2. DEFINITION
Bleeding from or into the genital tract after 28 weeks
of pregnancy but before the birth of baby. The first
and second stage of labor thus included.
INCIDENCE-3% amongst hospital deliveries.
3. CAUSES
THE causes of APH fall into the following categories:-
1.PLACENTAL 70%-Placenta praevia-35%
Abruptio placentae-35%
2.extraplacental causes-5%
local cervico vaginal lesions
cervical polyps
carcinoma cervix
varicose veins
local trauma
3.other causes-
excessive show
coagulopathies
uterine rupture
4.unexplained
4. Placenta Praevia
The placenta is said to be praevia when all or part of
the placenta implants in the lower uterine segment
and therefore lies in front of the presenting part.
INCIDENCE-Approximately 1% of all pregnancies are
complicated by clinical evidence of a placenta praevia.
Placenta praevia occurs more commonly in
multiparous women beyond the age of 35, in the
presence of multiple pregnancy and where there has
been a previous caesarean section.
5. CLASSIFICATION BASED ON
GRADES
Grade 1 – Just enters lower segment.
Grade 2 – the placenta reaches the margin of the
internal os but does not cover it.
Grade 3 – Partially covers os but not completely.
Grade 4 – Completely covers os
8. The placenta lies in the anterior or posterior wall, The
latter is more common. For clinical purpose the types
are graded into mild degree (type1 and type2
anterior)& major degree (type 2 posterior, type3 &
type 4)
9. ETIOLOGY
Dropping down theory- The fertilized ovum drops and
is implanted in the lower segment.
Defective decidua- results in spreading of the chronic
villi over a wide area in the uterine wall to get
nourishment.
Big surface area of the placenta.
10. SYMPTOMS
The only symptom is vaginal bleeding
The bleeding is sudden ,painless and recurrent
SIGNS-
1.ANEMIA
ABDOMINAL EXAMINATION-
1.Size of the uterus is proportional to the period of gestation.
2.The uterus is relaxed and elastic without any localized area of
tenderness.
3.Persistence of malpresentation like breach or unstable lie is more
frequent.
4.The head is floating in contrast to the period of gestation.
5.Foetal heart sound is usually present unless there is major
separation of placenta.
11. CONFIRMATION OF DIAGNOSIS
Painless and recurrent vaginal bleeding in the second
half of the pregnancy.
Ultrasonography is the initial procedure applied in the
diagnosis:-
1.Localisation of placenta(placentography).
sonography-trans abdominal
trans vaginal
colour doppler flow study
12. 2.CLINICAL-By internal examination
- direct visualization during cs section.
-examination of the placenta following vaginal
delivery.
Sonography provides simplest, most precise and safest
method of placental localization.
It can determine the extent of placental margin in
relation to the internal os. It can also determine fetal
size and status.
13. DIFFERENTIAL DIAGNOSIS
The commonest one from which it has to be
differentiated is bleeding from premature separation
of normally situated placenta(abruptio placentae)
14. DISTINGUISHING FEATURES OF
PLACENTA PREVIA AND ABRUPTIO
PLACENTA
CLINICAL FEATURES PLACENTA PREVIA ABRUPTIO PLACENTA
CLINICAL FEATURES
-NATURE OF BLEEDING
-CHARACTER OF
BLOOD
-G.C AND ANEMIA
-FEATURES OF
PREECLAMPSIA
PAINLESS,RECURRENT.
BLEEDING IS USUALLY
REVEALED.
BRIGHT RED
PROPOTIONATE TO
VISIBLE BLOOD LOSS
NOT RELEVANT
PAINFUL OFTEN
ATTRIBUTED TO
PREECLAMPSEA AND
TRAUMA.
REVEALED,CONCEALED
OR USUALLY MIXED.
DARK COLOURED
OUT OF PROPOTION
TO THE VISIBLE BLOOD
LOSS IN CONCEALED
OR MIXED VARIETY.
PRESENT IN ONE-
THIRD CASES.
