detailed description of APH and its causes

1. Antepartum Hemorrhage
(APH)
By
Dr Prema Swaroopa
Secondary DNB Resident
GMC Anantnag

2. Definition
• Any bleeding from or into the genital track after the period of viability
(24 weeks) but before the birth of the baby is called APH
Incidence
• 3-5 % of all pregnancies

3. Causes of APH Percentage
I. Maternal Causes
1. Placental Bleeding
a) Placenta Previa
b) Abruptio Placentae
70
35
35
2. Marginal Placental bleeding and unexplained or indeterminate APH 25
3. Extra placental causes
a) Excessive show
b) Cervical erosion and ectropion
c) Local infections of cervix and vagina
d) Cervical and vaginal trauma
e) Cervical polyp
f) CIN and carcinoma of cervix
g) Vulvovaginal varicosities
h) Post coital bleeding
i) Scar dehiscence and uterine rupture
j) Medical causes ( Factors VIII and IX deficiency)
4. Miscellaneous placental and umbilical cord anomalies
a) Circumvallate placenta
b) Velamentous insertion of umbilical cord
c) Succenturiate lobe
d) Congenital AV malformation
e) Aberrant blood vessel
II. Fetal Causes
a) Vasa previa < 1

4. PLACENTA PREVIA
• It is defined as placenta that is partially or wholly situated in the lower uterine segment
over or very near to the internal cervical os.
• Incidence : 1 in 300/400 deliveries ( 0.3 %)
• Etiology :
1. Age
2. Parity
3. Dropping Down Theory (Central Placenta Previa)
4. Defective decidua basalis
i. Elderly patients
ii. Grand multipara
iii. H/O MROP
iv. Endometrial ablation
v. Previous D&C
vi. MTP or spontaneous abortion

5. 5. Hyperplacentosis – Multiple pregnancy, anemia, Rh isoimmunization
6. Previous LSCS
i. No LSCS - 0.3%
ii. 2 LSCS - 0.7%
iii. 3 LSCS - 1.8%
iv. 4 LSCS - 4%
v. 5 LSCS - 10%
7. Fetal Malpresentations
8. Uterine Anomalies
9. Persistence Of Chorionic Laevae which encroach the lower uterine segment
10. Placental and cord anomalies
11. Smoking and drug abuse (cocaine)
Carbon monoxide production -> Tissue Hypoxia -> Compensatory Placental
Hypotrophy (Inflammatory or Atrophic changes)
12. Ethnic Groups – Asian Women
13. Maternal Serum AFP ( > 2.0 mom @ 16 weeks)
14. Fibroid Uterus
15. ART

6. Classification
• National Institute of Health
1. Placenta Previa
i. Complete/Total
ii. Partial
2. Low Lying Placenta
Placental edge lying with in 2 cms of perimeter around the os but does not cover it

7. Browne’s classification

8. Dangerous Placenta Previa
(Type – 2 Posterior)
1. Placenta over sacral promontory – Decreased AP diameter by 2.5
cms
2. Prevents engagement of presenting part
3. Cord Compression and Cord Prolapse – Fetal jeopardy
4. Fetal hypoxia (excessive compression of placenta)

9. Cause of Hemorrhage
• Inelastic placenta is shredded off from the wall of the progressively
thinning and dilating lower segment during the 3rd trimester of
pregnancy and labor
• Bleeding occurs from maternal open sinuses
• Being a physiological phenomenon the bleeding is called inevitable
• The mechanisms of spontaneous stopping of bleeding
i. Uterine muscles act as ligatures
ii. Thrombosis of open maternal sinus
iii. Mechanical pressure by the presenting part
iv. Placental infarctions

10. Clinical Features
Symptoms
• Sudden Bleeding (Inevitable, painless, profuse, recurrent)
• Warning hemorrhage (first bleeding)
• 80% of patients with placenta previa bleed before onset of labor
• Chance of bleeding are more in type 2 and type 3
• Severe bleeding in central placenta previa
Signs
• General Examination
• Pallor (proportionate to blood loss)
• Shock +/-
• Abdominal Examination
• Abdomen is soft
• Uterus – Relaxed, non tender, corresponding to POG
• Malpresentations (35% cases)
• Fetal paths FHS +
• Presenting part – floating
• FHS and placental shuffle
• Stallworthys sign + (Type 2B)
• Vulval Inspection

