2. At the end of this tutorial the student will
be able to:
Define APH
Discuss the etiology and differential diagnosis of
APH
Describe the assessment and management of a
woman with APH
3. Definition and
Classification
Definition bleeding from or in to the
genital tract, occurring from 22 weeks
(>500g) of pregnancy and prior to the
birth of the baby.
Classification Placenta praevia
Abruptio placenta
4. CAUSES OF 763 PREGNANCY-RELATED
DEATHS
DUE TO HEMORRHAGE
CAUSES OF HEMORRHAGE NUMBER (%)
Placental abruption 141 (19)
Laceration/uterine rupture 125 (16)
Uterine atony 115 (15)
Coagulopathies 108 (14)
Placenta previa 50 (7)
Uterine bleeding 47 (6)
Placenta accreta/increta/percreta 44 (6)
Retained placenta 32 (4)
6. (Should be taken after the mother is stable.)
Severity of the bleeding
-associated pain with the haemorrhage?
-Continuous pain : Placental abruption.
-Intermittent pain : Labour.
Time of onset
Triggering factors
A/w pain or uterine contractions?
Fetal movement
-If it reduced and associated with spontaneous or iatrogenic rupture of the fetal membranes : ruptured vasa
praevia
Hx of ruptured membranes
Hx cervical smear (date/normal or abnormal)
-Previous cervical smear history possibility of Ca cervix. Symptomatic pregnant women usually present with
APH (mostly postcoital) or vaginal discharge.
Previous ultrasound report
Risk factors for abruption and placenta praevia should be identified.
7. General: PULSE & BP
Abdomen:
The tense, tender or ‘woody’ feel to the uterus
indicates a significant abruption.
Painless bleeding, high fetal presenting part –
Placenta praevia
- soft, non-tender uterus may suggest a lower genital
tract cause or bleeding from placenta or vasa praevia.
8. Speculum :
-identify cervical dilatation or visualise a lower
genital tract cause.
Digital vaginal examination
- Should NOT be done until Placenta Praevia has
been excluded by USG.
10. Conser vative Management
Admit ( according to RCOG is 28weeks)
Monitor BP & Pulse rate
Pad chart - to monitor progress of the
leaking liquor
Minimize the abdominal examination
11. Monitor fetal well being
- Fetal kick chart(daily)
- CTG (weekly)
- U/S (fortnightly)
Steroid injection (> 24w, <36w) ‐ IM
dexamethasone 12mg stat and repeat the
second dose after 12 hours.
™ Any symptoms or signs of labour
12. Maternal complications Fetal complications
Anaemia Fetal hypoxia
Infection Small for gestational age and fetal
growth restriction
Maternal shock Prematurity (iatrogenic and
spontaneous)
Renal tubular necrosis Fetal death
Consumptive coagulopathy
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Complications of blood transfusion
13.
14. Definition The condition that
the placenta is wholly or partly
attached to the lower uterine
segment
Classification (GRADING/CLINICAL)
15. Type IV
Type IV
The placenta
The placenta
completely covers
completely covers
the cervical os.
the cervical os.
16. Type III
Type III
The placenta
The placenta
covers the os but
covers the os but
not at full
not at full
dilatation.
dilatation.
17. TYPE II
TYPE II
The placenta
The placenta
reaches the
reaches the
margin of
margin of
cervical os
cervical os
19. Cervix
Placenta
Uterus
A PLACENTA WHICH HAS IMPLANTED OVER THE OS
20. Minor : Deliver vaginally
Type 1 (anterior/posterior) Type 1 Posterior >
likelihood of fetal distress
Type 2 anterior
Major: Caesarean section
Type 2 posterior >
Type 2 posterior (dangerous type) chance of fetal distress
Type 3 Type 3 & 4
Type 4 anterior –cut
through placenta to
deliver. Hence need
to be fast and
efficient.
