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📋 ANTEPARTUM HEMORRHAGE (APH)

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DEFINITION

• Bleeding from or into the genital tract after 28th week but before birth of the baby (includes 1st and 2nd stage of labor)
• 28th week = lower limit of fetal viability (arbitrary)
• Incidence: ~3% of hospital deliveries

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CAUSES OF APH

1. Placenta Previa (~1/3)
2. Abruptio Placentae (~1/3)
3. Indeterminate/Unclassified (~1/3)

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PART 1: PLACENTA PREVIA

DEFINITION

INCIDENCE

• ~1/3 of all APH cases
• 0.5-1% of hospital deliveries
• 80% cases in multiparous women
• Increased risk: age >35 yrs, high birth order, multiple pregnancy

ETIOLOGY (Theories)

1. Dropping-down theory - fertilized ovum drops and implants in lower segment; explains central placenta previa
2. Persistence of chorionic activity in decidua capsularis - explains lesser degrees
3. Defective decidua - chorionic villi spread wide for nourishment, encroach onto lower segment; may lead to accreta/increta/percreta
4. Big placenta (e.g., twins) - encroaches onto lower segment

HIGH-RISK FACTORS (Box 19.1)

• Multiparity
• Age >35 yrs (4-fold increase)
• Asian race
• Infertility treatment
• Uterine scar (LSCS, myomectomy, hysterotomy)
• Prior curettage / prior placenta previa
• Multiple pregnancy
• Abnormal placenta (succenturiate lobe, big placenta)
• Smoking (placental hypertrophy due to CO-induced hypoxemia)

PATHOLOGICAL ANATOMY

• Placenta: large and thin, tongue-shaped extension, infarction/calcification, may be morbidly adherent
• Umbilical cord: battledore or velamentous insertion; cord may be close to internal os (risk of vasa previa)
• Lower uterine segment: soft, friable, increased vascularity

TYPES/DEGREES (Fig. 19.1)

• Mild degree = Type I + Type II anterior
• Major degree = Type II posterior + Type III + Type IV
• Most common location: posterior wall

CLINICAL FEATURES

Symptoms

• Painless, bright red vaginal bleeding - hallmark
• Sudden onset, no precipitating cause
• Recurrent - each bleed tends to be heavier than the last
• First bleed usually not alarming; subsequent bleeds may be torrential
• Most bleed before 38 weeks (earlier in major degrees)
• Some central cases may NOT bleed until labor starts
• No obvious trauma or hypertension as cause

Signs

• General condition and anemia proportionate to visible blood loss
• Uterus: size proportionate to gestation, relaxed, soft, elastic, no local tenderness
• Malpresentation: breech, transverse lie or unstable lie (more frequent)
• Floating head despite expected engagement - persistent head displacement (very suggestive)
• Head cannot be pushed into pelvis
• FHS usually present (unless major separation with exsanguination)
• Stallworthy's sign: slowing of FHR on pressing head into pelvis, recovers on release - suggests low-lying (especially posterior) placenta
• Vulval inspection only - note ongoing bleed, bright red blood, amount of loss
• NEVER do vaginal examination outside OT - risk of torrential hemorrhage

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DIAGNOSIS (Confirmation)

• Painless, recurrent bleeding in 2nd half of pregnancy = placenta previa until proven otherwise
• USG is initial and primary investigation

Placentography (USG)

• Transabdominal USG: Simple, non-invasive, first-line
• Transvaginal USG (TVS): More accurate for posterior placenta; safer than previously thought
  • Distance of placental edge from internal os:

    • 20 mm = vaginal delivery possible

    • <20 mm = likely to need LSCS
    • Placenta over os = LSCS mandatory
• USG report should state exact distance from placental edge to internal os
• Repeat USG at 32-36 weeks (placental migration occurs - many low-lying placentas move up)

Clinical Confirmation (Double Setup Examination)

• Done in OT under anesthesia with everything ready for LSCS
• Cervix examined with finger - if placenta felt, CS is done
• Only if CS is NOT planned (Type I, II anterior with fetal head well below the placenta)

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DIFFERENTIAL DIAGNOSIS (Table 19.1)

• Local cervical lesions (polyp, carcinoma) - differentiated by speculum exam
• Circumvallate placenta - slight bleeding, confirmed after placental inspection

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COMPLICATIONS

Maternal

• APH with varying degrees of shock (inevitable)
• Co-existent placental abruption (~10%)
• Malpresentation, unstable lie
• Premature labor (spontaneous or induced)