11. Diagnosis
1. Clinical
a. P/A – Malpresentation, free floating presenting part
b. P/S – Bleeding +, R/O local causes
c. Vaginal Examination is contraindicated.
2. Investigations
a. USG (98% accuracy after 30 weeks)
• TAS - False positive – Full bladder and myometrial contractions
• TVS – More sensitive (PV & TVS)
• Transperineal/Translabial USG
• Placental migration (Trophotropism) - 5% @ 16 to18 weeks - 0.5% @ term
• Less chances of migration
• Posterior placenta
• Thickness > 1 cm
• Lower edge < 2 cm
• History of previous LSCS
b. MRI
• Gadolinium Enhanced MRI – Morbidly adherent placenta
c. Basic Investigations
• CBC, Blood Group, RH Typing, VDRL, Urine Test, Coombs Test, Kleihauer – Betke Test
3. During LSCS
4. After Vaginal Delivery – Examination of placenta

12. Complications - Maternal
• During Antenatal Period
1. Vaginal bleeding - warning hemorrhage, AFP > 2.0 MOM
2. Malpresentations
3. Preterm labor
4. Longer hospital stay
5. Anemia
6. RH sensitization
7. Hemorrhagic shock
8. ARDS
9. DIC (Rare)
10. ARF (Rare)
11. Blood transfusion and complications

13. Complications - Maternal
• During Labor
1. PROM
2. Cord Prolapse
3. Intrapartum hemorrhage
4. Slow dilation of service
5. More surgical interference
6. Increased PPH - Imperfect contraction and retraction, large surface area of placenta,
preexisting anemia, adherent placenta, tears in cervix - soft and more vascular
7. Retained placenta
8. Abruption of placenta
9. Hysterectomy
10. Air embolism
• During Puerperium
1. Secondary PPH
2. Puerperal Sepsis
3. Non involution
4. Venus Thromboembolism (0.5%)

14. Maternal Mortality (1-5)%
• Hemorrhage, Shock, Operative Delivery
• Reduction in deaths
1. Early Diagnosis
2. Avoid PV Examination
3. More availability of blood transfusion facilities
4. Effective Anti biotics
5. Liberal LSCS with expert anesthetist
6. Skilled management

15. Complications - Fetal
1. Perinatal Mortality (7-25)%
• Prematurity
• Asphyxia – separation of placenta
• Congenital malformations
• Cord accidents
• Maternal Hypovolemia and shock
2. Prematurity
3. LBW Babies – Placental Insufficiency, Preterm labor
4. Fetal Hypoxia
5. Fetal Injuries
6. Congenital Malformation – Spina Bifida
7. Fetal Malpresentations
8. Fetal Hypovolemia

16. Management
1. Prevention – Not preventable but following are beneficial
i. Antenatal Care
ii. Family planning
iii. Reducing LSCS
iv. Universal targeted scan of all women @ 18-22 weeks
2. Treatment
All patients of APH should be admitted. Blood loss is considered as placenta previa unless proved
otherwise
i. Detailed history
ii. Condition of patient and soiling of clothes
iii. Clinical examination
iv. Per abdomen examination
v. Blood samples collected
vi. IV access to be secured
vii. Consultant informed
viii. Bedside ultrasound
ix. Vaginal examination is contra indicated

18. Expectant Management(Macafee and
Johnson regimen)
• AIM
To prolong pregnancy for achieving fetal maturity without
compromising the maternal condition with round-the-clock facility
center
• Indications
1. Good health (HB > 10)
2. GA < 37 weeks
3. No active vaginal bleeding
4. Patient not in labor
5. Good fetal condition – USG and Ultrasound