15. ABDOMINAL
EXAMINATION
-HEIGHT OF UTERUS
-FEEL OF UTERUS
-MALPRESENTATION
-FHS
PLACENTOGRAPHY
PROPIONATE HEIGHT
SOFT,RELAXED
COMMON,HEAD IS
HIGH FLOATING.
USUALLY PRESENT
PLACENTA IN LOWER
MAY BE
DISPROPIOTIONATELY
ENLARGED IN
CONCEALED TYPE.
MAY BE TENSE,TENDER
OR RIGID.
UNRELATED.THE HEAD
MAY BE ENGAGED.
USUALLY ARSENT
SPECIALLY IN
CONCEALED TYPE.
PLACENTA IN UPPER
19. MANAGEMENT
PREVENTION-Adequate antenatal care.
-adequate diagnosis of low lying placenta at
20 weeks and routine ultrasound at 34 weeks to confirm
diagnosis.
AT HOME-1.Patient is immediately put to bed.
2.To asses the blood loss.
3.To note the pulse ,bp and degree of anemia.
4.Quick but gentle abdominal examination to
mark the height of uterus.
5.VAGINAL EXAMINATION MUST NOT BE
DONE.
20. Transfer to hospital-shift the patient to an equipped
hospital having facility of blood transfusion, caesarean
section, neonatal care unit etc.
ON ADMISSION-1.Asses the amount of blood loss by
noting general condition, bp ,pulse rate etc.
2.Blood samples are taken for group
cross matching.
3.An infusion of normal saline is
started and cross matched blood transfusion should be
started.
4.Inspection of the vulva.
21. FORMULATION OF LINE OF
TREATMENT
EXPECTANT TREATMENT
ACTIVE INTERFERANCE
22. EXPECTANT TREATMENT
It was advocated by macafee and thompson(1945)
The aim is to continue pregnancy for fetal maturity
without compromising the maternal health.
PRE-REQUISITES-1.Availability of blood transfusion
whenever required.
2. Facilities for caesarean section
should be available throughout 24 hours.
23. SELECTION OF CASES-1.Mother is in good health
status
2.Duration of pregnancy<37 weeks.
3.Active vaginal bleeding is absent.
4.Foetal well being is assured.
24. CONDUCT OF EXPECTANT TREATMENT-1.Bed rest.
2.Investigations like blood grouping, hemoglobin
estimation and urine for protein estimation are done.
3.Periodic inspection of the vulval pads and fetal
surveillance with USG at interval of2-3 weeks.
4.Supplementary haematinics should be given and the
blood loss is replaced by adequate cross matched blood
transfusion.
5.2-3 days after the bleeding stops a gentle speculum
examination is made to exclude local cervical and vaginal
lesions for bleeding.
25. Expectant treatment is carried upto 37 weeks of
pregnancy by the time the baby becomes sufficiently
mature.
Premature termination can be done in conditions like-
1.recurence of brisk hemorrhage which is continuing.
2.the fetus is dead.
3.the fetus is found congenitally
malformed on investigation.
26. ACTIVE TREATMENT
INDICATIONS-1.Bleeding occurs at or after 37 weeks
of pregnancy.
2.Patient is in labor.
3.Bleeding is continuing and of moderatedegree.
4.Baby is dead or congenitally malformed.
27. DEFINITIVE TREATMENT
1.Vaginal exam in the operation theater followed by
- a)Low rupture of membranes
- b)CS section
2. Cs section without internal exam.
CONTRADICTION OF VAGINAL EXAM-1.Patient is in
exsanguinated state.
2. Major degrees of placenta praevia confirmed by
ultrasound
3.Assosiated complicating factors such as malpresentation,
pregnancy with previous history of cs section, contracted
pelvis etc.
28. Vaginal examination in operation theatre is followed
by-
a).Low rupture of membranes.
b).Caesarean section.
Low rupture of membranes-1.labour is induced by
using long Kocher’s forceps in lesser degree of placenta
praevia.
2.Amniotomy helps in initiation of labor and thereby
encourages decent of the head. This in turn presses on
the separated placenta and controls the bleeding.
29. PRECAUTION DURING VAGINAL DELIVERY-
1.All steps should be taken to restore blood volume.
2.Ergometrine 0.25 mg should be given intravenously
with the delivery of anterior shoulder.
