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Bleeding in pregnancy

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Bleeding in pregnancy Bleeding in pregnancy Presentation Transcript

  • BLEEDING IN PREGNANCY
    Early Pregnancy Bleeding – Antepartum Haemorrhage
    • Spontaneous Abortion
    • Threatened Miscarriage View slide
    • Inevitable Miscarriage View slide
    • Implantation Bleeding
    • Decidual Bleeding
    • Ectopic Pregnancy
    EARLY PREGNANCY BLEEDING
    • Spontaneous Abortion
    • Threatened Miscarriage
    • Inevitable Miscarriage
    EARLY PREGNANCY BLEEDING
  • Spontaneous Abortion
    Defined as the involuntary loss of the products of conception prior to 24 weeks gestation
    It is thought that 15% of conceptions result in miscarriage
    Majority occur within first trimester
  • Spontaneous AbortionCauses
    Maldevelopment of the conceptus
    Most common cause
    Chromosomal abnormalities account for 70% of defective conceptions
    Spontaneous mutations may still arise
    Defective Implantation
    Hydatidiform Mole
    Fibroids
  • Spontaneous AbortionCauses
    Maternal Infection
    Due to high temperature relating to general metabolic effect of fever
    Result of transplacental passage of viruses, e.g.
    Influenza
    Rubella
    Pneumonia
    Toxoplasmosis
    Cytomegalovirus
    Listeriosis
    Syphilis
    Brucellosis
    Appendicitis
  • Spontaneous AbortionCauses
    Genital Tract Infections
    Bacterial vaginosis
    Vaginal mycoplasma infection
    Medical Disorders
    Diabetes
    Thyroid disease
    Hypertensive disorders
    Renal disease
  • Spontaneous AbortionCauses
    Endocrine Abnormalities
    Poor development of the corpus luteum
    Inadequate secretoryendometrium
    Low serum progesterone levels
    Uterine Abnormalities
    Structural abnormalities implicated in 15% of early pregnancy losses e.g.
    Double uterus
    Unicornuate, bicornuate, septate or subseptate uterus
    Failure of uterus to develop to adult size, remaining infantile
  • Spontaneous AbortionCauses
    Retroversion of the Uterus
    Does not itself cause abortion
    As uterus fails to enlarge into abdomen, vaginal and abdominal manipulation to correct the retroversion causes abortion
    Cervical Weakness
    Caused by laceration of cervix or undue stretching of internal os as a result of previous medical abortion or childbirth
    Membranes bulge through cervical canal and rupture
    Characterised by recurrent late pregnancy losses
  • Spontaneous AbortionCauses
    Environmental Factors
    Environment teratogens such as lead and radiation
    Ingested teratogenetic substances such as drugs (namely cocaine) and alcohol
    Smoking
    Maternal Age
    Women in late 30’s and older at higher risk, irrespective of previous obstetric history
  • Spontaneous AbortionCauses
    Stress and Anxiety
    Severe emotional upset may disrupt hypothalmic and pituitary functions
    Paternal Factors
    Poor sperm quality
    Source of chromosomal abnormalities
    Immunologocial Factors
    Maternal lymphocytes with natural killer cell activity may affect trophoblast development
    Autoimmune diseases such as antiphospholipid syndrome
  • Spontaneous AbortionCauses
    Despite detailed investigations,no cause can be found for themajority of cases of spontaneous abortion
  • Spontaneous AbortionThreatened Miscarriage
    Signs and Symptoms
    Pain: Variable, possibly slight lower abdominal pain or backache
    Bleeding: Scant, during first 3 months
    Cervical Os: Closed, no dilation
    Uterus: If palpable, soft and not tender
  • Spontaneous AbortionThreatened Miscarriage
    No vaginal assessment as may provoke uterine activity
    No evidence that bedrest is effective
    Woman should be referred for medical attention straight away
    A pregnancy test is carried out and ultrasound performed to assess viability
    Heavy or increased amount of bleeding in an ominous sign and may precede inevitable abortion
  • Spontaneous AbortionInevitable Miscarriage
    Signs and Symptoms
    Pain: Severe, rhythmical
    Bleeding: Heavy, clots
    Cervical Os: Open with dilation
    Uterus: If palpable, smaller than expected
  • Spontaneous AbortionInevitable Miscarriage
    As name indicates, it is unavoidable pregnancy loss
    Gestational sac separates from uterine wall and uterus contracts to expel the contents of conception
    Midwife should attend at once when called as woman may collapse from blood loss
    Speculum examination in hospital, input from obstetrician or gynaecologist
    Oxytocic drug may be given after products expelled
  • Spontaneous AbortionIncomplete Miscarriage
    Signs and Symptoms
    Pain: Severe
    Bleeding: Heavy, profuse
    Cervical Os: Open with dilation
    Uterus: Tender and painful
    Other: Tissue present in cervix
    Shock
  • Spontaneous AbortionIncomplete Miscarriage