19. • Conduct Of Expectant Management
1. Bedrest with bathroom facilities (daily vitals and fetal wellbeing)
2. Inspection of vulval pads and USG @ 2-3 weeks
3. HB, Blood Group and Urine tests. Blood and blood products to be arranged.
4. Iron, Folate, Calcium supplements. Blood Transfusion.
5. After 2-3 days speculum examination – R/O local causes.
6. Tocolytics avoided
7. Cervical Cerclage – not helpful
8. Anti D Injection – RH -ve Women
9. Steroid therapy - < 34 weeks
• Contraindications for expectant management
1. Patient deteriorating
2. Persistent Hemorrhage
3. GA > 37 weeks
4. Fetal distress
5. EFW >= 2.5kg
6. Patient in labor
7. Congenital anomalies of fetus
8. Fetal death

20. Definitive Treatment
Active treatment is done in patients of GA >= 37 weeks
• Type 1, 2 anterior PP – Induction of labor with ARM + Oxytocin.
LSCS – severe bleeding, fetal distress, obstetric indication
• Double Setup Vaginal Examination
• Indications
1. Inconclusive USG Report
2. USG – Type 1, II A PP
3. USG Not available
• Procedure
• Informed consent
• IV drip
• 2 units blood arranged
• General Anesthesia preferred
• 2 scrubbed team should be present
• Bladder Catheterized
• Sims speculum – inspect cervix
• One finger digital examination

21. Contra Indications of Vaginal Examination
• Poor general condition
• Major degree of PP – USG
• Malpresentations, previous LSCS, CPD
Precautions During Vaginal Delivery
• Adequate Hydration and Blood Transfusion
• AMTSL
• Proper examination of cervix and vagina after delivery
• Baby cord blood HB is checked

22. Cesarean Delivery
• Indications
• Major degree of PP (IIB, Type 3 and 4)
• Type I, IIA – Excessive bleeding, Fetal distress
• Other complicating factors for vaginal delivery
• Elective LSCS for PP is usually preferred.
• Jehova witness women – erythropoietin, parental iron, autologous BT
• General anesthesia preferred

23. Type of Operation
• Lower Uterine Segment LSCS
• Advantages
• Familiar technique
• Bleeding at placental site better visualized and managed
• Morbidly adherent placenta – efficiently managed
• Disadvantages
• Dilated vessels – anterior LUS bleed excessively when cut
• In anterior PP placenta is cut
• Severe fetal anemia due to fetal exsanguination
• Cut margins very vascular and fragile – suturing difficult
• Classical LSCS Delivery
• Advantages
• Fast surgery
• Fetus quickly extracted
• Disadvantages
• Lower segment not visualized properly
• Classical incision complications

24. Difficulties in LSCS in PP
1. Lower Segment not well formed
2. May require lower segment vertical incision
3. Anterior placenta – excessive bleeding
4. Placenta accreta – hysterectomy, internal artery embolization
5. Excessive bleeding

25. Practical Approach to LSCS and difficulties
1. Infraumbilical vertical incision given through Cohen's transfers incision (fast)
2. Dilated vessels on anterior uterine wall – ligated and cut
3. Cleavage plane is developed with fingers between uterus and placenta -> membranes
visualized, ARM done
4. Cord is clamped quickly to prevent fetal examination
5. Bleeding points sutured with 1-0 vicryl
6. PPH – drugs, massage, hot packs
7. Bleeding not controlled – betadine gauze
8. Balloon device inflation
9. B – Lynch sutures, Cho’s sutures – 1-0 catgut
10. Uterine or internal iliac artery ligation
11. Pelvic artery embolization
12. Hysterectomy

26. ABRUPTIO PLACENTA
• Definition
• Premature separation of normally situated placenta in the upper uterine
segment (accidental hemorrhage)
• Incidence
• 1 in 200 deliveries
• Maternal mortality 2-5 %
• Perinatal mortality 22-40%

27. Etiology
• Past history
• Advanced maternal age and parity
• Ethnicity
• Single umbilical artery
• HTN Disorders in pregnancy (20-50%)
• Vasospasm of blood vessel – anoxic endothelial damage – extravasation of blood in decidua basalis
• Trauma
• Vascular accident
• Supine hypotensive syndrome
• Nutritional and Social Factors
• Grand multiparity
• Advancing age
• Folic acid deficiency
• Malnutrition
• Poverty
• Cigarette smoking
• Cocaine abuse

