Antepartum Hemorrrhage

• Unknown in the majority of cases
• Previous placenta separation
• Defective trophoblastic invasion
• Direct abdominal trauma
• High parity
• Uterine over-distention
• Polyhydramnios
• Multiple pregnancy
• Fibroids
• Sudden decompression e.g. in artificial rupture of membrane
• Smoking, alcohol and cocaine use
• Hypertension
• Vascular diseases
• Leiomyomas
• Advanced maternal age
• Male fetal sex

• Unremitting abdominal (uterine) or low back pain (2/3 of cases)
• Irritable, tender and often hypertonic uterus
• Visible or concealed hemorrhage
• Fetal distress may be present/absent depending on the severity of separation
• The degree of pallor is usually not reflective of the amount of blood lost (also PCV)

• Clotting profile- clotting time, fibrinolysis test, fibrinogen estimation and fibrinogen degradation products.
• Hb estimation and hematocrit
• Full blood count and differentials
• USS: an hyperechoeic foci posterior to the placenta suggestive of a fresh bleed or hypoechoeic collection in formed clots.
• It should be noted that USS findings are inconclusive in most case. It is mostly useful for ruling out placenta previa.
• Blood grouping and cross-matching at least 4 to 6 units of blood is very necessary.
• Urinalysis- presence of protein in the urine in association with hypertension implicates pre-eclampsia.
• Serum electrolyte, urea and creatinine to determine the level of renal involvement.

Expectant

Hospital admission and bed rest in mild abruption placenta

Predisposing factors such as hypertensive disorders is treated if present

Fetal surveillance, including watching out for fetal growth restriction with regular USS

• Fetal kick chart
• Cardiotocography
• Biophysical profile
• Non-stress test

Blood should be transfused to correct anemia and the patient should be delivered as soon as she reaches term (37 completed weeks) provided there are no contraindications.

Emergency

There is no place for expectant management in moderate or severe abruptio placentae

Quick resuscitation is required

Set up two large bore intravenous cannulae (size 14 or 16)

Blood is taken for necessary investigations and analgesic is given

Grouping and cross-matching of at least 6 units of blood should be requested

Intravenous infusion of crystalloids such as normal saline or ringer’s lactate should be commenced if blood is not immediately available.

Blood should be given as soon as it is available.

A foley catheter is inserted on admission for continuous bladder drainage and to monitor urinary output as oliguria is a common complication.

Clotting time should also be estimated.

Once resuscitation is commenced, attempts should be made to empty the uterus.

• Amniotomy and augmentation of labor with oxytocin
• The aim is to deliver the patient within 6—8 hours
• Active management of the third stage of labor.

Indications for caesarean section

• Fetal distress in the of absence of favorable conditions for vaginal delivery (e.g. nulliparous woman with cervical dilatation < 3-4cm)
• Rapidly enlarging uterus with concealed hemorrhage.
• Uncontrolled hemorrhage with rapidly deteriorating maternal condition.

Maternal

• Hemorrhage/Hypovolemic shock
• Renal failure
• Sheehan syndrome
• DIC
• Amniotic fluid embolism

Fetal

• Fetal distress due to hypoxia
• Prematurity
• Intrauterine growth restriction
• Intrauterine fetal death
• CNS abnormalities
• Perinatal mortality

Types I-IV

It is further sub-divided into “a” and “b” depending on whether it is anterior or posterior.

• Recurrent 1st and 2nd trimester spotting
• Recurrent APH in late pregnancy
• Sudden, painless profuse bleeding in 3rd trimester.
• Abnormal lie and presentation in 15% of cases with the presenting part high up
• The fetal heart tracing is usually reassuring
• It should be noted that in 10% of cases there could be slight abdominal pains initially.
• Bleeding placenta previa usually results from formation of placenta at the lower uterine segment or effacement and dilatation or from increased venous pressure in the poorly supported venous lakes in the decidua basalis

Points to note

• With the development of the lower uterine segment, the low lying placenta will be taken to a higher station
• Therefore, repeat USS is required in the third trimester before definitive action is taken
• A vaginal or rectal digital examination should not be undertaken until diagnosis has been established

• Multiparity
• Multiple gestation
• Previous caesarean section
• Abnormal placentation e.g. succenturiate lobe
• Advancing age— it is more common in women over the age of 35 years.
• Uterine scar— scar in the uterus as in previous CS or previous myomectomy may predispose to placenta previa. Other conditions such as frequent episodes of dilatation and curettage and evacuation of uterus for retained products of conception and manual removal of placenta.
• Infertility treatment
• Smoking

Ultrasound

Transabdominal

• Widely used in Nigeria
• Accuracy of 95%
• Full bladder is required for good examination

Transvaginal

• Accuracy of almost 100%
• Patient does not need a full bladder
• Recommended as a confirmatory method if placenta previa is suspected at transabdominal USS.
• The fear of probe provoking further bleeding should be discountenanced as vaginal probes are designed not to enter the cervical canal and should not go beyond 3 cm in the vagina.

MRI

• Superior to routine USS in terms of image quality but very expensive and usually unaffordable for many in developing countries.

Double setup

• Used to be called examination under anesthesia
• Now can be done carefully without anesthesia but at about 38 weeks gestation when the fetus is to be delivered
• Indicated when ultrasound findings are inconclusive or when ultrasound or it’s expertise is not available

It is dependent on a number of factors

• The degree of placenta previa
• The duration of pregnancy
• Viability of the fetus
• Parity of the patient
• Presentation and station
• Status of the cervix
• Whether or not labor has started

Resuscitation

• Insertion of two large bore IV cannulae
• IV infusion with crystalloids such as normal saline
• Blood transfusion should be commenced as soon as it is available if blood loss is heavy.
• Assess fetal well-being
• Further management will depend on the severity of bleeding and the wellbeing of the mother and fetus.

Expectant therapy

Expectant management will suffice if

The baby is less than 37 weeks

Bleeding is slight

Maternal and fetal conditions are stable

No other significant complicating factors

The aim is to achieve fetal maturity with a stable maternal wellbeing

There may be need for blood transfusion during this period.

Steroids are given for lung maturity

Most authors believe the pregnancy should not be allowed to progress beyond 38 weeks.

For types I and IIa placenta previa, the treatment is artificial rupture of membrane followed by IV oxytocin infusion to induce labor and effect delivery.

For types IIb, III and IV the treatment is cesarean section. However, CS should be performed irrespective of the type of irrespective of the type if significant hemorrhage occurs during labor or at any time during the conservative management.

Emergency situations

• Immediate resuscitation with blood if massive bleeding
• Cesarean section should be carried out promptly irrespective of the maturity of the fetus if the baby abd also the mother are to be salvaged.

Indications for vaginal delivery

• Marginal previa
• Cephalic presentation
• Continuous fetal heart monitoring should be available

• Hypovolemic shock
• IUGR
• Prematurity
• Increased perinatal morbidity and mortality
• Intrapartum and postpartum hemorrhage
• Rhesus isoimmunization
• Maternal death