    Gestational sac is incompletely expelled, with usually the placental tissue retained
    Static or slowly falling HCG levels
    Evacuation of retained products of conception from the uterus carried out
    Medical management possible using prostaglandin analogues such as misoprostol
    If surgical evacuation required, woman should be screened for chlamydial infection
    Transfusion may be given if blood loss excessive
  • Spontaneous AbortionComplete Miscarriage
    Signs and Symptoms
    Pain: Diminishing or absent
    Bleeding: Minimal or absent
    Cervical Os: Closed
    Uterus: If palpable, firm and contracted
  • Spontaneous AbortionComplete Miscarriage
    Gestational sac completely expelled
    History of abdominal pain, bleeding with passing of clots and tissue
    Once miscarriage is complete, pain and bleeding subside, cervix closes
    Ultrasound shows empty uterus coupled with falling HCG levels
  • Spontaneous AbortionMissed Miscarriage
    Signs and Symptoms
    Pain: Absent
    Bleeding: Some spotting possible, brown loss
    Cervical Os: Closed
    Uterus: If palpable, smaller than expected
  • Spontaneous AbortionMissed Miscarriage
    Also known as delayed or silent abortion
    Usually follows threatened abortion
    Bleeding occurs between uterine wall and gestational sac and embryo dies
    Layers of blood clots form and later become organised
    Retainment of fetus inhibits menses
    Other signs of pregnancy diminish
    Confirmed by ultrasound
    Surgical evacuation or expectant management possible
  • Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease
    GTD general term that covers
    Hydatidiform mole (benign)
    Choriocarcinoma (malignant)
  • Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease
    Clinical presentation of Hydatidiform Mole
    Exaggerated signs of pregnancy, appearing by 6-8 weeks due to high levels of HCG
    Bleeding or a blood stained vaginal discharge after period of amenorrhoea
    Ruptured vesicles, resulting in light pink or brown vaginal discharge, or detached vesicles, which may be passed vaginally
    Anaemia as a result of the gradual loss of blood
    Early-onset pre-eclampsia
    On examination, uterine size exceeding that expected for gestation
    On palpation, a uterus that feels ‘doughy’ or elastic
  • Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease
    Hydatidiform Mole
    Gross malformation of trophoblast
    Chorionic villi proliferate and become avascular
    Found in cavity of uterus and rarely within uterine tube
    Can lead to development of cancer, therefore accurate and rapid diagnosis, treatment and follow-up paramount
    Two forms of mole
    Complete hydatidiform mole (risk of choriocarcinoma)
    Partial mole
  • Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease
    Treatment of Hydatidiform Mole
    Treatment is to remove all trophoblastic tissue
    In some cases, mole will abort spontaneously
    If this does not occur, vacuum aspiration or D and C necessary
    Spontaneous abortion carries less risk of malignant change
    Pregnancy to be avoided in follow up period
    IUCDs contraindicated and hormonal methods of contraception to be avoided until HCG levels normal
  • Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease
    Choriocarcinoma
    Malignant disease of trophoblastic tissue
    HCG levels will rise and test will become strongly positive again
    May occur in next pregnancy following evacuation of mole
    Condition rapidly fatal unless treated
    Disease spreads by local invasion and via bloodstream
    Metastases my occur in lungs, liver or brain
  • Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease
    Treatment of Choriocarcinoma
    Responds extremely well to chemotherapy
    Cytotoxic drugs are used singly or in combination with other therapy
    Nearly always completely successful
    Pregnancy should be avoided for at least one year on completion of treatment
    Subsequent pregnancy will require close HCG monitoring as there is a risk of recurrance
  • Spontaneous AbortionSeptic Miscarriage
    Signs and Symptoms
    Pain: Severe or variable
    Bleeding: Variable, may be offensive
    Cervical Os: Open
    Uterus: Bulky, tender and painful on examination
  • Spontaneous AbortionSeptic Miscarriage
    May occur after spontaneous or induced abortion, more likely after incomplete miscarriage
    Causitive organisms include Staphyloccusaureus, Clostridium welchii, Escherichia coli, Klebsiella, Serratiaand Bacteroidesspecies, and group B haemolytic streptococci
    Woman will feel acutely ill with fever, tachycardia, headache, nausea and general malaise
    High vaginal swab and blood cultures should be taken
    Antibiotics before any surgical intervention
    Risks include septicaemia, endotoxic shock, DIC, liver and renal damage, salpingitis and infertility
  • Spontaneous AbortionMidwifery Assessments
    Blood loss
    • Amount?