• Early rupture of membranes
• Cord prolapse (abnormal cord attachment)
• Slow cervical dilatation
• Intrapartum hemorrhage
• Increased operative interference (LSCS, hysterectomy)

• PPH due to: imperfect lower segment retraction, large placental surface area with atonic uterus, pre-existing anemia
• Morbidly adherent placenta (accreta/increta/percreta) - 15% association; 10-15% risk with 1 prior CS, ~60% with 3+ prior CS
• Retained placenta, manual removal hazards
• Cervical and lower segment trauma

• Sepsis (increased operative interference + placental site near vagina + anemia)

Fetal

• Prematurity (most common cause of fetal loss)
• IUGR
• Congenital malformations (increased)
• Fetal asphyxia from placental separation
• Fetal anemia from fetal blood loss
• Perinatal mortality: ~10% (major degrees)

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MANAGEMENT

On Admission (Immediate)

1. IV access (wide bore), IV fluids
2. Blood grouping, cross-matching; Hb, hematocrit
3. Urine for protein
4. Do NOT do vaginal examination
5. USG to confirm diagnosis and placental location
6. Blood transfusion if required
7. Assess fetal well-being (CTG, USG)

Subsequent Management

A. Expectant Management (Conservative)

• Hb >10 g%, hematocrit >30%
• <37 weeks gestation
• No active bleeding
• Fetal well-being assured

1. Bedrest (bathroom/toilet privileges)
2. Hb estimation, blood grouping, urine protein
3. Vulval pad inspection periodically; USG every 2-3 weeks
4. Hematinics; cross-matched blood transfusion if anemic
5. Speculum (Cusco's) exam 2-3 days after bleeding stops (to exclude local causes)
6. Tocolysis (MgSO4) if bleeding + uterine contractions
7. Cervical cerclage - NOT helpful (RCOG 2005)
8. Rh immunoglobulin to all Rh-negative unsensitized women
9. Betamethasone if <34 weeks (for fetal lung maturity)

• Recurrent brisk, continuing hemorrhage
• Fetal death
• Congenital malformation of fetus

B. Active/Definitive Management (Delivery)

1. Bleeding at or after 37 weeks
2. Patient in labor
3. Exsanguinated state on admission
4. Continuing moderate-degree bleeding
5. Non-reassuring fetal cardiac status / dead fetus / known fetal malformation

• Cesarean section for all with sonographic evidence of major placenta previa (Type II posterior, III, IV) or clinical signs
• Vaginal delivery may be considered for Type I and Type II anterior with engaged fetal head and facilities for immediate LSCS

Cesarean Section for Placenta Previa - Key Points

• Adequate blood (4-6 units) cross-matched and ready
• Incision away from placenta (do NOT incise through placenta)
• Deliver baby first without placental separation if possible
• Placenta accreta suspected: leave placenta in situ if no bleeding; close uterus; consider hysterectomy if bleeding
• Conservative methods to control hemorrhage: B-Lynch suture, isthmic cervical apposition suture, uterine/internal iliac artery ligation, uterine artery embolization (UAE)
• Multidisciplinary team (urologists, pelvic surgeons, transfusion specialists) essential
• Check baby's Hb at birth; arrange transfusion if needed

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PART 2: ABRUPTIO PLACENTAE

DEFINITION

VARIETIES

USG Localization of Hemorrhage

• Retroplacental - between placenta and myometrium (worst prognosis; 50% fetal mortality)
• Subchorionic - between placenta and membranes (10% fetal mortality)
• Preplancental/Subamniotic - between placenta and amniotic fluid

ETIOLOGY

• Pre-eclampsia/hypertension - most common association (in 45% cases)
• Trauma (direct blow, external version)
• Sudden decompression of uterus (ROM in polyhydramnios, delivery of first twin)
• Short umbilical cord
• Folic acid deficiency
• Uterine anomaly or fibroid
• Smoking, cocaine use
• Thrombophilias (antiphospholipid syndrome, Factor V Leiden)
• Previous abruption (10x recurrence risk)

PATHOPHYSIOLOGY

• Decidual arterial spasm → vascular congestion → rupture → retroplacental hematoma
• Hematoma expands → further placental separation
• Couvelaire uterus: blood extravasation between muscle fibers → bruised, tense uterus
• DIC: release of tissue thromboplastin → consumptive coagulopathy → hypofibrinogenemia (<150 mg/dL), elevated FDP and D-dimer

CLINICAL GRADING

CLINICAL FEATURES

Symptoms

• Painful, dark red vaginal bleeding (contrast to placenta previa)
• Abdominal pain - sudden onset, constant, severe
• History of precipitating cause often present

