what causes antepartum haemorrhage

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What causes antepartum haemorrhage (APH)?

The causes of APH include: placenta praevia, placental abruption and local causes (such as bleeding from the vulva, vagina or cervix). Placenta previa & placental abruption constitute 50% of APH. Symptoms of antepartum haemorrhage (APH) consist of vaginal bleeding in late pregnancy and before delivery.

What is an antepartum hemorrhage?

Unsourced material may be challenged and removed. Antepartum bleeding, also known as antepartum haemorrhage or prepartum hemorrhage, is genital bleeding during pregnancy after the 28th week of pregnancy up to delivery. It can be associated with reduced fetal birth weight.

What causes placenta haemorrhaging?

At the time of contraction or delivery the connecting placental arteries and veins may rupture resulting in significant haemorrhaging. Incidences of vasa previa and haemorrhaging in the presence of a succenturiate placenta are highly increased.

What is the prognosis of antepartum hemorrhage?

It is associated with significant maternal and fetal morbidity and mortality. Common causes of antepartum hemorrhage are bloody show associated with labor, miscarriage, placental previa, and placental abruption. Rare causes include vasa previa and uterine rupture.

What are the cause of antepartum hemorrhage?

An antepartum haemorrhage (APH) is bleeding from the vagina that occurs after the 20th week of pregnancy and before the birth of your baby. The common causes of bleeding during pregnancy are cervical ectropion, vaginal infection, placental edge bleed, placenta praevia or placental abruption.

What are the signs and symptoms of antepartum haemorrhage?

It presents classically with vaginal bleeding, abdominal pain, uterine contractions and tenderness. On clinical examination, the uterus is irritable, with increased baseline tone. There may be evidence of fetal distress. In severe cases, the mother may show cardiovascular decompensation with evidence of hypovolaemia.

How do you prevent antepartum hemorrhage?

Antepartum hemorrhage could be prevented by early registration, regular antenatal care, early detection of high risk cases, and early referral to a higher center. Good facilities for cesarean section, availability of blood banks, and use of contraceptives can improve maternal and perinatal outcome of APH.

What are the complications of antepartum hemorrhage?

However, during APH, complications can be fetal as well as maternal. The maternal complications are malpresentation, premature labor, PPH, sepsis, shock and retained placenta [6]. Various fetal complications are prematurity, low birth weight, intrauterine death, congenital malformation and birth asphyxia [7].

What is the management of APH?

The mainstays of management of massive haemorrhage are effective communication between clinical staff, resuscitation, monitoring and accurate diagnosis of the underlying cause. The bleeding will be arrested by delivery of the fetus. Severe bleeding: the mother's life should take priority.

How is antepartum hemorrhage diagnosed?

Any vaginal bleeding at or after 24 weeks must be diagnosed as an antepartum haemorrhage if any of the following are present: A sanitary pad is at least partially soaked with blood. Blood runs down the patient's legs. A clot of blood has been passed.

How common is hemorrhage during birth?

Postpartum hemorrhage (also called PPH) is when a woman has heavy bleeding after giving birth. It's a serious but rare condition. It usually happens within 1 day of giving birth, but it can happen up to 12 weeks after having a baby. About 1 to 5 in 100 women who have a baby (1 to 5 percent) have PPH.

Can having an Orgasim cause bleeding while pregnant?

Your uterus may lightly contract after you orgasm, much like Braxton Hicks contractions. If you have a placenta previa and experience bleeding after orgasm, contact your provider.

How does oxytocin stop bleeding?

In low-income countries, drugs to prevent or treat postpartum haemorrhage (uterotonics) are not always available. Oxytocin is one such drug. Oxytocin prevents excessive postpartum bleeding by helping the uterus to contract.

What does antepartum mean in medical terms?

Antepartum, which means occurring or existing before birth, is the name of the unit that you may be admitted to should you require specialized in-hospital care for you and your baby prior to being ready to deliver.

What is hemorrhaging after giving birth?

Postpartum hemorrhage is heavy bleeding after the birth of your baby. Losing lots of blood quickly can cause a severe drop in your blood pressure. It may lead to shock and death if not treated. The most common cause of postpartum hemorrhage is when the uterus does not contract enough after delivery.

What are the risk factors of placenta previa?

