Bleeding from the genital tract in the late pregnancy, after 20th weeks of gestation and before the onset of labor. This may place the life of the mother and fetus at risk.

1. Antepartum
Hemorrhage
By: Daren R. Goco BSM,RM

2. Antepartum Hemorrhage
• Bleeding from the genital tract in the late
pregnancy, after 20th weeks of gestation and
before the onset of labor.
• This may place the life of the mother and fetus at
risk.

3. Effect on the fetus
• Fetal mortality and morbidity are increased as a
result of severe vaginal bleeding in pregnancy.
• Still birth or neonatal death may occur.
• Premature placental separation and consequent
hypoxia may result in severe neurological damage
in the baby.

4. Effect 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.

5. Causes:
1. Placental Causes:
 Placenta abruption
 Placenta Previa
 Vasa Previa
2. Cause in genital tract:
 Labor
 Rupture of uterus
 Trauma
 Infection (cervicities & vulvovaginities)
 Tumors
3. Bleeding disorder:
Congenital (Von Willebrand disease)
Acquired (DIC)

6. Placenta Previa

7. Placenta Previa
• In this condition the placenta is partially or wholly
implanted in the lower uterine segment on either the
anterior or posterior wall.
• The lower uterine segment grows and stretches
progressively after the 12week of pregnancy.
• In later weeks this may cause the placenta to separate
and severe bleeding can occur.
• Bleeding is caused by shearing stress between the
placental trophoblast and maternal venous blood
sinuses.

8. Risk Factor for Placenta Previa
• Multiparity
• Advanced maternal age (40years)
• Previous Cesarean Section (risk increase with the higher number of C section)
• Previous termination of pregnancy
• Multiple pregnancy
• Smoking
• Deficient endometrium due to presence or history of:
 uterine scar
 endometritis
 manual removal of placenta
 curettage
 submucous fibroid
• Assisted conception

9. Degree of Placenta Previa
Type 1 placenta Previa
(Low lying)
• the majority of the
placenta is in the upper
uterine segment.
• Vaginal birth is possible.
• Blood loss is usually mild and the mother
and fetus remain in good condition.

10. Type 2 Placenta Previa
(Marginal Placenta Previa)
• The placenta is parcially
located in the lower segment
near the internal cervical os.
• Vaginal birth is posible,
particularly if the placenta is
anterior.
• Blood loss is usually moderate, athough
the condition of the mother and fetus can vary.
• Fetal hypoxia is more likely to be present than
maternal shock.

11. Type 3 Placenta Praevia
(Partial Placenta Praevia)
• The placenta is located over
over the internal cervical os
but not centrally.
• Bleeding is likely to be severe,
particularly when the lower segment
stretches and the cervix begin to efface and dilate in
late pregnancy.
• Vaginal birth is inappropriate because the placenta
precedes the fetus.

12. Type 4 Placenta Previa
(Complete Placenta Previa)
• The placenta is located cen-
trally over the internal cervical
os and the hemorrhage is
very likely.
• Cesarean section is essen-
tial in order to save the live of the mother and

13. Indication of Placenta Previa
Bleeding from the vagina is only sign and it is painles.
The uterus is not tender or tense.
The presence of placenta praevia should be considered
when the presenting part of the fetus is above the pelvis
and/or the lie is unstable.
Using ultrasnic scanning will confirm the extence of
placenta praevia and establish its degree.
The color of the blood is bright red, denoting fresh
bleeding
The low placenta location allows all the lost blood to
escape unimpended and retroplacental clot is not
formed, reason pain is not a feature of placenta praevia
Note: the degree of placenta praevia does not necessarily correspond to the amount of bleeding.

14. General Examination
• If the hemorrhage is slight blood pressure, respiration rate
and pulse rate may be normal.
• Severe hemorrhage the blood pressure will be low and the
pulse rate raised because f shock
Note: the degree of shock correlates with the amount of blood lost from the vagina.
• Respiratory rate are also rapid and the mother may have air
hunger due to a reduction in the number of red blood cell in
the cerculation available for the uptake of oxygen.
• The mother color will be pale and her skin cold and moist.
• With severe bleeding the mother lose consciousness.

15. Abdominal Examination
• May find that the lie of the fetus is oblique or
transverse and the fetal head may be high in a
primigravida near term.
• The uterine consistency is normal and pain is not
experienced by the mother when her abdomen is
palpated.
• Must not attemp to do vaginal examination as this
could precipitate a torrential hemorrhage and
worsen the situation.

16. Assessing the Fetal Condition
Ask the mother if the fetal activity has been normal.
Be aware of diminution or cessation of fetal
movements, which may occur if fetal hypoxia is
severe.
Excessive fetal movement is sometime said that is an
indication of fetal hypoxia.
Note: Assess the fetal condition using an ultrasound fetal monitor such as
cardiotocograph (CTG) or handled device. A pinard stethoscope may be used if these
are not available. Fetal oxygenation depends upon the portion of the placenta
remaining attached. Fetal hypoxia is anemergency and medical asistance should be
called urgently.