28. Etiology
• Thrombophilias
• Factor 5 Leiden
• Lupus anticoagulant antibody
• ECV
• Short Cord
• Sudden decompression – twins, hydramnios
• PROM, PPROM
• Uterine anomalies
• Abnormal placenta
• Malformed fetus
• After snake bite
• High levels of AFP and HCG, decreased inhibin A (sick placenta syndrome)
• Pregestational diabetes
• Hyperhomocystinemia
• 3-7 times more risk
• Elevated homocysteine – vascular endothelial damage
• Subclinical hypothyroidism

29. Clinical Types
1. IMAGES HERE

30. Page’s Clinical Grading Of Abruptio Placenta
Page’s Classification (1951)
Grade 0 Clinically unrecognised before delivery but diagnosed
after delivery – Examination of placenta
Grade 1 1. External bleeding – slight
2. Shock – absent
3. Uterus – irritable, tenderness +/-
4. FHS – good
Grade 2 1. External bleeding – mild to moderate
2. Shock – absent
3. Uterine tenderness +
4. Foetal distress or death
5. Coagulation defect + Or Anuria
Grade 3 Maternal shock or coagulopathy with foetal death

31. Sher’s Clinical Grading Of Abruptio Placenta
Grade Retro Placental Clots Foetal Heart
I 150 ml <= Present. Diagnosed after delivery
II 150-500ml Abnormal in 92% cases
III IIIA – Without coagulopathy
IIIB – With coagulopathy
Absent FHS
Alternate Grading of Haemorrhage
Mild Less than 15% blood loss.
No change in vitals
Moderate 15-30% of blood volume
Vitals – tachycardia, low BP
Severe More than 30% blood volume with shock

32. Pathology
Vasospasm of uterine vessels and then relax – (Anoxic Injury) Venus
engorgement and arteriolar rupture into decidua
Rupture of vessels and hemorrhage in decidua basalis
Decidua splits
Decidual Hematoma (Retroplacental)
Separation, Compression, Destruction of adjacent placenta

33. Couvelaire Uterus (Uteroplacental Apoplexy)
Extensive intravasation of blood into the uterine muscles with severe
form of concealed abruptio placenta
• Gross Examination –
• Patchy or diffused dark port wine color of uterus
• Starts from cornu and then spreads
• Peripheral hemorrhages underneath uterine peritoneum
• Effusion of blood into peritoneal cavity, broad ligament,
tubal serosa, in the substance of ovaries – port wine stain look
• Microscopic examination
• Blood and fluid in uterine muscles – muscular dissociation in middle and
outer layers

34. Hepatic and Renal Changes
• Severe cases – fibrin knot formed in the hepatic sinusoids
• Renal
• Oliguria anuria (mild) – acute tubular necrosis
• Renal cortical necrosis (Severe)
DIC
• 5% cases – coagulation failure, excess fibrinolysis
Investigations
• General
• CBC
• Coagulation profile – Serum fibrinogen level, PT, APTT, FDP, BT, CT, D-dimer
• Serum Electrolytes, LFT
• ABG
• Blood Group and cross matching
• Kleihauer – Betke Test
• Ultrasound abdomen
• R/O Placenta Previa
• State of fetus
• Retroplacental clots
• Jello sign

35. Clinical Features
Symptoms Revealed Concealed and Mixed
1. Vaginal Bleeding Slight, continuous, dark red, rarely
severe
Absent, present in mixed
2. Abdominal Pain Discomfort + Acute
3. Symptoms of Pre-eclampsia Edema, headache, vomiting - rare High frequency
4. Past History – eclampsia, HTN, CRD Present High Incidence
Signs
1. Shock Absent Main feature
2. Anaemia Mild or absent + moderate to severe
3. Evidence of Pre-eclampsia May be present High incidence
4. Abdomen Examination Localised tenderness, normal uterine
height, foetal presentation, FHS+
Tense, tender, hard, raised fundal height,
increased abdominal guard, foetal part not
felt, FHS not easily heard
5. Vulval Inspection Slight bleeding Bleeding -, present in mixed
6. Vaginal Examination in OT No placenta felt but clot felt No
7. Urine output Normal Reduced

