM dexamethasone 12mg stat and repeat the second dose after 12 hours.

Any symptoms or signs of labour  �

Maternal complications Fetal complications

Anaemia Fetal hypoxia

Infection Small for gestational age and fetal growth restriction

Maternal shock Prematurity (iatrogenic and spontaneous)

Renal tubular necrosis Fetal death

Consumptive coagulopathy

Postpartum haemorrhage

Prolonged hospital stay

Psychological sequelae

Complications of blood transfusion

Definition The condition that the placenta is wholly or partly attached to the lower uterine segmentClassification (GRADING/CLINICAL)

Type IV The placenta completely covers the cervical os.

Type IV The placenta completely covers the cervical os.

Type III The placenta covers the os but not at full dilatation.

Type III The placenta covers the os but not at full dilatation.

TYPE II The placenta reaches the margin of cervical os

TYPE II The placenta reaches the margin of cervical os

TYPE 1 The placenta enroaches into lower segment

A PLACENTA WHICH HAS IMPLANTED OVER THE OS

Placenta

Cervix

Uterus

Minor : Type 1 (anterior/posterior) Type 2 anterior

Major: Type 2 posterior (dangerous type) Type 3 Type 4

Deliver vaginallyType 1 Posterior > likelihood of fetal distress

Caesarean sectionType 2 posterior > chance of fetal distressType 3 & 4 anterior –cut through placenta to deliver. Hence need to be fast and efficient.

ETIOLOGY

Advancing maternal age Multiparity Prior cesarean section ,manual

removal of placenta and dilatation and curettage(D&C)

Multiple gestation Smoking History of PP

PATHOLOGY

Maternal influence

Haemorrhage Shock Anemia

Fetal influence Distress or

death IUGR Premature Neonatal death

The incidence of placenta praevia is 0.5%, bleeding from a placenta praevia is about 20% of all cases of antepartum hemorrhage.

The incidence of placenta praevia is 0.5%, bleeding from a placenta praevia is about 20% of all cases of antepartum hemorrhage.

PATHOPHYSIOLOGY

During the trimester of pregnancy Slight or severe bleeding from the vagina without evident cause and without any pain on the abdomen.

During delivery Severe haemorrhage is inevitable as the cervix dilates, especially in type I and type II.

During the third stage of labour Postpartum haemorrhage

•Intermittent painless PV bleeding

•Minimal/spotting

•Bleeding mainly from mother

•Abdomen is soft and nontender

•CTG usually normal

•a/w with abnormal lies and presentation

Maternal:1)FBC2)BUSE/RP3)GSHFetal1)CTG2)U/S

Low Lying Placenta PraeviaImage shows (Transvaginal Ultrasound, 33 weeks gestation): On transvaginal scan, the placenta is situated on the posterior uterine wall (arrow) and extends to 15mm of the internal cervical os. The cervix is long and closed through its entire length and measures 38mm. Normal fetal measurements and activity are noted which are not illustrated.

Partial Placenta PraeviaImage by (Transvaginal Ultrasound): The placenta partially overlies the internal cervical os (arrow).

Complete Placenta PraeviaImage by (Transvaginal Ultrasound): The placental completely covers the top of the internal cervical os (arrow).

Type I,II(ant) Type II( post), III,IV

ARM +/- oxytocin

Satisfactory progress without bleeding

Vaginal delivery

Bleeding continues

Caesarean section

Caesarean section