Risk factors for placenta previa include the following:Multiparity.Prior cesarean delivery.Uterine abnormalities that inhibit normal implantation (eg, fibroids, prior curettage)Prior uterine surgery (eg, myomectomy) or procedure (eg, multiple dilation and curettage [D and C] procedures)Smoking.Multifetal pregnancy.More items...

What are the classification of antepartum haemorrhage?

ClassificationStageAmount of Blood LossSpottingStains, streaking, or spotting of bloodMinor HaemorrhageLess than 50mLMajor Haemorrhage50-1000mL without signs of circulatory shockMassive HaemorrhageGreater than 1000mL with or without signs of circulatory shock

How common is antepartum haemorrhage?

APH complicates 3–5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide. 1 Up to one-fifth of very preterm babies are born in association with APH, and the known association of APH with cerebral palsy can be explained by preterm delivery.

What is antepartum period?

Medical Definition of antepartum : relating to the period before parturition : before childbirth antepartum infection antepartum care.

What does antepartum mean in medical terms?

Antepartum, which means occurring or existing before birth, is the name of the unit that you may be admitted to should you require specialized in-hospital care for you and your baby prior to being ready to deliver.

What is an antepartum hemorrhage?

Antepartum hemorrhage (Bleeding in late pregnancy) Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby. APH complicates 3–5% of pregnancies; and is a leading cause of perinatal and maternal mortality worldwide.

What causes APH in the vagina?

The causes of APH include: placenta praevia, placental abruption and local causes (such as bleeding from the vulva, vagina or cervix). Abruption is more likely to be related to conditions occurring during pregnancy and placenta praevia is more likely to be related to conditions existing prior to pregnancy.

What is the cause of APH?

The causes of APH include: placenta praevia, placental abruption and local causes (such as bleeding from the vulva, vagina or cervix). Placenta previa & placental abruption constitute 50% of APH.

What is the term for the premature separation of a normally situated placenta from the uterine wall?

previous placental praevia, and. cigarette smoking. Placental abruption/ abruptio placentae –Placental abruption is the premature separation of a normally situated placenta from the uterine wall, resulting in haemorrhage before the delivery of the foetus.

What is APH in pregnancy?

Symptoms of antepartum haemorrhage (APH) consist of vaginal bleeding in late pregnancy and before delivery. Along with vaginal bleeding other symptoms may be-

What causes abruption in the placenta?

The precise cause of abruption is unknown, but risk factors for placental abruption include: pre-eclampsia, fetal growth restriction, non-vertex presentations, polyhydramnios, advanced maternal age, multiparty, low body mass index (BMI), pregnancy following assisted reproductive techniques, intrauterine infection, premature rupture of membranes, abdominal trauma (both accidental and resulting from domestic violence), smoking, drug misuse (cocaine and amphetamines) during pregnancy and maternal thrombophilia. Bleeding in first trimester also increases the risk of abruption later in the pregnancy.

When does placenta previa resolve?

Some types of placenta previa resolve on their own by 32–35 weeks of pregnancy as the lower part of the uterus stretches and thins out. Labor and delivery then can occur normally. If placenta previa does not resolve, cesarean delivery may be needed. (b) In APH due to placental abruption symptoms include:

What is an antepartum hemorrhage?

Antepartum haemorrhage (APH) is defined as genital tract bleeding from 24+0 weeks’ gestation and complicates 3-5% of pregnancies. 1. The three most important causes of APH are placenta praevia, placental abruption and vasa praevia, these result in high morbidity and mortality for both mother and baby. Other causes of APH include lower genital tract ...

What are the causes of APH?

The three most important causes of APH are placenta praevia, placental abruption and vasa praevia, these result in high morbidity and mortality for both mother and baby.

Why does placenta praevia increase the likelihood of APH?

Placenta praevia increases the likelihood of APH due to poor attachment of the placenta to the uterine wall.

What is the term for the complete or partial detachment of the placenta before delivery?

Placental abruption is the complete or partial detachment of the placenta before delivery. Complete abruption accounts for 7% of cases whilst partial abruption is more common, accounting for 93% of cases. Overall placental abruption accounts for around a quarter of all cases of APH.

Why does placental abruption occur?

The cause of placental abruption is often unknown. It may occur due to trauma or injury to the abdomen.

How common is partial abruption?

Complete abruption accounts for 7% of cases whilst partial abruption is more common, accounting for 93% of cases.