36. Clinical Features
Investigations Revealed Concealed and Mixed
1. Placental USG Helpful In differentiation from PP Sonolucent retroplacental clot in upper
segment
2. HB Anaemia proportionate to blood loss Severe anaemia out of proportion to blood
loss
3. Coagulation Profile Normal Usually abnormal
• CT > 6 mins
• Fibrinogen level < 150 mg/dl
• Platelets < 1 lakh/cm
• Increased APTT
• Increased FDP and D-dimer
4. Urine for protein May be present Usually present

37. Complications
Maternal
• Hemorrhagic shock
• PPH
• DIC
• Oliguria and Anuria
• Puerperal Sepsis
• Sheehan’s Syndrome
• Recurrence
• Death

38. Complications
Fetal
• Perinatal Death
• 25to30% - Revealed type
• 50to100% - Concealed type
• Causes
• Prematurity
• Asphyxia
• Small for gestational age
• Congenital anomalies (2-5 times higher)

39. Management
Prevention
• Elimination of known risk factors
• Correction of anemia in ANC period
• Folic acid administration from early pregnancy
• Early diagnosis and timely treatment to minimize complications
• Prevent diagnose and appropriate treatment of hypertensive
disorders
• CVS and Amniocentesis under ultrasound guidance
• Avoid physical trauma, ECV under anesthesia should be avoided
• Avoid sudden decompression of uterus – amniotomy
• Avoid supine hypotension

41. Vaginal Delivery
• Baby Invariably Dead – Vaginal delivery safer
• Amniotomy +/- Oxytocin (Usually with in 6 hours)
• Placenta promptly delivers
• 10 units oxytocin IM to prevent PPH
• Incase of IUD, labor is induced, amniotomy avoided
Cesarean Delivery
• Significant abruption +, fetus alive and mature to survive
• Uncontrolled bleeding
• Fetal distress
• Failure to progress of labor
• Maternal condition unstable
• DIC
• General anesthesia – hypotension and coagulopathy

42. 3rd Stage
• High dose oxytocin infusion
• Examination of placenta post delivery – severity of abruption
• Anti D – Non isoimmunized patient
Post Natal Care
• Hemodynamic stability – BP, Pulse, Urine output
• Coagulation profile should be repeated

43. Indeterminate Antepartum Hemorrhage
(IAPH)
• It is a diagnosis of exclusion after ruling out placenta previa,
abruption placenta, local lesions
• Incidence 2-5 %
• Origin of bleeding due to marginal separation of normally sited
placenta – reduced functional reserve
• Morbidity due to pre term delivery
• Clinically – moderate pain less vaginal bleeding with placenta in upper
segment with no abruption on ultrasound, no lesions on P/S
• Patient stable < term – conservative management. Close surveillance
• Higher incidence of pre term deliveries and congenital fetal
abnormalities

44. Morbidly adherent placenta
• Placenta is firmly adherent to the uterine wall due to partial or total absence of decidua basalis
and the fibrinoid layer (Nitabuch Layer)
• Initially – 1 in 2500 deliveries
• Now – 1 in 210 deliveries
• Types
Placenta Accreta Spectrum Disorders (PAS)
• Grade 1 – Chorionic Villi attached to myometrium (Accreta)
• Grade 2 – Villi invade myometrium (Increta)
• Grade 3 – Villi penetrate myometrium up to Serosal (Percreta)

45. Etiology
• Maternal age > 35 years
• Multiparity
• Previous LSCS
• Placenta Previa
• Prior LSCS
• Previous DNC
• Previous MROP
• Previous Myomectomy
• Previous uterine adhesiolysyso
• Uterine Anomalies
• Endometrial Ablation
• Puerperal Sepsis
• IVF
• H/O Adherent Placenta

46. • USG
• Absence of the sub-placental sonolucent zone[normal decidual basalis] – placenta
accreta.
• Distance <1mm b/w uterine serosa-bladder interface
• Retroplacental vessels and large placental lakes.
• Anterior low-lying or previa, complete placenta previa on level 2 usg at 18-24 weeks
in a patient with previous LSCS should have prompt evaluation for PAS disorders.
Diagnosis

