Antepartum Hemorrhage (APH) Notes

APH is defined as PVB (antepartum hemorrhage) in pregnancy from 28 weeks (though some sources say 20 weeks) until the onset of labor.
It is PVB in pregnancy at a gestation when the baby is considered viable for extra-uterine life.
Bleeding amount is variable.

Placenta Previa: Accounts for approximately 35% of cases.
Abruptio Placenta: Accounts for approximately 40% of cases.
Local Causes:
- Cervicitis
- Vulvo-vaginal varicosities
- Genital infections
- Genital tumors
- Trauma to the genitalia
- Hematuria
Vasa Previa: When the umbilical blood vessels pass through the membranes before reaching the placenta.
Coagulation Disorders: E.g., Factor 8 deficiency.
Unknown: Approximately 15% of cases.

Results from the implantation of the placenta in the lower uterine segment such that a portion of it encroaches on the internal cervical os.

Type 4 (Total/Complete Placenta Previa): The internal cervical os is completely covered by the placenta.
Type 3 (Partial Placenta Previa): The placenta partially covers the os but not completely.
Type 2 (Marginal Placenta Previa): The placenta only reaches the margins of the internal cervical os.
- Type 2A: The placenta reaches the margins on the anterior aspect.
- Type 2B: The placenta encroaches on the posterior aspect – cannot safely be delivered vaginally due to increased bleeding risk.
Type 1 (Low Lying Placenta): Implantation is on the lower uterine segment but away from the internal os.

Painless PVB
Occurs after 37 weeks gestation but may occur earlier in cases of complete placenta previa.
Mild and may start when the patient is asleep.
No predisposing factors like trauma.
May be provoked by intercourse.
Quantity of bleeding varies with subsequent provocation.
Coitus becomes contraindicated in complete placenta previa.

Confirmed by palpating the placenta through the cervix (not usually done except in a double setup as it may precipitate bleeding).
Abdominal exams may reveal malpresentations.
If cephalic, the head lies high above the pelvic inlet.
When in labor, the uterus relaxes completely in between contractions.
Diagnosis is confirmed by ultrasound.

Determined by:

Life-threatening hemorrhage, maturity, and labor: deliver.
Severe hemorrhage: do C-section (c/s).
Non-severe hemorrhage but in labor/fetus is mature: do EUA (Examination Under Anesthesia) under a double setup.
EUA to determine the degree of previa.
- Type 2A/Type 1: do ARM (Artificial Rupture of Membranes) and initiate syntocinon and observe.
- Type 2B: Fetal head will still need to push through the placenta, causing significant bleeding - do c/s.
Bleeding due to previa, not near term, and not life-threatening: manage conservatively by:
- Speculum to rule out other causes.
- Bed rest and monitor bleeding by use of pads.
- Discharge those who can access hospital when PVB stops( after bleeding stops).
- Give steroids to initiate lung maturation so that delivery can be done at the next severe episode.

With early diagnosis and hospitalization, blood replacement, C-section use, and reduced vaginal examination, maternal mortality due to PP should be reduced to zero.
Perinatal mortality rate:
- Increased by 17-20% due to prematurity and intrauterine asphyxia due to maternal shock and placental separation.
- APH is more risky to the mother than to the baby that is why maternal mortality should be reduced to zero.

This is the separation of a normally implanted placenta occurring after 28 weeks but before birth.
Retroplacental hemorrhage occurs into the decidua basalis, and the extent of the separation is variable.
Depending on the site and extent of separation, the blood may escape out of the cervix (revealed abruptio placenta).
Separation, but blood remains retained behind the placenta (concealed abruptio placenta) - worse than revealed.

Depends on the extent of placental separation.

Severe:
- Extensive separation.
- Continuous abdominal contractions with or without bleeding followed by a lack of fetal movements, which might be followed by vigorous fetal movements.
- The degree of maternal shock is out of proportion to the quantity of observed bleeding.
- Uterus becomes tender and does not appear to relax in between contractions.
- Spontaneous labor sets in and progresses very rapidly.
Mild:
- Few or no other signs apart from bleeding.
- Diagnosis of exclusion.
- No pain, no change in fetal status.
- No retroplacental clots.
- Do u/s to rule out other causes

Coagulation Disorder (DIC): As a result of the release of thromboblastic materials from the retroplacental clot, use up of all the clotting factors.
Renal Failure: Depends on the volume of blood lost and duration of shock.
PPH (Postpartum Hemorrhage): Because all the clotting factors are already used up by the time of delivery of the placenta. The presence of fibrin degenerating products also interferes with uterine contractions and relaxation.

Perinatal mortality is quite high because of intrauterine asphyxia and prematurity.
There is significant risk to the mother, MM can however be reduced by improved management which entails blood replacement, prevention of shock by using IVF before blood is availed for transfusion.