    • Nature?
    • When did it start?
    • What were you doing at the time?
    Pain
    Menstrual History
    • Confirm LMP
    Symptoms of Pregnancy
    • Still present?
    • Have they changed?
    Obstetric History
    Gynaecological History
    • Cervical infections
    • Cervical operations
    Contraceptive History
    Blood Group and Rhesus Status
  • Spontaneous AbortionMidwifery Responsibilities
    Referral
    Support groups
    Recurrent miscarriage clinic
    GP/gynaecologist-obstetrician
    Advice
    Expect a grief reaction
    Dependent on gestation, lactation may occur
    Understand it takes weeks – months to recover from a miscarriage physically and even longer emotionally
    Menstruation may return four to six weeks later
    Await the next normal period before trying to conceive
    Expect bleeding for up to two weeks
    No intercourse, swimming, tampons for two weeks or duration of bleeding
    Support
    Remember the partner too
    • Implantation Bleeding
    EARLY PREGNANCY BLEEDING
  • Implantation Bleeding
    As the trophoblast erodes the endometrial endothelium and the blastocyst implants, a small vaginal loss may be apparent
    Occurs at approximately 10-12 days post conception, around the same time as expected menses and may be mistaken for a woman’s period, although abnormal (usually bright red and lighter)
    It is significant when calculating LMP for estimation of due date
    • Decidual Bleeding
    EARLY PREGNANCY BLEEDING
  • Decidual Bleeding
    Occasionally there is bleeding from the decidua during the first 10 weeks, usually at around the time menses is expected
    Caused by menstrual hormones
    Especially common in the early stages of pregnancy, before the lining has completely attached to the placenta
    Not thought to be a health threat to mother or fetus
    May affect calculation of EDD
    • Ectopic Pregnancy
    EARLY PREGNANCY BLEEDING
  • Ectopic Pregnancy
    Occurs when a fertilised ovum implants itself outside the uterine cavity
    Sites can include the uterine tube, an ovary, the cervix or the abdomen
    95% implant in the uterine tube (tubal pregnancy), of which 64% are implanted in the ampulla of the fallopian tube (where fertilisation takes place)
  • Ectopic PregnancyRisk Factors
    Any alterations of the normal function of the uterine tube in transporting gametes contributes to the risk of ectopic pregnancy:
    Previous ectopic pregnancy
    Previous surgery on the uterine tube, pelvic or abdominal surgery which may cause adhesions
    Exposure to diethylstillboestrol in utero (postcoital contraception)
    Congenital abnormalities of the tube
    Endometriosis
    Previous infection including chlamydia, gonorrhoea and pelvic inflammatory disease
    Use of intrauterine contraceptive devices
    Assisted reproductive technology
    Delayed childbearing (>35 years)
  • Ectopic PregnancySigns of Ectopic Pregnancy
    Tubal pregnancy very rarely remains asymptomatic beyond 8 weeks gestation
    Typical Signs:
    Localised/abdominal pain
    Amenorrhoea
    Vaginal bleeding or spotting
    Atypical Signs:
    Shoulder pain
    Abdominal distension
    Nausea, vomiting
    Dizziness, fainting
  • Ectopic PregnancyClinical Presentation
    Pelvic pain can be very severe
    Acute symptoms are the result of tubal rupture (more likely to occur between 5-7 weeks gestation) and relate to the degree of haemorrhage there has been
    Ultrasound enables an accurate diagnosis of tubal pregnancy, making management more proactive
    Vaginal ultrasound, combined with the use of sensitive blood and urine tests which detect the presence of HCG, helps to ensure diagnosis is made earlier
    If the tube ruptures, shock may ensue; therefore resuscitation, followed by laparotomy, is needed
    The mother should be offered follow-up support and information regarding subsequent pregnancies
  • Ectopic PregnancyDiagnosis
    The woman will give a history of early pregnancy signs
    The uterus will have enlarged and feel soft
    Abdominal pain may occur as the tube distends and uterine bleeding may be present
    Abdomen may be tender and distended
    Shoulder tip pain due to referred pain
    Woman may appear pale, complain of nausea and collapse
