Antepartum hemorrhage (APH) is vaginal bleeding occurring after 20 weeks of gestation but before the delivery of the baby.
Incidence:
- Occurs in 2–5% of pregnancies.
- Leading cause of maternal and perinatal morbidity and mortality.
Causes of APH
1. Placenta Previa (20%)
- Abnormal implantation of the placenta over or near the internal cervical os.
2. Placental Abruption (30%)
- Premature separation of a normally implanted placenta before delivery.
3. Other Causes (50%)
- Vasa Previa (Fetal vessels running over the cervix).
- Uterine rupture (Seen in previous C-sections).
- Cervical causes (Cervicitis, Polyps, Carcinoma).
1. Placenta Previa
Definition:
Placenta previa occurs when the placenta partially or completely covers the internal os.
Types of Placenta Previa:
- Complete Placenta Previa – Placenta totally covers the internal os.
- Partial Placenta Previa – Placenta partially covers the os.
- Marginal Placenta Previa – Placental edge reaches the margin of the os.
- Low-Lying Placenta – Placenta implanted in the lower uterine segment, but does not reach the os.
Risk Factors for Placenta Previa:
- Previous placenta previa
- Previous C-section or uterine surgery
- Multiparity
- Advanced maternal age (>35 years)
- Multiple pregnancy
- Smoking, Cocaine use
Clinical Features:
- Painless, bright red vaginal bleeding after 28 weeks.
- Soft, non-tender uterus.
- Fetal heart sounds present (if not complicated).
Diagnosis:
- Transvaginal Ultrasound (Gold Standard) – Locates the placenta.
- Avoid vaginal examination (can trigger massive bleeding).
Management:
- Hemodynamically stable patients:
- Hospital admission for observation.
- Bed rest and avoid intercourse.
- Steroids (Betamethasone) for fetal lung maturity if <34 weeks.
- Severe hemorrhage or term pregnancy (≥37 weeks):
- Cesarean section (Preferred mode of delivery).
2. Placental Abruption
Definition:
Placental abruption is the premature separation of the placenta from the uterine wall before delivery.
Risk Factors for Placental Abruption:
- Hypertension (Most common cause).
- Trauma (Motor vehicle accidents, falls, domestic violence).
- Smoking, Cocaine use.
- Polyhydramnios (Sudden rupture of membranes).
- Previous placental abruption.
Clinical Features:
- Painful, dark red vaginal bleeding.
- Rigid, tender uterus (Woody hard uterus).
- Fetal distress or absent fetal heart sounds (IUFD).
Types of Abruption:
- Revealed (External Hemorrhage) – Blood escapes through the vagina.
- Concealed (Internal Hemorrhage) – Blood collects behind the placenta, no visible bleeding.
- Mixed (Both External & Concealed bleeding).
Complications:
- Maternal Shock & DIC (Disseminated Intravascular Coagulation).
- Fetal Hypoxia, Intrauterine fetal demise (IUFD).
- Couvelaire Uterus (Extravasation of blood into myometrium → Uterus appears blue & atonic).
Diagnosis:
- Clinical diagnosis (Painful vaginal bleeding + Tender uterus).
- Ultrasound (Retroplacental hematoma may be seen).
Management:
- Mild cases & Preterm fetus:
- Monitor BP & fetal well-being.
- Steroids for fetal lung maturity.
- Severe cases or fetal distress:
- Emergency C-section (Definitive treatment).
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3. Other Causes of APH
Vasa Previa
- Definition: Fetal blood vessels run over the cervix, at risk of rupture.
- Clinical Features:
- Sudden vaginal bleeding after membrane rupture.
- Fetal distress (Bradycardia).
- Diagnosis:
- Transvaginal ultrasound with Doppler.
- Management:
- Emergency C-section.
Uterine Rupture
- Occurs in women with previous C-section scars.
- Severe abdominal pain, fetal distress, loss of contractions.
- Management: Immediate laparotomy & C-section.
Cervical Causes (Polyps, Carcinoma, Cervicitis)
- Post-coital bleeding common.
- Diagnosed by speculum examination & biopsy.