Where does the placenta praevia occur?

Key points. Placenta praevia occurs when the placenta lies in the lower uterine segment. The placenta may be low lying, partially covering the internal os or completely covering the internal os. Placenta praevia presents as painless vaginal bleeding.

What is an antepartum hemorrhage?

Objective: Antepartum haemorrhage (APH) defined as bleeding from the genital tract in the second half of pregnancy, remains a major cause of perinatal mortality and maternal morbidity in the developed world.

When a probability of placenta accreta is raised, what should be arranged?

When a probability of placenta accreta is raised, multidisciplinary input involving the patient and the family, the anaesthetist, obstetrician and the sonographer should be arranged. Advance planning should be made for management of delivery. The options are subsequent hysterectomy after delivery or leaving the placenta in-situ in order to reduce surgical complications and blood loss. Of the four maternal deaths due to placenta praevia in the triennium 2000–2002, all had at least on previous Caesarean, and three had a history of placenta accreta.

How to diagnose abruption of the placenta?

The diagnosis of placenta abruption is made clinically and then confirmed by evaluation of the placenta after delivery. It presents classically with vaginal bleeding, abdominal pain, uterine contractions and tenderness. On clinical examination, the uterus is irritable, with increased baseline tone. There may be evidence of fetal distress. In severe cases, the mother may show cardiovascular decompensation with evidence of hypovolaemia. The fetal heart may be absent, and there is a serious risk of development of coagulopathy in the mother due to consumption of clotting factors. The clinical signs of blood loss are out of proportion to the amount of vaginal bleeding. Ultrasound is an insensitive and unreliable tool for detecting or excluding placental abruption, as negative sonographic findings are common with clinically significant abruptions. The diagnosis may be confirmed postpartum on gross examination of the placenta, which reveals a clot and/or depression in the maternal surface, known as a delle. In less severe cases, the diagnosis of placental abruption may not be obvious, particularly if the haemorrhage is largely concealed and it may be misdiagnosed as idiopathic preterm labour.

Where is the placenta located?

Usually the placenta is situated in the upper uterine segment. Placental abruption is the premature separation of a normally situated placenta from the uterine wall, resulting in haemorrhage before the delivery of the fetus.

What is the evaluation of APH?

Conclusion: In cases presenting with APH, the evaluation consists of history, clinical signs and symptoms and once the mother is stabilized, a speculum examination and an ultrasound scan.

Is hypertension a causal relationship?

A causal relationship between hypertension and abruption is controversial. Most explanations implicate vascular or placental abnormalities, including increased fragility of vessels, vascular malformations, or abnormalities in placentation. The absence of transformation from muscular arterioles to low-resistance, dilated vessels as in normal pregnancy and the lack of trophoblastic invasion of uterine vessels is thought to result in decreased placental blood flow and dysfunctional endothelial responses to vasoactive substances. These abnormal placental vessels may predispose to ischaemia and rupture of involved vessels, thus causing placental abruption.

Can a haematoma be concealed?

may be in whole or in part concealed, if the haematoma does not reach the margin of the placenta and

What is an antepartum hemorrhage?

Antepartum haemorrhage is an obstetric emergency contributing to a significant amount of perinatal & maternal morbidity and mortality. Antepartum haemorrhage is defined as bleeding from the vagina after 24weeks. It occurs in 2-5% of pregnancies and is an important cause of fetal and maternal death.

How many deaths are caused by antepartum hemorrhage?

It occurs in 2-5% of pregnancies and is an important cause of fetal and maternal death. Thirty percent of maternal deaths are caused by antepartum haemorrhage of which 50% are associated with avoidable factors. 2 The causes of antepartum hemorrhage can be divided into three main groups, placenta previa, placental abruption and others.

What is the incidence of caesarean section?