    Severe pain felt during pelvic exam
    A mass may be felt on one side of the uterus
    Hormonal assay will find progesterone levels low and hCG levels falling
    USS may show fluid or and mass in pelvic cavity and absence of intrauterine pregnancy
  • Ectopic PregnancyDiagnosis
    Nowadays occurrence of an extra-uterine pregnancy is diagnosed with a combination of serum hCG levels and ultrasound scan
  • Ectopic PregnancyTreatment
    Common perception is that everyone with an ectopic needs an operation to deal with it
    However, a number of treatment options are available including expectant management if no bleeding, pain or shock
    If there is evidence of pain and bleeding producing shock, immediate treatment is essential, as it is a life-threatening condition
    This is a surgical emergency and in most cases a laparotomy is performed
  • Ectopic PregnancySurgical Treatment
    Salpingectomy
    Salpingectomy (tubal removal) is the principle treatment especially where there is tubal rupture
    Salpingotomy
    Conservative surgical management may be employed when the ectopic has not ruptured and where the tube appears normal
    This is called salpingotomy, where the ectopic is removed and the tube allowed to heal
  • Ectopic PregnancyExpectant Treatment
    Used when pain is less and indicators are that the ectopic is a small one or it is not bleeding too much
    Expectant approach involves close follow up with hCG tests every 2-7 days until levels have returned to normal
    Is successful in 90% of selected patients
    Methotrexate – a drug that destroys actively growing tissues such as the placental tissues that support the pregnancy is used as an injection in selected cases to avoid surgery (in non ruptured ectopic)
    Side effects include abdominal pain for 3 – 7 days in 50% of cases and mild symptoms of nausea, mouth dryness and soreness and diarrhoea
    • Placental Abruption
    • Placenta Praevia
    ANTEPARTUM HAEMORRHAGE
  • Antepartum Haemorrhage
    Defined as bleeding from the genital tract after the 24th week of gestation and before the onset of labour
    Bleeding during labour is referred to as Intrapartum Haemorrhage
    Bleeding usually due to placental separation, but can also be due to incidental causes from extraplacental sites in the birth canal, such as cervical polyps or some other local lesion
  • Antepartum HaemorrhageEffects on the Fetus
    Mortality and Morbidity increased as a result of severe vaginal bleeding in pregnancy
    Stillbirth or neonatal death may occur
    Premature separation of the placenta and subsequent hypoxia may result in severe neurological damage in the baby
  • Antepartum HaemorrhageEffects on the Mother
    If bleeding is severe, it may be accompanied by shock and disseminated intravascular coagulation (DIC)
    The mother may die or be left with permanent ill health
    APH is unpredictable and the woman’s condition can deteriorate rapidly at any time
    Rapid decisions about the urgency of need for medical or paramedic presence, or both, must be made often at the same time as observing and talking to the woman and her partner
  • Antepartum HaemorrhageCauses of Bleeding in Late Pregnancy
  • Antepartum HaemorrhageInitial Assessment of Physical Condition
    Take a detailed history from the woman
    Take observations: Temperature, Pulse, Respiratory Rate, Blood Pressure
    Observe for any pallor or breathlessness
    Assess the amount of blood loss
    Perform a gentle abdominal examination, observing signs that the woman is going into labour
  • Antepartum HaemorrhageInitial Assessment of Physical Condition
    Ask the mother is the baby has been moving as much as normal
    Attempt to auscaltate the fetal heart
    Insert large bore canula, take bloods for FBC, Cross match, LFTs, Clotting times, Kleihaur if necessary
    Obstetric referral
    Anti-D administration if applicable
    Steroids if <34 weeks gestation
  • Antepartum HaemorrhageInitial Assessment of Physical Condition
    On no account must any vaginal or rectal examination be done; nor may an enema or suppository be given to a woman suffering from an Antepartum Haemorrhage
  • Differential Diagnosis
    Pain
    Did the pain precede bleeding and is it continuous or intermittent?