21. ETIOLOGY
Advancing maternal age
Multiparity
Prior cesarean section ,manual removal
of placenta and dilatation and
curettage(D&C)
Multiple gestation
Smoking
Histor y of PP
22. PATHOLOGY
The incidence of placenta praevia is 0.5%, bleeding from a placenta
The incidence of placenta praevia is 0.5%, bleeding from a placenta
praevia is about 20% of all cases of antepartum hemorrhage ..
praevia is about 20% of all cases of antepartum hemorrhage
Fetal influence
Maternal Distress or death
influence
IUGR
Haemorrhage
Premature
Shock
Neonatal death
Anemia
24. During the trimester of pregnancy Slight or
severe bleeding from the vagina without evident
cause and without any pain on the abdomen.
During delivery Severe haemorrhage is inevitable
as the cervix dilates, especially in type I and type II.
During the third stage of labour Postpartum
haemorrhage
25. •Intermittent painless PV bleeding
•Minimal/spotting
•Bleeding mainly from mother
•Abdomen is soft and nontender
•CTG usually normal
•a/w with abnormal lies and presentation
28. Low Lying Placenta Praevia
Image shows (Transvaginal Ultrasound, 33
weeks gestation): On transvaginal scan, the
placenta is situated on the posterior uterine wall
(arrow) and extends to 15mm of the internal
cervical os. The cervix is long and closed
through its entire length and measures 38mm.
Normal fetal measurements and activity are
noted which are not illustrated.
Partial Placenta Praevia
Image by (Transvaginal Ultrasound): The
placenta partially overlies the internal
cervical os (arrow).
Complete Placenta Praevia
Image by (Transvaginal
Ultrasound): The placental
completely covers the top of the
internal cervical os (arrow).
29.
30.
31.
32. Type I,II(ant) Type II( post), III,IV
ARM +/- oxytocin
Caesarean
section
Satisfactory
progress without Bleeding continues
bleeding
Caesarean section
Vaginal
delivery
Editor's Notes
FBC Coagulation profile Blood Grouping and CXM, GSH. Ultrasound- TRO PP/ IUD D-dimer : AP colour doppler TVS – VP In all women who are RhD-negative, a Kleihauer test should be performed to quantify FMH to gauge the dose of anti-D Ig required.
WHEN to admit ? Based on individual assessment - Discharge after reassurance and counselling Women presenting with spotting who are no longer bleeding and where placenta praevia has been Excluded. However, a woman with spotting + previous IUD due to placenta abruption, an admission would be appropriate. - All women with APH heavier than spotting and women with ongoing bleeding should remain in hospital at least until the bleeding has stopped
If preterm delivery is anticipated, a single course of antenatal corticosteroids ( dexamethasone 12mg 12 hourly ,2 doses) to women between 24 and 34 weeks 6 days of gestation. Tocolytics should NOT be given unless for VERY preterm women who need time to transfer to hospital with NICU. For very preterm ( 24-26 weeks ) , - conservative management if mother is stable . - Delivery of fetus – life threatening At these gestations, experienced neonatologists should be involved in the counselling of the woman and her partner
*These are four grading that are commonly recognized. *Implantation of placenta over or near the internal os of cervix. *Confirm diagnosis of PP can be done at 28 weeks when LUS forming. *Leading cause of vaginal bleeding in the 2 nd and 3 rd trimester.
Type I – The placenta is near the cervix.
Type II – The placenta reaches the edge of the cervix.
Type III – The placenta covers the cervix when it is closed, but not completely when it is open.
Type IV – The placenta completely covers the cervix even when it is open
*these are the clinical classification which we classified the grading into more specific types. with the use of ultrasound,the placenta is designated as major/minor
Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection Minor haemorrhage – blood loss less than 50 ml that has settled Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock Massive haemorrhage – blood loss greater than 1000 ml and/or signs of clinical shock. Recurrent APH - > one episode
Quantity the amount of bleeding(pads? Spotting/minimal) Nature of the bleeding(fresh blood/clots) a/w symptoms (abd pain,uterine contraction,leaking liquor/show) Symptoms of anaemia Preceded events(sexual intercourse,vaginal discharge,abd trauma,massage,heavy work)
ultrasound use to confirm diagnosis and fetal gestation with the use of ultrasound,the placenta is designated as major/minor BUSE-blood urea and serum electrolyte
The appropriate treatment for the placenta praevia should depend on the type and the gestational age of the fetus.