47. • MRI
• Best modality when there is a strong suspicion of placenta accreta to know the depth of
invasion and parametrial extension (posterior placenta).
• Findings of MRI include uterine bulge with heterogenous placenta, intraplacental bands ,
focal interruptions in the hypointense myometrial border and tenting of bladder.
• BIOCHEMICAL MARKERS
• Maternal serum AFP levels usually raised
• 11-12 wks. of pregnancy- hCG and its free beta-subunit are usually lower and pregnancy
associated plasma protein A is higher in maternal serum –PAS disorders.

48. Ultrasound Modality Ultrasound Finding
Ultrasound IID Loss of clear zone Loss of hypoechoic plain in myometrium below placental
bed
Abnormal placental Lacunae Numerous lacune – turbulent flow
Bladder wall interruption Loss of bright bladder wall b/w uterine serosa and bladder
Myometrial thinning Myometrium over placenta <1mm
Placental bulge Abnormal bulge of serosa into the bladder lumen
Focal exophytic mass Placental tissue is seen break through the uterine serosa
into the bladder
Colour doppler Uterovesical hypervascularity Hypervascularity seen b/w myometrium and posterior
wall of bladder
Subplacental hypervascularity Hypervascularity seen in the placental bed
Bridging vessels Vessels extending from the placenta across the
myometrium and beyond the serosa into the bladder
Placental lacunae feeder vessels Vessels with high velocity flow from myometrium into the
placental lacunae.

49. • Excessive bleeding
• Hemorrhagic and neurogenic shock
• Sepsis
• Uterine inversion
• Hysterectomy
• Bladder perforation
• Mortality
COMPLICATIONS:

50. • ELECTIVE LSCS with a consent for hysterectomy b/w 35+ 0 to 36+6
weeks after antenatal steroids – gold standard
• Delivery at a tertiary center – multidisciplinary team.
• Preoperative USG – to determine the upper end of the placenta- to
plan for the uterine incision – to deliver the baby without placental
disruption
• Preoperative checklist
• Written informed consent for hysterectomy, icu care, ventilation care.
• Consent – injury to bladder, ureter , bowel .
• All blood products
• Balloon occlusion or embolization arrangements as standby procedures.
MANAGEMENT:

51. • Partial placenta accreta ( focal) –
• manual removal is usually possible and as much as placenta as possible is
removed. Oxytocics , uterine packing if needed. Hysterectomy – bleeding not
controlled.
• Total placenta accreta –
• Hysterectomy – parous women (uncontrolled bleeding)
• Young women- conservative management.
• If patient not bleeding profusely – uterine incision closed and placenta left insitu.
• Iv broad spectrum antibiotics given.
• Methotrexate and uterine artery embolization.
• Preoperative ballooning is done.
• Placenta increta and percreta – hysterectomy (retrograde) with blood
transfusion.

52. • In placenta increta & percreta – placenta invades the wall of uterus,
myometrium is thin & friable –plane b/w bladder &uterus is
obliterated
• Uterine wall is disrupted – profuse bleeding occurs.
• RH - after utero- ovarian & round ligament, & if possible uterine
artery ligated – vagina is opened posteriorly.
• Clamps are applied from below upwards – bladder is lifted off from
uterus from below upwards from lateral paravesical space to medial.
• Bladder invasion – cystotomy & invaded portion excised.
• Post surgery – check bladder integrity – methylene blue+ NS.
Retrograde hysterectomy

53. • Measures to prevent urinary tract injuries
• Preoperative cystoscopy – to check for bladder involvement
• Preoperative placement of uterine stents
• Filling bladder with methylene blue – prior to bladder mobilization
• Measures to prevent blood loss :
• Pelvic artery embolization. – catheters placed under fluoroscopic guidance
into internal iliac artery. Hemostatic substances administered.
• Balloon occlusion catheters before hysterectomy – inflated during surgery.
• Prophylactic bilateral ligation of anterior division of internal iliac artery.

