Antepartum haemorrhage | Medical Science Optional Notes for UPSC PDF Download

Antepartum hemorrhage-Causes

Antepartum hemorrhage (APH) is characterized by bleeding from the genital tract after the 28th week of pregnancy but before the onset of labor and childbirth.
The causes of antepartum hemorrhage include:

• Placental Causes:
  • Abruptio Placenta
  • Circumvallate Placenta
• Uterine Causes:
  • Uterine Rupture
  • Uterine Trauma
• Miscellaneous Causes:
  • Maternal Vascular Lesions
  • Cervical Lesions

Antepartum Hemorrhage Differential Diagnosis

Antepartum Hemorrhage - Risk Factors

Placenta previa

• Low-Lying Placenta (Stage 1): The placenta is situated in the lower uterine segment, with its edge near but not reaching the internal os.
• Marginal Previa (Stage 2): The placenta's edge is at the margin of the internal os.
• Partial Previa (Stage 3): The internal os is partially covered by the placenta.
• Total Previa (Stage 4): The internal os is entirely covered by the placenta.

These stages represent the degrees of placenta previa, ranging from the placenta being close to the internal os (but not reaching it) to completely covering it.

Expectant Management for Placenta Previa

• Macafee and Johnson recommended an expectant management approach.
• The goal is to sustain the pregnancy for optimal fetal maturity while safeguarding maternal health.

Prerequisites for Expectant Management

• Adequate blood availability for potential transfusions.
• 24/7 availability of cesarean section facilities.
• Maternal health criteria: Hemoglobin >10 g%, hematocrit >30%.
• Pregnancy duration <37 weeks.
• Absence of active vaginal bleeding.
• Ensured fetal well-being, assessed through various measures like hemoglobin levels, blood grouping, urine protein analysis, vulval pad inspection, and fetal surveillance using ultrasound.
• Provision of supplementary hematinics.
• Rh Immunoglobulin administration for Rh-negative (unsensitized) women.
• Corticosteroids for fetal lung maturity if gestational age is <34 weeks.
• Options for tocolysis with magnesium sulfate in the presence of mild uterine contractions, especially in extremely premature fetuses.
• Immediate delivery in cases of active bleeding or evidence of fetal distress.
• Immediate delivery for pregnancies beyond 37 weeks of gestation.

Route of delivery

• Vaginal delivery should never be attempted outside the operating room in a patient with placenta previa
• Lower segment cesarean section is almost always preferred; ideally scheduled at 36-37 weeks gestation
• Induction of labor and/or vaginal delivery may be performed in the operating room if the mother is hemodynamically stable, fetal cardiac status is reassuring, and the placenta lies > 2 cm away from the internal os on ultrasonography

Placenta previa-complications

Maternal Complications

• Antepartum Hemorrhage: Bleeding before childbirth.
• Malpresentation: Abnormal fetal positioning during birth.
• Premature Labour: Onset of labor before 37 weeks of gestation.
• Cord Prolapse: Umbilical cord descends ahead of the fetus during labor.
• Intrapartum Hemorrhage: Bleeding during childbirth.
• Early Rupture of Membranes: Breaking of amniotic sac before labor begins.
• Postpartum Hemorrhage: Excessive bleeding after childbirth.
• Retained Placenta: Failure of the placenta to deliver after childbirth.
• Puerperal Sepsis: Infection occurring after childbirth.

Fetal Complications

• Low Birth Weight: Newborn weight below the normal range.
• Birth Asphyxia: Inadequate oxygen supply to the baby during birth.
• Intrauterine Device (IUD): Presence of a contraceptive device in the uterus during pregnancy.
• Birth Injuries: Harm to the baby during the birthing process.
• Congenital Malformations: Structural abnormalities present at birth.

Accidental hemorrhage/Abruptio placenta

• Abruption placenta (accidental hemorrhage/premature separation of placenta) 
• Premature separation of normally implanted placenta 
• It can be of concealed/revealed/mixed type
• Revealed type is the most common type. Concealed type has maximum fetal distress

Abruptio placenta-complications

• Intrauterine fetal death (occurs in ~ 12% of cases) 
• Maternal DIC and hypovolemic shock 
• Acute kidney injury
• Sheenhan syndrome 
• Couvelaire uterus

Couvelaire uterus

• It is also known as uteroplacental apoplexy. 
• It is observed in severe type of concealed abruption placentae.
• There is massive intravasation of blood into uterine musculature up to serosa coat. 
• It can be diagnosed only by laparotomy. 
• The presence of Couvelaire uterus observed in Cesarean Section per se is not an indication for hysterectomy.

Recurrent abruption

• Because many of the predisposing factors are chronic and therefore repetitive, it would be reasonable to conclude that placental abruption would have a high recurrence rate.
• In fact, the woman who has suffered an abruption— especially one that caused fetal death—has an extraordinarily high risk for recurrence.
• For women who had two severe abruptions, the risk for a third was increased 50-fold.
• Management of a pregnancy subsequent to an abruption is difficult because another separation may suddenly occur, even remote from term.

Abruptio placenta-Management

Vasa previa

• Umbilical blood vessels in a velamentous placenta aren't supported and are situated beneath the presenting part, crossing the cervical opening.
• Rupture of membranes or spontaneous tearing of these vessels causes antepartum hemorrhage.
• The bleeding originates from the fetus rather than the mother.
• Color Doppler is useful for diagnosing this condition during pregnancy.

Management

• Confirmed case of vasa previa with out bleeding: Admit at 28-32 weeks, plan elective Cesarean Section depending on fetal lung maturity. 
• Vasa previa with bleeding:
  • Delivery should be done by Emergency Cesarean section. 
  • Neonatal blood transfusion may be needed.

Antepartum hemorrhage-Repeats

Q1: A primi gravida complains of vaginal bleeding at 34 weeks of pregnancy. What are the causes? How will you differentiate between placenta previa and revealed variety of Abruptio placenta? (1995)

Q2: Discuss placenta previa in detail. (1999)

Q3: Define accidental hemorrhage. How would you manage a woman at 34 weeks of pregnancy, who comes to casualty with history of painful bout of bleeding? Mention foetal and maternal complications associated with accidental hemorrhage. (2013) 

Q4: Define antepartum haemorrhage. How would you manage a patient at 34 weeks of pregnancy who comes to casualty with a history of painless bout of bleeding? Mention the foetal and maternal complications associated with this condition. (2014) 

Q5: A primi gravida patient reports in casualty at 34 weeks of pregnancy with the painless bout of bleeding Per Vaginum. What is your probable diagnosis? How would you manage the patient? What foetal and maternal complications are associated with this condition?  (2016) 

Q6: Write notes on issues you would raise in counselling a woman about be delivered at 28 weeks gestation after placental abruption. (2018)