Antepartum Hemorrhage (APH) - Causes, Risk Factors & Management PDF

**Antepartum Hemorrhage (APH)** **Antepartum hemorrhage (APH)** is defined as **vaginal bleeding from the genital tract after 20 weeks of gestation but before the delivery of the baby**. It is a significant cause of maternal and fetal morbidity and mortality and requires prompt evaluation and manag...

**Antepartum Hemorrhage (APH)** **Antepartum hemorrhage (APH)** is defined as **vaginal bleeding from the genital tract after 20 weeks of gestation but before the delivery of the baby**. It is a significant cause of maternal and fetal morbidity and mortality and requires prompt evaluation and management. **Causes of Antepartum Hemorrhage** APH can be categorized into **placental causes** and **non-placental causes**: **A. Placental Causes (Common Causes)** 1\. **Placenta Previa**: The placenta is implanted in the lower uterine segment, partially or completely covering the cervical os. **Types**: Marginal Partial Complete **Presentation**: Painless vaginal bleeding, often bright red. Common in the late second or third trimester. 2\. **Placental Abruption** (Abruptio Placentae): Premature separation of a normally implanted placenta from the uterine wall. **Presentation**: Painful vaginal bleeding. Uterine tenderness, rigidity, or frequent contractions. May have concealed bleeding (no external blood loss but significant internal hemorrhage). 3\. **Vasa Previa**: Fetal blood vessels traverse the membranes covering the cervical os. **Presentation**: Painless bleeding, often occurring after membrane rupture. Associated with fetal distress or exsanguination. **B. Non-Placental Causes** 1\. **Genital Tract Lesions**: Cervical ectropion, polyps, or carcinoma. Vaginal varices or trauma. 2\. **Uterine Rupture**: A tear in the uterine wall, often associated with a history of uterine surgery (e.g., cesarean section or myomectomy). Rare but catastrophic, presenting with severe abdominal pain, shock, and fetal distress. 3\. **Infections**: Cervicitis or vaginitis. 4\. **Coagulopathy**: Maternal bleeding disorders (e.g., thrombocytopenia, disseminated intravascular coagulation). **Risk Factors for APH** 1\. **Placenta Previa**: Previous cesarean delivery. Advanced maternal age. Multiparity. Uterine surgeries (e.g., myomectomy, dilation, and curettage). Smoking or substance use. 2\. **Placental Abruption**: Hypertensive disorders (chronic or gestational hypertension, preeclampsia). Trauma or external cephalic version. Premature rupture of membranes (PROM). Smoking or cocaine use. Previous history of abruption. 3\. **Vasa Previa**: Low-lying placenta. Multiple gestation. In vitro fertilization. **Clinical Features** **Placenta Previa:** **Bleeding**: Painless, bright red. **Onset**: Sudden, often recurrent. **Uterus**: Non-tender, relaxed. **Placental Abruption:** **Bleeding**: Painful, dark red. **Onset**: Sudden, may be associated with trauma or hypertension. **Uterus**: Rigid, tender, with frequent contractions. **Fetal Distress**: Common. **Vasa Previa:** **Bleeding**: Painless, associated with rupture of membranes. **Fetal Distress**: Severe, may lead to fetal exsanguination. **Differential Diagnosis** 1\. Bloody show (normal in labor). 2\. Cervical or vaginal trauma. 3\. Cervical ectropion or polyps. 4\. Genital tract infections. **Diagnosis of Antepartum Hemorrhage** **Clinical Assessment** **History**: Onset, amount, and character of bleeding. Associated symptoms: pain, uterine contractions. Risk factors (e.g., previous cesarean, hypertension). **Physical Examination**: Avoid vaginal examination unless placenta previa is ruled out. Check for uterine tenderness, rigidity, and fetal heart tones. Assess maternal vitals (e.g., hypotension, tachycardia). **Investigations** 1\. **Ultrasound**: First-line imaging to identify placenta previa or abruption. Assess placental location, fetal viability, and amniotic fluid volume. 2\. **Laboratory Tests**: Complete blood count (CBC): Assess for anemia or thrombocytopenia. Coagulation profile: Rule out coagulopathy or disseminated intravascular coagulation (DIC). Blood group and crossmatch: Prepare for transfusion if needed. 3\. **Fetal Monitoring**: Non-stress test or biophysical profile for fetal well-being. **Management of Antepartum Hemorrhage** **Initial Management** 1\. **Stabilize the Mother**: Ensure airway, breathing, and circulation (ABC). Intravenous (IV) access with large-bore cannulas. Fluid resuscitation with crystalloids. Transfuse blood products if required (packed red blood cells, fresh frozen plasma). 2\. **Monitor the Fetus**: Continuous fetal heart rate monitoring. 3\. **Determine Cause**: Ultrasonography to confirm placental location and rule out previa or abruption. **Specific Management** 1\. **Placenta Previa**: **Mild bleeding, stable mother and fetus**: Admit for observation. Bed rest and corticosteroids (if gestation \