The incidence of caesarean section in present study is 90%. The incidence of caesarean section in placenta previa group is 100% similar to the study done by Khouri JA & Sultan MG. 13 The incidence of caesarean in the abruption placentae group in the present study is 73% while that reported by Hurd et al. 14 from the UK and the study reported by Rochelle et al. 15 at Washington State were 50% & 37.9% respectively. In the present study, there was no mortality. Thirty six percent of these cases were complicated by PPH. The commonest cause of PPH was uterine atony followed by coagulation failure. Crane et al. 16 reported the incidence of PPH in APH to be 19 %. 16 In this study 75% of patients required blood transfusion. Brenner et al. 17 and William 18 reported the incidence of blood transfusion as 36% and 52.4% respectively. The very high rates of blood transfusion in the present study might be due to the reason that most of the patients were already anaemic at the time of admission. Four patients (4%) required caesarean hysterectomy and 8 patients (6.45%) required CCU admission. Sixty five per cent of women with APH had preterm delivery in the study, this study is consistent with those of Silver et al. 19 and Cotton et al. 20 who reported an association of prematurity with APH of 71% and 77.5% respectively. Forty per cent of babies were low birth weight while other authors such as Arora et al. 7 and Khosla et al. 21 reported 77% and 66% low birth weight respectively. Perinatal mortality was 21% (19/91) in the present study (24.44% in placenta previa and 19.23% in abruptio placenta group) while Arora et al. 7 and Khosla et al. 21 reported very higher perinatal mortality 61.5% and 53.5% respectively. In comparison, the incidence reported by Robbins et al. 22 18.44%. This difference may be due to advanced neonatal intensive care facility in the present institute.

What is the cause of abruptioplacentae?

Placenta previa exists when the placenta is implanted wholly or in part into the lower segment of the uterus. An abruptioplacentae is the condition whenever bleeding occurs due to premature separation of a normally sited placenta. Other causes are cervical polyp, cervical carcinoma local lesions of vagina and cervix.

What are the complications of intrapartum hemorrhage?

Complications involving the placenta, membranes, cord and foetus usually place the foetus at risk and may also increase maternal risk in the intrapartum period. Antepartum hemorrhage is one of the major complication. 1

How old are people with APH?

Mean age of patients presented with APH in this study is 26-30 years which is similar to the result reported by Das et al. 8 Abbasi et al. 9 also reported the mean age 30 years in a study from tertiary care hospital in Sindh. 9 Incidence of APH is more in multigravida (72%) than in primigravida (28%) in our study. Other studies such as Gillium et al. 10 and Clark et al. 11 have also reported high incidence of APH in multipara which was about 5-8 times higher than primigravida thus confirming the role of endometrial damage caused by repeated childbirth, a risk factor for uteroplacental bleeding in pregnancy. Scarring of uterus due to previous uterine surgery stands out as a one of the major etiological factors for APH, more specifically placentprevia. In the present study, 46% (57/124) cases presented with APH had history of previous uterine surgery in the form of caesarean section, myomectomy, curettage (61% Caesarean section (35/57), 52% (30.57) MTPs & check curettage following abortion). In the present study, 33 out of 45 (73%) cases were associated with pregnancy induced hypertension suggesting it is one of the major risk factors for abruption resulting in APH. This is comparable to the study of Bryan et al. 12 which suggested that Pre-eclampsia is an etiological factor in 80% cases of placental abruption.

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Summary

occurring within the third trimester. It is associated with significant maternal and fetal morbidity and mortality. Common causes of antepartum hemorrhage are

Placental abruption

The partial or complete separation of the placenta from the uterus prior to delivery; subsequent hemorrhage occurs from both maternal and fetal vessels.

What causes a fetal hemorrhage?

Placenta previa, placental abruption, uterine rupture , and vasa previa are all causes of antepartum hemorrhage. Placental abruption is a separation of the placenta most often accompanied by vaginal bleeding, uterine tenderness, and increased uterine activity. Uterine rupture is a defect in the uterine wall that results in fetal distress and/or maternal hemorrhage. Vasa previa is of no threat to the mother; however, there is a velamentous insertion of the cord where the fetal vessels traverse the fetal membranes ahead of the presenting part. Rupture of these vessels can cause fetal exsanguination. Patients with antepartum hemorrhage are also at risk for postpartum hemorrhage. Underestimation of blood loss is a frequent problem in such cases.

What is the differential diagnosis of antepartum hemorrhage?

In the setting of antepartum hemorrhage, the main clinical differential diagnosis is placenta previa. This differential diagnosis can typically be resolved by imaging studies. If gross examination is performed, features that support the diagnosis of placenta previa include point of membrane rupture that reaches the edge of placental disc and marginal and velamentous umbilical cord insertions; however, these features are not specific. Furthermore, cases of both placenta previa and placenta abruption may exhibit maternal surface disruption, and both placenta previa and chronic abruption may exhibit marginal retroplacental blood clots.