Signs

• Uterus: tense, hard, "woody" or board-like, very tender - hallmark
• Fundal height may be MORE than expected (concealed blood)
• Fetal parts difficult to feel
• FHS may be absent (especially Grade 3)
• Shock may be disproportionate to visible blood loss (concealed hemorrhage)
• Pre-eclampsia signs may coexist

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INVESTIGATIONS

• Hb, hematocrit
• Coagulation profile: fibrinogen level, FDP, prothrombin time, APTT, platelets
• ABO/Rh grouping
• Urine for protein
• USG: confirms retroplacental hematoma (may miss acute bleed)

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COMPLICATIONS

Maternal

• Hemorrhagic shock (often out of proportion to visible loss)
• DIC (consumptive coagulopathy) - fibrinogen <150 mg/dL
• Acute renal failure/cortical necrosis (from severe hypotension + DIC)
• Postpartum hemorrhage (Couvelaire uterus, atony)
• Sepsis
• Sheehan's syndrome

Fetal

• Fetal distress
• IUGR
• Prematurity
• Fetal death (especially Grade 3; retroplacental hematoma has 50% mortality)

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MANAGEMENT

On Admission

1. IV access (wide bore); Ringer's solution; arrange blood transfusion
2. Bloods: Hb, hematocrit, coagulation profile (fibrinogen, FDP, PT, APTT, platelets), ABO/Rh, urine protein
3. Close maternal and fetal monitoring (Flowchart 19.3)

Management Options

Definitive Treatment (Delivery)

• Amniotomy (low rupture of membranes) - accelerates labor, increases uterine tone
• Advantages: initiates myometrial contraction, expedites delivery, better compression of spiral arteries, reduces thromboplastin entry → reduces DIC/renal cortical necrosis risk
• Oxytocin drip to accelerate if needed
• Vaginal delivery favored if: limited abruption, reassuring FHR, facilities for continuous electronic monitoring, prospect of early vaginal delivery, or dead fetus

• Continuing bleeding or >Grade 1:
  • (A) Induction of labor by amniotomy + oxytocin; delivery usually in 4-6 hours
  • (B) Cesarean section if:
    • Severe abruption with live fetus
    • Unfavorable cervix (amniotomy not possible)
    • Vaginal delivery not imminent despite amniotomy
    • Amniotomy failed to control bleeding or stop process
    • Adverse features: fetal distress, falling fibrinogen, oliguria
  • Note: Regional anesthesia generally avoided with significant coagulopathy (use general anesthesia)

Managing Complications

• Volume replacement based on volume deficit
• Fresh blood, packed cells, FFP, platelets as needed

• Target fibrinogen >150 mg/dL
• 1 unit (500 mL) fresh blood contains 0.5 g fibrinogen, raises level by ~12.5 mg/dL
• Platelet count increases by 10,000-15,000/mm³ per unit
• Deliver to arrest pathological process
• Details - see coagulopathy chapter

• Common with traumatic abruption
• 300 mg anti-D immunoglobulin to all Rh-negative women
• Fetal-to-maternal bleed usually <15 mL

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PART 3: INDETERMINATE BLEEDING

• Cause not clearly understood
• Diagnosis by exclusion (rule out placenta previa, abruption, local causes)

• Vasa previa - most important
• Marginal sinus hemorrhage
• Circumvallate placenta
• Marked decidual reaction on endocervix
• Excessive show

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VASA PREVIA

Definition

Diagnosis

• Color-flow Doppler TVS: antenatal diagnosis
• Detection of nucleated RBCs (Singer's alkali denaturation test) or fetal Hb (Apt test) in vaginal blood - diagnostic
• Associated with fetal distress (tachycardia, sinusoidal FHR pattern)

Fetal Prognosis

• Fetal mortality ~50% (fetal exsanguination - fetal vessels bleed)

Management

• Antenatal admission at 28-32 weeks for confirmed vasa previa
• Expectant management (for fetal lung maturity) - similar to placenta previa
• Antenatal corticosteroids given
• Bleeding vasa previa → Category-1 emergency LSCS immediately
• Intrapartum diagnosis → expeditious delivery
• Confirmed vasa previa at term (≥37 wks) → elective LSCS before labor onset
• Neonatal blood transfusion may be needed

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KEY COMPARISON: PLACENTA PREVIA vs ABRUPTIO PLACENTAE

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Source: DC Dutta's Textbook of Obstetrics (9th Edition), Chapter 19 - Antepartum Hemorrhage