    Onset of bleeding
    Was this associate with any event such as coitus?
    Amount of blood loss visible
    Is there any reason to suspect that some blood has been retained in utero?
    Colour of the blood
    Is it bright red or darker in colour?
    Degree of shock
    Is this commensurate with the amount of blood visible or more severe?
  • Differential Diagnosis
    Consistency of the abdomen
    Is it soft or tense and board-like?
    Tenderness of the abdomen
    Does the mother resent abdominal palpation?
    Lie, presentation and engagement
    Are any of these abnormal when account is taken of parity and gestation?
    Audibility of the fetal heart
    Is the fetal heart heard?
    Ultrasound scan
    Does a scan suggest that the placenta is in the lower uterine segment?
  • Antenatal HaemorrhageSupportive Treatment
    Provide woman and partner with emotional reassurance
    Give rapid fluid replacement (warmed) with a plasma expander, and later with whole blood if necessary
    Give analgesia
    If at home, arrange transfer to hospital
    Subsequent management depends on the definite diagnosis
  • Section 88 Maternity NoticeReferral Guidelines
    Previous Obstetric History
    LEVEL 2(Code 3001)- Previous Placental Abruption
    Current Pregnancy
    LEVEL 2 (Code 4004)- Antepartum Haemorrhage
    LEVEL 3 (Code 4020)- Placenta Praevia (At or >32 weeks)
    • Placental Abruption
    ANTEPARTUM HAEMORRHAGE
  • Placental Abruption
    Premature separation of a normally situated placenta, occurring after the 24th week of pregnancy
    Aetiology is not always clear, some predisposing factors are:
    Pregnancy-induced hypertension or pre-eclampsia
    A sudden reduction in uterine size, e.g. SRM with polyhydramnios or after the birth of a first twin
    Short umbilical cord
    Direct trauma to the abdomen (risk remains for 2 days following trauma)
    High parity
    Previous caesarean section
    Cigarette smoking or illicit drug use (esp. Cocaine)
  • Placental Abruption
    Blood loss may be:
    Revealed
    Concealed
    Mixed
    Separation may be:
    Mild
    Moderate
    Severe
    Complications of Placental Abruption:
    Disseminated Intravascular Coagulation
    Postpartum Haemorrhage
    Renal Failure
    Pituitary Necrosis
  • Placental AbruptionMild Separation of the Placenta
    Separation and the haemorrhage are minimal
    Mother and fetus are in a stable condition
    No indication of maternal shock
    Fetus is alive, with normal heart sounds
    Consistency of uterus is normal
    No tenderness on abdominal palpation
  • Placental AbruptionManagement of Mild Separation of the Placenta
    Ultrasound scan
    Determine placental location
    Identify any degree of concealed bleeding
    Monitoring of fetal heart rate
    Frequently to assess fetal condition whilst bleeding persists
    CTG should be carried out once or twice daily
    Admission to hospital
    Women who are not yet 37 weeks gestation may be cared for in an antenatal ward for a few days
    May be discharged if there is no further bleeding and placenta has been found to be in the upper uterine segment
  • Placental AbruptionManagement of Mild Separation of the Placenta
    Induction of Labour
    May be offered for woman who have passed the 37th week of pregnancy
    Especially if there has been more than one episode of mild bleeding
    Further management
    Heavy bleeding or evidence of fetal distress may indicate that a caesarean section is necessary
  • Placental AbruptionModerate Separation of the Placenta
    Separation of about one-quarter
    Considerable amount of blood may be lost, some of which will escape from the vagina and some will be retained as a retroplacental clot or an extravasation into the uterine muscle
    Mother will be shocked, with tachycardia and hypotension
    Degree of uterine tenderness with abdominal guarding
    Fetus may be alive, although hypoxic and intrauterine death is also a possibility
  • Placental AbruptionManagement of Moderate Separation of the Placenta
    Fluid replacement
    Should be monitored with the aid of a central venous pressure line
    Monitoring of fetal condition
    Should be assessed with continuous CTG if the fetus is alive