What causes blood loss in VLBW?

Acute blood loss in the VLBW infant is unusual and can result from prenatal events such as fetomaternal hemorrhage; antepartum hemorrhage or twin-twin transfusion syndrome; or intrapartum events such as a tight nuchal cord , resulting in an imbalance between blood flow to and from the fetus or postnatally from a large subgaleal hematoma or hemorrhage into an organ such as the liver or brain. Acute blood loss can result in significant hypotension, but due to the immediate compensatory mechanisms of the cardiovascular system, this effect may be delayed. Similarly, a drop in the infant’s hemoglobin level can also be delayed following significant acute hemorrhage.

Does placenta previa cause postpartum hemorrhage?

Even in the absence of antepartum hemorrhage, placenta previa carries a risk for postpartum hemorrhage, primarily caused by uterine atony, as the lower uterine segment does not have the same contractile ability as the fundus after delivery.16 Anticipation of this potential complication is key, and the availability of uterotonics and intrauterine balloon tamponade should be confirmed in addition to planning for potential surgical maneuvers such as B-Lynch sutures or hysterectomy. Consideration should be given to preparation of blood products before delivery, as the hemorrhage can be brisk, leading to maternal hemodynamic instability.

Where does antepartum bleeding originate?

Cervical canal and distal genital tract. Most cases of Antepartum haemorrhaging originate from within the cervical canal or vagina. The amount of bleeding in these areas are typically limited to spotting or minor antepartum haemorrhaging.

How many degrees of antepartum haemorrhage are there?

The total amount of blood loss and signs of circulatory shock due to blood determine the severity of the antepartum haemorrhaging. There are 4 degrees of antepartum haemorrhaging: Stage. Amount of Blood Loss. Spotting.

What is the placenta praevia?

Placenta praevia. Placenta praevia refers to when the placenta of a growing foetus is attached abnormally low within the uterus. Intermittent antepartum haemorrhaging occurs in 72% of women living with placenta praevia. The severity of a patient's placenta praevia depends on the location of placental attachment; Type.

Why does the placenta wrap twice around the foetus?

This is to compensate for an undersized chorionic plate resulting in a decreased nutritional supply to the foetus. Thickening of the placental edge due to a circumvallate placenta can lead to placental abruption, causing antepartum haemorrhaging.

What happens when the placenta abruption occurs?

Placental abruption occurs when the placenta detaches from the endometrium. Detachment causes antepartum haemorrhaging at the location of abruption. Depending on the site of detachment, haemorrhaging may or may not be apparent. If abruption occurs behind the placenta where blood cannot escape through the cervix, blood will pool and form a retroplacental clot. Only when the site of detachment occurs on the side facing the cervical opening can the total amount of haemorrhaging be measured by vaginal bleeding. Using vaginal bleeding as a measurement of the severity of the placental abruption is therefore ineffective. The scale of haemorrhaging depends on the degree to which the placenta has separated from the uterine wall. In the case of partial placental separation, haemorrhaging can be minor. However, in the case of total placental separation haemorrhaging will be major and emergency delivery will typically be the course of action. Placental abruption causes blood loss from the mother and loss of oxygen and nutri ents to the placenta occasionally leading to preterm labour. Other causes of placental abruption can be abdominal trauma or sudden decompression of amniotic fluid, however it is not uncommon for the cause of placental abruption to be unknown.

What is the term for a genital bleeding during pregnancy?

Antepartum haemorrhage (APH), prepartum haemorrhage. Specialty. Obstetrics. Antepartum bleeding, also known as antepartum haemorrhage or prepartum hemorrhage, is genital bleeding during pregnancy after the 28th week of pregnancy up to delivery. It can be associated with reduced fetal birth weight.

What is the maternal portion of the placenta?

During pregnancy the layer of endometrium that attaches directly to developing blastocyst becomes the maternal portion of the placenta, also known as the decidua basalis. In the absence of a decidua basalis, trophoblast cells on the developing blastocyst form an abnormally deep attachment to the uterine wall, this is known as abnormal placentation. Abnormal placentation can categorised into 3 types, depending on the depth of infiltration of the chorionic villi into the uterine wall:

Introduction

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Placenta Praevia

Placental Abruption

Vasa Praevia

Other Causes of APH

Summary

References