1. May 31, 2023 APH 1
ANTEPARTUM HAEMORRHAGE

2. APH 2
May 31, 2023
Antepartum Haemorrhage
 vaginal blood loss >15 mL after 20 weeks’
gestation
 5% of all pregnancies
 Accounts for 20 -25% of perinatal mortality

3. APH 3
May 31, 2023
Causes
 Placenta praevia 20%
 Placental abruption 30%
 Others/ unknown 45%
 Vasa praevia
 Marginal sinus bleeding
 Rupture uterus
 Local causes 5%

4. APH 4
May 31, 2023
Local causes of APH
 Only 5% of APH
 Causes include:
 Cervicitis
 Cervical erosion, polyp
 Cervical cancer
 Vaginal/ vulval varicocities
 Vaginal infections
 Foreign bodies
 Genital lacerations
 Bloody show
 Degenerating fibroids
 non-genital tract bleeding

5. APH 5
May 31, 2023
Severity of bleeding
 Mild (<15% circulatory volume)
 No change in vital signs
 No postural hypotension
 Normal urine output
 Moderate (15 - 30%)
 Postural changes in BP or pulse
 Symptoms (thirst, dypsnoea etc.)
 Severe (>30%)
 Shock
 Fetal distress
 Oliguria

6. APH 6
May 31, 2023
Initial management of APH
 Admit
 History
 Examination
 Observation
 NO PV Exam
 IV access/ resuscitate
 Clotting screen
 Cross match
 Kleihauer test
 CTG
 Placental localization
 Speculum examination
when placenta praevia
excluded, bleeding
settled
 Anti-D if Rh-negative

7. APH 7
May 31, 2023
Placental abruption
 Separation of placenta before delivery
 Starts with bleeding into decidua basalis
 Impairs placental function
 About 1.5% of pregnancies
 Perinatal mortality 10%

8. APH 8
May 31, 2023
Complications
 DIC
 Fetal death
 Hypovolaemic shock
 Fetomaternal hemorrage

9. APH 9
May 31, 2023
Predisposing factors of abruption
 Hypertension
 External trauma - MVA, ECV
 Acute decompression of polyhydramnios
 PROM
 Substance abuse -tobacco, cocaine,
amphetamines
 Past history of abruption
 Antiphospholipid syndrome
 Multiple pregnancy

10. APH 10
May 31, 2023
Classification of abruption
 Mild
 Blood loss < 200 mL
 No uterine tenderness or rigidity
 Normal CTG
 Moderate
 Blood loss > 200 mL OR
 Uterus tense and tender OR
 Abnormal CTG
 Severe
 Fetal death - DIC in 30%

11. APH 11
May 31, 2023
Clinical features
 Vaginal bleeding in 80% (Revealed)
 Abruption is ‘Concealed in 20%
 Initial bleeding
 Pain, uterine tenderness, rigidity
 Sudden increase in fundal height
 Fetal distress or death
 DIC

12. APH 12
May 31, 2023
Diagnosis
 Clinical diagnosis, confirmed retrospectively by
examination of placenta
 Clinical features important in concealed
abruption
 Ultrasound unreliable
 Only shows 25% of abruptions

13. APH 13
May 31, 2023
Management
 Admit
 History, examination
 Assess blood loss
 Nearly always more than revealed
 IV access, X match, DIC screen
 Assess fetal well-being
 Placental localization

14. APH 14
May 31, 2023
Clinical flow chart
Is the fetus
alive?
No
Yes
Severe
abruption
(10% of
cases)
Resuscitate
Induction of labour
Vaginal delivery
CTG
Abnormal
?DIC
Yes
No
Correct
Caesarean section
Normal
Uterus tense
IOL
CTG
Abnormal CTG
Normal CTG
Vag del
Uterus soft
> 38/52
< 38/52
Conservative
management

15. APH 15
May 31, 2023
Placenta praevia
 Placenta implanted on lower uterine segment
 1% of all pregnancies
 Perinatal mortality rate ~ 3%
 Major problem is preterm delivery
 At 18 weeks, ~5% of placentas are ‘low lying’

16. APH 16
May 31, 2023
Classification
4 grades or degrees of placenta praevia:
1. Low-lying: edge not near internal os, but could
be palpated by finger through cervix.
2. Marginal: edge of placenta reaches but does
not cover os.
3. Partial: placenta partially covers internal os.
4. Total: placenta completely covers internal os.

17. APH 17
May 31, 2023
Aetiology/ associations
 Uterine surgery or instrumentation
 Previous CS, D&C, myomectomy
 1 previous CS + anterior placenta praevia
= 25% risk placenta accreta
 P H placenta praevia
 Increasing parity and age
 Multiple pregnancy

18. APH 18
May 31, 2023
Clinical presentation
 Painless Recurrent Vaginal bleeding
 1/3 < 30 weeks
 1/3 30-35 weeks
 1/3 > 36 weeks
 Usually first episode mild
 Earlier is worse
 Often gets worse
 Abnormal presentation or lie

19. APH 19
May 31, 2023
Diagnosis
 Placental localization is by ultrasound
examination
 Transvaginal ultrasound better
 Not always right
 PPV 93%, NPV 96%
 At 18 weeks, 5-10% of placentas low
lying.
 Repeat scan at 32 - 34 weeks

20. APH 20
May 31, 2023
Management
 Admit to hospital
 NO VAGINAL EXAMINATION
 IV access
 Placental localization
 Conservative treatment until fetal maturity if
possible

21. APH 21
May 31, 2023
Management
Severe
bleeding
Caesarean
section
Moderate
bleeding
Gestation
>34/52
<34/52
Resuscitate
Steroids Unstable
Stable
Resuscitate
Mild bleeding
Gestation
<36/52
Conservative care
>36/52

22. APH 22
May 31, 2023
Delivery
 Delivery is by Caesarean section
 Usually LSCS, go around placenta
 Beware morbidly adherent placenta
 Occasionally Caesarean hysterectomy
necessary

23. APH 23
May 31, 2023
Outpatient management
 Inpatient observation for 72 hours without
bleeding
 Stable haematocrit > 35%
 Reactive CTG
 Can call ambulance 24 hours/day
 Rest at home, no intercourse
 Patient understands complications
 Weekly follow-up until delivery

24. APH 24
May 31, 2023
Asymptomatic patients
 Placenta praevia now diagnosed
prior to bleeding
 If no bleeding, no need to admit
before 34 weeks
 Admit if bleeds
 Delivery still by CS at 37-38 weeks
 Uncertainty about admission
between 34 and 37 weeks - admit
grades 3 and 4

25. APH 25
May 31, 2023
Vasa Praevia
 Vellamentous insertion of cord, bipartite or
succenturriate placenta
 Fetal vessels in membranes over cervix
 May rupture at or before ROM
 Suspect in small APH with abnormal CTG
 Confirm with Apt test

26. APH 26
May 31, 2023
How to do an Apt test
 Place 5 mL water in each of 2 test tubes
 To 1 test tube add 5 drops of vaginal blood
 To other add 5 drops of maternal (adult) blood
 Add 6 drops 10% NaOH to each tube
 Observe for 2 minutes
 Maternal (adult) blood turns yellow-green-brown;
fetal blood stays pink.
 If fetal blood, deliver STAT.

27. APH 27
May 31, 2023
APH of uncertain origin
 2.5% of all deliveries
 PNM 2% (3x background rate)
 Initial management as for all APH
 Monitor fetal well-being
 Marginal sinus bleeding
 Retrospective diagnosis
 Increased incidences of PROM, preterm labour