17. Management of Placenta Previa
The management of placenta praevia depends on:
• The amunt of bleeding
• The condition of mother and baby.
• The location of the placenta
• The stage of the pregnancy.

18. Complication Include:
• Maternal shock, resulting from blood loss and
hypovolemia.
• Anesthetic and surgical complications, which are ore
common in women with major degree of placenta previa,
and in those for whom preparation for surgery has been
suboptimal.
• Air embolism, an occasional occurrence when the sinuses
in the placental bed have been broken.
• Fetal hypoxia and its sequel due to placental separation
• Fetal death, depending on gestational and amount of
blood loss.

19. Abruptio Placenta

20. Abrutio Placenta
Premature separation of normal situated
placenta occurring after 22nd week of
pregnancy.
Separation of the placenta from the site
of uterine implantation before delivering
of the fetus.

21. Risk Factor
• Multiparity
• Hypertension
• Blunt external abdominal trauma/direct
• Smoking
• Poor nutrition
• Age older than 35 yrs old
• Short umbilical cord.
• Coccaine/ prohibited drug user.
• Previous third trimester bleeding
• Alcohol use

22. Type of Abruptio Placenta
• Concealed Hemorrhage
• Revealed Hemorrhage
• Mixed Hemorrhage

23. Concealed Hemorrhage - there is no vaginal bleeding,
but the mother will have all sign and symptoms of
hypovolemic shock. Causes uterine enlargement and
extreme pain.
Revealed Hemorrhage - the dissection occur along the
uterine wall and blood escapes through the cervix.
Mixed Hemorrhage - a combination of two situation
where some of the blood drain via the vagina and
some is retained behind the placenta.

24. Grading System for Abrution
Grade 0
Less than 10% the total placental surface
has been detached, no symptoms , small
retro placental clot is noted at birth
Grade I
Approximately 10-20% of the total placental
surface has detached, vaginal bleeding and
mild uterine tenderness are noted, mother
and fetus are in distress.
Grade II
Approximately 20-50% of total placental
surface has detached, has uterine
tenderness and tetany, sign of fetal distress
are noted. The mother is not in hypovolemic
shock.
Grade III
More than 50% of placental surface has
detached, uterine tetany is severe, mother is
in shock and often experiencing
coagulopathy, fetal death occurs.

25. Indication of Abrutio Placenta
• Sharp abdominal pain/ back pain
• Uterine tenderness
• Vaginal bleeding (dark red in color)
• Sign of maternal shock
• Fetal distress

26. Assessing the Mother's
Condition
• History of pre-eclampsia
• History of physical domestic violence should be
considered
• Accidents are cause of trauma to the abdomen.
• External cephalic version injudiciously performed may
also resul in placental separation.
• Should enquire about the time of onset and whether
the bleeding began simultaneously or later.

27. General examination
• The woman is likely to be anxious, experiencing abdominal pain, and her
skin will be pale and moist if she is shocked.
• Clinical examination, the mother may have obvious edema of the face,
fingers and prebital area of the lower limbs attributable to pre-
eclampsia.
• Low blood pressure and raised pulse rate are sign of shock.
• If the mother has pregnancy induce hypertension the blood pressure is
within the normal limits, having raised prior to the hemorrhage.
• Respirations may be normal or rapid, and reduce oxygenation may lead
to air hunger.
• Temperature will usually normal.
• The amount of any visible blood loss should be estimated and the color
noted. Freshly lost blood is bright red; blood stain utero for any length
of time is change in brown color.

28. Abdominal Examination
• Concealed hemorrhage may lead to uterine
enlargement.
• Uterus has a hard consistency
• Palpation may be difficult and should not be
attemp if the uterus is rigid and excessively painful.
• Palpation should be kept to a minimum in order to
avoid further pain and damage.

29. Assessing fetal condition
• Woman should be aware of cessation of fetal
movement.
• CTG recording will be given for more complete
information about fetal condition.

30. Management for Abruptio
Placenta
Medical Management:
• The woman should be hospitalized and monitored carefully
for sign of increassing placental separation.
• Ultrasound is necessary to differentiate abruptio placenta
from placenta previa
• Monitor fetal heart rate and fetal condition by CTG
• Monitor vital sign
• Check urine output, hematocrit, platelet counts, and
fibrinogen concentration determination.
• Cesarean birth delivery
• Blood replacement.

31. Complication
• DIC is a complication of moderate to severe
placenta abrution
• Postpartum hemorrhage
• Renal failure may occur as result to hypovolemia
and consequent poor perfusion of the kidneys.
• Pituitary necrosis is another possible consequence
of prolonged and severe hypotension ( Sheehan's
Syndrome)
• Maternal and fetal mortality.

32. Thank you.