    Immediate caesarean section may be indicated once the woman’s condition is stablised
  • Placental AbruptionManagement of Moderate Separation of the Placenta
    If fetus is alive or has already died, vaginal birth may be contemplated
    Such a birth is advantageous because it enables the uterus to contract and control the bleeding
    Spontaneous labour frequently accompanies moderately severe abruption, but if it does not, then amniotomy is usually sufficient to induce labour
    Syntocinon may be used with great care, if necessary
    Delivery is often quite sudden, after a short labour
    Drugs to attempt to cease labour is usually inappropriate
  • Placental AbruptionSevere Separation of the Placenta
    Acute obstetric emergency
    Two-thirds of the placenta has become detached
    2000 mls of blood or more are lost from the maternal circulation
    Most or all of the blood can be concealed behind the placenta
    Woman will be severely shocked, perhaps to a degree far beyond what might be expected from the amount of blood loss visible
  • Placental AbruptionSevere Separation of the Placenta
    Woman will have severe abdominal pain with excruciating tenderness; the uterus has a board like consistency
    Hypotensive, however woman may be normotensive owing to preceding hypertension
    The fetus will almost certainly be dead
    Features associated with severe haemorrhage:
    Coagulation defects (e.g. DIC)
    Renal failure
    Pituitary failure
  • Placental AbruptionManagement of Severe Separation of the Placenta
    Treatment is same as for moderate separation
    Whole bloods transfused rapidly and subsequent amounts calculated in accordance with the woman’s central venous pressure
    Labour may begin spontaneously in advance of amniotomy and the midwife should be alert for signs of uterine contraction causing periodic intensifying of abdominal pain
    However, if bleeding continues of a compromised fetal heart rate is present, caesarean section may be required as soon as the woman is adequately stable
    The woman requires constant explanation and psychological support, despite the fact that her shocked condition may mean she is not fully conscious
    Pain relief must be considered
    Don’t forget the partner!
    • Placenta Praevia
    ANTEPARTUM HAEMORRHAGE
  • Placenta Praevia
    Placenta partially or wholly implanted in the lower uterine segment on either the anterior or posterior wall
    Lower segment of uterus grows and stretches progressively after the 12th week of pregnancy
    In later weeks, this may cause the placenta to separate and severe bleeding can occur
  • Placenta PraeviaDegree of Placenta Praevia
    Type 1 Placenta Praevia
    Majority of placenta is in the upper uterine segment
    Blood loss is usually mild
    Mother and fetus remain in good condition
    Vaginal birth is possible
    Type 2 Placenta Praevia
    Placenta is partially located in the lower segment near the internal cervical os
    Blood loss is usually moderate
    Condition of mother and fetus can vary
    Vaginal birth is possible, particularly if placenta is anterior
  • Placenta PraeviaDegree of Placenta Praevia
    Type 3 Placenta Praevia
    Placenta is located over the internal cervical os but not centrally
    Bleeding is likely to be severe
    Vaginal birth is inappropriate
    Type 4 Placenta Praevia
    The placenta is located centrally over the internal cervical os
    Torrential haemorrhage is very likely
    Caesarean section is essential
  • Indications of Placenta Praevia
    Bleeding from vagina is the only sign, and it is painless
    Uterus is not tender or tense
    Presence of placenta preavia should be considered when:
    Fetal head is not engaged in a primigravida (after 36 weeks gestation)
    There is a malpresentation, especially breech
    The lie is oblique or transverse
    The lie is unstable, usually in a multigravida
    Location of the placenta under USS will confirm the existence and extent of placenta praevia
  • Management of Placenta Praevia
    Management of placenta praevia depends on:
    The amount of bleeding
    The condition of mother and fetus
    The location of the placenta
    The stage of pregnancy