Differentiating Placenta Previa vs. Placental Abruption
|
Feature |
Placenta Previa |
Placental Abruption |
|
Bleeding |
Painless, bright red |
Painful, dark red |
|
Uterus |
Soft, non-tender |
Rigid, tender |
|
Fetal Distress |
Absent unless severe |
Present (Common) |
|
Diagnosis |
Transvaginal USG |
Clinical, USG (Retroplacental clot) |
|
Management |
C-section if severe |
Emergency C-section if severe |
Management of Antepartum Hemorrhage (General Approach)
- Assess Maternal & Fetal Status:
- Monitor BP, pulse, urine output, Fetal heart rate (FHR).
- IV Access & Fluid Resuscitation:
- Two large-bore IV cannulas, IV crystalloids, blood transfusion if needed.
- Avoid Vaginal Examination Until Placenta Previa is Ruled Out.
- Ultrasound to Identify Cause.
- Steroids (Betamethasone) if <34 Weeks for Fetal Lung Maturity.
- Delivery Plan:
- Placenta Previa: C-section at 37 weeks or earlier if severe bleeding.
- Placental Abruption: Emergency C-section if fetal distress.
Summary of Antepartum Hemorrhage
|
Condition |
Cause |
Key Features |
Management |
|
Placenta Previa |
Low-lying placenta |
Painless, bright red
bleeding |
C-section if severe or term |
|
Placental Abruption |
Premature placental separation |
Painful, dark red bleeding,
rigid uterus |
Emergency C-section if
fetal distress |
|
Vasa Previa |
Rupture of fetal vessels |
Sudden bleeding after ROM,
fetal distress |
Emergency C-section |
|
Uterine Rupture |
Previous C-section scar rupture |
Severe pain, fetal
distress, loss of contractions |
Laparotomy & C-section |
Key Takeaways
- Placenta Previa = Painless bleeding.
- Placental Abruption = Painful bleeding + Rigid uterus.
- Avoid vaginal exams in suspected Placenta Previa.
- Delivery is the only definitive treatment.
1. Sabina Officinalis
- Gushing bright red bleeding, often with clots.
- Severe lower abdominal and back pain, radiating to the thighs.
- History of recurrent miscarriages in the third month.
- Bleeding worsens with the slightest motion.
- Sensation of heaviness in the uterus, as if everything will fall out.
2. Trillium Pendulum
- Profuse, bright red bleeding, worsened by movement.
- Sensation of the pelvis falling apart, relieved by tight bandaging.
- Marked exhaustion and fainting from excessive blood loss.
- Recurrent pregnancy bleeding, often seen in women with fibroids.
- Better with firm pressure or lying down.
3. Secale Cornutum
- Thin, dark, prolonged bleeding that seems unstoppable.
- Burning sensation in the uterus, as if on fire.
- Excessive weakness and trembling due to blood loss.
- Aggravation from warmth, better with cold applications.
- Often seen in women with a history of prolonged labor or uterine fibroids.
4. Millefolium (Yarrow)
- Bright red, painless bleeding, even from minor exertion.
- Worsens with standing for long periods or physical activity.
- History of previous hemorrhages during pregnancy.
- Dizziness and faintness due to excessive blood loss.
- No associated cramping or uterine pain.
5. Hamamelis Virginiana
- Dark, passive, slow bleeding with venous congestion.
- Blood appears thin and watery, often without clots.
- Aching sensation in the pelvis and legs.
- Extreme fatigue and sluggish circulation.
- History of varicose veins or venous disorders.
Key Takeaways
- Sabina: Bright red, profuse bleeding with severe cramps, worse from movement.
- Trillium Pendulum: Gushing bright red bleeding, pelvic weakness, relieved by tight bandaging.
- Secale Cornutum: Slow, dark, continuous bleeding with burning pain and uterine atony.
- Millefolium: Painless, bright red bleeding from capillary fragility.
- Hamamelis: Passive, slow, venous bleeding with exhaustion and sluggish circulation.
Important Note:
- Antepartum hemorrhage is a medical emergency. Always seek urgent medical care.
- Homeopathy can be used as supportive treatment under medical supervision to help control minor bleeding, strengthen the uterus, and aid recovery.
- Regular monitoring via ultrasound and medical follow-ups are essential to assess placental health and fetal well-being.