54. • Prerequisites :
• No predisposing factors for sepsis
• Close follow up
• Proper counseling – emergency hysterectomy & complications
1. Leaving placenta in situ :
• Preserve fertility
• Continuous monitoring is possible
• Hands-off technique – umbilical cord ligated close to insertion, hysterotomy closed.
• Uterotonics, balloon tamponade, UAE, Internal iliac ligation.
• Residual tissue – 6 months to completely absorbed.
• Serial USG for monitoring
• Follow up – weekly – 1st 2 months – no complications – monthly visits till placenta completely
reabsorbed.
• Clinical examination – bleeding , temp , pp
• Pelvic USG- size of retained tissue’
• Lab tests – HB, TLC, Vaginal Sample for culture
• Complications – sepsis and coagulopathy
• Methotrexate – Chances of infections, pan cytopenia, nephrotoxicity – not recommended
Conservative management:

55. 2. Hysteroscopic Reception of Retained adherent placenta
• Not recommended for increta and percreta
• Depth of placenta invasion – measured preoperatively on TVS
• Placental remanence removed under laparoscopic guidance
• Benefits
• Reduce pain
• Continuous visualization – minimum injury to uterus and structures
• Decrease chance of adhesions
• Hysteroscopic Reception of Retained adherent placenta
3. Placental – Myometrial en-bloc excision and repair
• Indicated for focal accreta and accessible border of healthy myometrium present
• Triple P procedure
• Preoperative placental localization
• Pelvic devascularization
• Remove the placenta with en-bloc myometrial excision and uterine repair. During excision 2 cm margin
preserved above bladder - closure
• Contraindicated in percreta with lateral extensions into broad ligament, cervix or ureters.
Conservative management:

56. • Delayed hemorrhage
• DIC
• Endometritis
• Sepsis
• Uterocutanious fistula & AV Fistula
• Long term – adhesions, recurrence
Failure of Conservative Management
• On going hemorrhage
• Hemodynamic instability
• DIC
• Severe persistent pain
Risks of Conservative management

57. • Prevent complications of immediate hysterectomy
• Advantages
• Decreased hemorrhage
• Plane of surgery better visualized
• Bladder invasion better identification of UV fold – decreased bladder injury
• Complications
• DIC hemorrhage
Delayed or Interval Hysterectomy

58. • Type 1 - Fetal blood vessels travers the
membranes below the presenting part,
unsupported by placental tissue or cord.
Secondary to velamentous insertion in a single
or a bilobed placenta.
• Type 2 – Fetal blood vessels running between
lobes of placenta with one or more accessory
lobes
Vasa Praevia

59. • Incidence : Rare 1:1200 to 1:5000 deliveries
• High perinatal mortality – 33 to 100 % - asphyxia,
hemorrhagic shock, fetal anemia.
• Risk Factors
• Bilobed placenta
• Succenturiate lobe
• Placenta previa in second trimester
• IVF
• Multiple pregnancies
• Congenital malformations – Spina bifida, renal anomalies
exomphalos
Vasa Praevia

60. • Vaginal bleeding after spontaneous or ARM
• Sudden onset fetal heart irregularities –
• decelerations, bradycardia or sinusoidal pattern
• Rarely FHR abnormalities without bleeding
Antenatal Diagnosis
• USG - Echogenic parallel or circular lines seen overlying the cervix
• Color doppler – TVS most accurate
• Fetal vascular wave forms on pulsed doppler in at least one aberrant artery vessel
running in free placental membranes with in 2 cms of cervix diagnostic
• P/V Examination – pulsating vessel through membranes
• Confirm fetal blood in vagina – APT test (NAOH), Londersloot test (0.1 N KOH) – Fetal
hemoglobin resistant to alkaline denaturation
• Hemoglobin electrophoresis is reliable
Clinical Presentation

61. • Elective LSCS prior to ROM – 34 to 36 weeks
• In confirmed cases of vasa previa – admit @ 30 to 32 weeks
• Antenatal steroids for fetal lung maturity
• In undiagnosed cases at delivery urgent LSCS (swift delivery),
aggressive neonatal resuscitation and blood transfusion for fetal
survival
Management

62. Thank You