30. CS section-It not only reduces maternal risk but also
improves the fetal salvage.
INDICATION OF CS SECTION-1.Severe degree of
placenta previa.
2.Lesser degree of placenta previa where amniotomy
fails to stop bleeding or fetal distress appears.
3.Complicating factors associated with lesser degree of
placenta praevia where vaginal delivery is found
unsafe.
31. Prognosis-1.Immediate transfer to hospital without a
vaginal examination will minimize the risk to both the
mother and fetus.
2.The prognosis varies with the type of placenta
preavia, the method of treatment and the condition of
the patient on arrival in hospital.
32. ABRUPTIO PLACENTAE
DEFINITION – It is one form of APH where the bleeding occurs
due to premature separation of a normally situated placenta.
VARIETIES-
REVEALED- following separation of placenta the blood
insinuates downwards between the membranes and the decidua.
CONCEALED-The blood collects behind the separated placenta
or collected in between the membrane and the decidua. The
collected blood is prevented from coming out of the cervix by
the presenting part which presses the lower segment. This type is
rare.
MIXED- In this type some part of the blood collects
inside(concealed) and a part is expelled out(revealed).This is
quite common.
33.
34.
35. ETIOLOGY
The prevalence is more with
1.High birth order pregnancies gravida 5 and above.
2.Advancing age of the mother.
3. Poor socio economic status.
4. Malnutrition.
5. Smoking.
6. Hypertension in pregnancy is the most important predisposing factor. Pre-
eclampsea gestation hypertension and essential hypertension are all associated
with placental abruption.
7.TRAUMA- Traumatic separation of the placenta leads to its marginal
separation with escape of blood outside. The trauma may be due to-
a).Attempted external cephalic version.
b).Road traffic accidents.
c). Needle puncture at amniocentesis.
36. 8.SUDDEN UTERINE DECOMPRESSION- Sudden decompression leads to
diminished surface area of the uterus resulting in separation of placenta. This
may occur following-
a).Delivery of the first baby of twins.
b).Sudden escape of liquor amnii in hydroamnios.
c).Premature rupture of membranes.
9. SHORT CORD- Can bring about placental separation during labor by
mechanical pull.
10.SUPINE HYPOTENSION SYNDROME.
11. Placental anomaly- Circumvallate placenta.
12. Folic acid deficiency.
13. UTERINE FACTOR- Placenta implanted over a septum.
14. Torsion of the uterus.
15.Thrombophilias.
16.Prior abruption.
37. CLINICAL CLASSIFICATION
GRADE 0- Clinical feature may be absent. The diagnosis is
made after inspection of the placenta following delivery.
GRADE 1- 1. Vaginal bleeding is slight.
2.Uterus: irritable, tenderness may be minimal.
3. Maternal BP and fibrinogen levels unaffected.
4. FSH is good.
GRADE 2-1.Vaginal bleeding mild to moderate.
2.Uterine tenderness is always present.
3. Maternal pulse is high, BP is maintained.
4. Fibrinogen level may be decreased.
5. Fetal distress or even fetal death occurs.
38. GRADE 3- 1.Bleeding is moderate to severe or may be
concealed.
2. Uterine tenderness is marked.
3. Shock is pronounced.
4. Fetal death.
5.Associated coagulation defect or anuria may
complicate.
39. CLINICAL FEATURES
The clinical features depend on-
Degree of separation of placenta.
Speed at which separation occurs.
Amount of blood concealed inside the uterine cavity.
40. REVEALED MIXED
SYMPTOMS
CHARACTER OF
BLEEDING
GENERAL CONDITION
ABDOMINAL
DISCOMFORT OR PAIN
FOLLOWED BY
VAGINAL
BLEEDING(USUALLY
SLIGHT)
CONTINOUS DARK
COLOUR.
PROPOTIONATE TO
THE VISIBLE BLOOD
LOSS.SHOCK IS USALLY
ABSENT.
THE PATIENT HAS
ACUTE INTENSE PAIN
ABDOMEN FOLLOWED
BY SLIGHT VAGINAL
BLEEDING.
CONTINOUS DARK
COLOUR OR BLOOD
STAINED SERIOUS
DISCHARGE.
SHOCK IS
PRONOUNCED WHICH
IS OUT OF
PROPORTION TO THE
VISIBLE BLOOD LOSS.
41. PALLOR
FEATURES OF PRE-
ECLAMPSIA
UTERINE FEEL
FETAL PARTS
FHS
URINE OUTPUT
RELATED WITH THE
VISIBLE BLOOD LOSS.
MAY BE ABSENT.
NORMAL FEEL WITH
LOCALIZED
TENDERNESSS.
CAN BE IDENTIFIED
EASILY.
USUALLY PRESENT
NORMAL
PALLOR IS USALLY
SEVERE AND OUT OF
PROPORTION TO THE
VISIBLE BLEEDING.
FREQUENT
ASSOCIATION
UTERUS IS TENSE
TENDER AND RIGID.
DIFICULT TO MAKE
OUT.
USUALLY ABSENT
USUALLY DIMNISHED.
42. PROGNOSIS
IN REVEALED TYPE- Maternal risk is proptionate to the
visible blood loss.
IN CONCEALED VARIETY-The prognosis is very
uncertain. The following complications may occur-
1.Haemorrhage.
2.shock.
3.Blood coagulation disorder-It occurs due to excess
consumption of plasma fibrinogen due to disseminated
intra vascular coagulation and retro placental bleeding.
There is overt hypofibrinogenemia and elevated level of
fibrin degradation products.
43. 4.Oliguria and anuria.
5.postpartum hemorrhage occurs due to-Atony of
uterus and increase in FDP.
6.Puerperal sepsis.
Fetal- In revealed type the fetal death is to the extent
of 25-30%. In concealed type the fetal death is
appreciably high ranging from 50-100%. The death are
due to prematurity and anoxia.
44. MANAGEMENT
TREATMENT
IN THE HOSPITAL-
A).Revealed type-Assesment of the case is to be done as
regards amount of blood loss, Maturity of the fetus,
Whether the patient is in labor or not.
PRELIMINARIES- 1.Blood is sent for haemoglobin and
haematocrit estimation coagulation profile,
prothrombin time , urine for detection of protien.
2.Ringers drip is started with a wide bore canula and
arrangement for blood transfusion is made.
45. DEFINITIVE TREATMENT-THE PATIENT IS IN LABOR-
1.Rupture of the membranes with escape of liqour amnii
accelerates labor and increases the uterine tone allowing
the separated placenta to be compressed between the fetal
bulk and uterine wall.
2. Oxytocin drip may be started to accelerate labor
THE PATIENT IS NOT IN LABOR- 1.For pregnancy 37 weeks
or more –Induction of labor is to be done by low rupture of
membranes with or without oxytocin.
.INDICATION OF CS SECTION- a).Appearance of fetal
distress.
b).amniotomy fails to control bleeding.
c).Associated complicating factors.
46. 4.Pregnancy less than 37 weeks- a).BLEEDING
MODERATE TO SEVERE AND CONTINUING-low
rupture of the membranes is quite effective.
c).Oxytocin drip may be added.
c). Bleeding slight or has stopped- The patient is put
on conservative treatment.
47. B).mixed or concealed type- Principles of management
are-
1.To correct hypovolaemia and to restore the blood
loss- Normal saline or haemaccel infusion with a wide
bore canula is started and arrangement is made for
urgent blood transfusion.
2. To bring about effective uterine contraction and
termination of the abruption process.
48. VAGINAL DELIVERY- Following rupture of membrane
labor is usually completed quickly. Placenta with varying
amount of reteroplacental clot is expelled.Intravenous
methergen 0.2 mg should be given with the delivery of the
anterior shoulder.
CS SECTION-It is indicated in two extreme group of cases-
Early-With unfavourable cervix where speedy vaginal
delivery is not possible and good prospect of fetal survival.
2.LATE-In spite of amniotomy and oxytocin the progress of
labor is delayed and instead the general condition gradually
deteriorates with appearance of complicating factor like
oligouria or falling fibrinogen level or there is evidence of
fetal distress.
