A number of clinical and epidemiological studies have identified predisposing risk factors for placental abruption. The most predictive is abruption in a previous pregnancy. risk factors for placental abruption include: pre-eclampsia, fetal growth restriction, non-vertex presentations, polyhydramnios, advanced maternal age, multiparity, low body mass index (BMI), pregnancy following assisted reproductive techniques, intrauterine infection, premature rupture of membranes, abdominal trauma (both accidental and resulting from domestic violence), smoking and drug misuse (cocaine and amphetamines) during pregnancy. First trimester bleeding increases the risk of abruption later in the pregnancy Maternal thrombophilias have been associated with placental abruption Risk factors for placenta PRAVIA - Previous placenta praevia , Previous caesarean sections , Previous termination of pregnancy, Multiparity, Advanced maternal age (>40 years) , Multiple pregnancy Smoking Deficient endometrium due to presence or history of: • uterine scar • endometritis • manual removal of placenta • curettage • submucous fibroid Assisted conception In view of the known associations between placental abruption and tobacco use, cocaine and amphetamine misuse, women should be advised and encouraged to modify these risk factors. No evidence was identified that specifically investigated smoking cessation and APH. A Cochrane review concluded that smoking cessation programmes in pregnancy reduce the proportion of women who continue to smoke, and reduce low birthweight and preterm birth. The pooled trials have inadequate power to detect reductions in perinatal mortality or very low birthweight and did not specifically analyse rates of APH. It is considered good practice to avoid vaginal and rectal examinations in women with placenta praevia, and to advise these women to avoid penetrative sexual intercourse. Complications of APH 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

1. ANTEPARTUM HAEMORRHAGE
DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S.
Dr Alka Mukherjee Nagpur 1

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty
Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN
RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Organizing secretary AMWICON – 2019
 Life member, IMA, NOGS, NARCHI, AMWN &
Menopause Society, India, Indian medico-legal &
ethics association(IMLEA), ISOPARB, HUMAN RIGHTS
 Founder Member of South Rapid Action Group,
Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS
Nagpur, NKPSIMS, ESIS and Treasury, Nagpur for “
WOMEN SEXUAL HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 VIDARBHA RATNA PURASKAR - 2019
Past Position
 Vice President of NOGS(2016-2017)
 Organizing joint secretary ENDO-GYN
 Vice President IMA Nagpur (2017-2018)
 Organizing joint secretary ENDO-GYN 2019

3. DEFINITION
• Antepartum haemorrhage (APH): bleeding from the genital
trans after the 20th week of pregnancy and before the onset
of labour.
• Antepartum haemorrhage complicates 2-5% of all
pregnancies.
• It is associated with increased rates of maternal and prenatal
morbidity and mortality
• significant healthcare costs

4. CLASSIFICATION
A. Placenta praevia (30%): When the placenta lies in the lower
uterine segment. Bleeding - as painless, causeless and
recurrent.
B. Placental abruption (25%): Bleeding from normally situated
placenta. This may be a marginal bleed or in association
with significant placental separation
C. Vasa praevia: A rare condition in which umbilical vessels
traverse the foetal membranes of lower uterine segment,
unsupported by umbilical cord or placenta.
D. Cervical and lower genital tract bleeding (45%): It includes
bleeding from any site within the genital tract, like
ectropion, cervicitis, polyp, dysplasia or carcinomas

6. Antepartum haemorrhage can be
divided into two categories:
1. Major haemorrhage requiring immediate action.
2. Antepartum haemorrhage where immediate resuscitative
measures are not required.
• If the actual blood loss is often more than is immediately
apparent from hemodynamic assessment (e.g. pulse and
blood pressure).
• This is because otherwise healthy women are well able
compensate for acute loss without overt signs or symptoms
of shock .

8. EARLY RESUSCITATIVE MEASURES
The required urgency of assessment and the escalation of treatment
will largely depend upon the clinical features.
Measures -
 Control of bleeding,
 Restoration of circulating blood volume for oxygenation of tissues
 Diagnosing and treating the underlying cause of the bleeding.
• Prompt assessment is imperative.
• Team including an experienced obstetrician, anaesthetist,
haematologist and other assistance as needed
• Replacing the blood lost, with the transfusion of blood products.
Major obstetric units need to have a well stocked blood bank or at
least access to a nearby one

9. INITIAL ASSESSMENT
Haemodynamically unstable – FOLLOW ABC
- Assess woman's condition
- Obtain baseline maternal and foetal observations
• History may be obtained from relatives
• Check estimated date of delivery and available reports of
investigations and antenatal record
• Check last ultrasound (if available) for placental location.

10. MATERNAL ASSESSMENT
• Assess airway and breathing (may be compromised in
severely hypotensive)
• Start oxygen at 8 L/min
• Obtain 2 large bore IV access (16G or larger bore)
• Initial fluid replacement with crystalloid is as effective as
with colloid
• Insert a urinary catheter with urometer; record hourly urine
output
• Gentle abdominal palpation for fundal height, lie and
presentation

11. • Blood loss: Note the amount, colour, consistency, pattern
and time of bleeding,
• Weigh pads, linen, etc. for estimation of blood loss?
• Uterine activity. Assess if soft, tense, tender or non-tender
• Ultrasound for placental localisation (portable and/or
formal)
• Bloods: Complete blood picture, group, cross match and save
(X match 4 units is heavy bleeding), coagulation profile,
Kleihauer if Rh negative.

12. • Speculum examination only (until placenta praevia is
excluded)—to observe amount and source of bleeding (may
be combined with catheterisation by a doctor on duty).
• CTG: To assess foetal well-being.
• Consider delivery: To improve maternal hemodynamics
• Medications: If time permits.
a. Corticosteroids for foetal lung maturation
b. Consider MgSO, for foetal neuroprotection if <30 weeks
gestation and imminent delivery is likely.
c. Anti-D if Rhesus negative.
d. Analgesia if required.

13. “ENLIGHTEN BUT NOT FRIGHTEN".
 Documentation simultaneously.
 Intake output charts and
 Interventions carried out with time frame.
 Communication and explanations to the woman, her
partner and family should be
i. prompt,
ii. frequent and
iii. WAY that they will understand.

14. • NASG - use of non-pneumatic anti-shock garment (NASG) as a
first-aid for preventing and reversing hypovolemic shock
secondary to obstetric haemorrhage.
• light weight and reusable garment made of Neoprene and Velcro
with small foam ball to provide uterine compression.
• It is low cost ($ 1.04 per use) low technology tool for resource
constrained countries.
• It will stabilise a woman to enable her to reach the destination for
suitable management (ambulance drive).
• It is not recommended for patients with viable foetus or women
with cardiac disease.
• Several studies in developing countries have shown that it can
decrease maternal mortality.

15. ANTEPARTUM HAEMORRHAGE: IMMEDIATE
RESUSCITATIVE MEASURES
Where immediate resuscitative measures are not required -
• Initial Assessment & history
• Timing and amount of blood loss, e.g. number of pads used
• Associated features, e.g. abdominal pain and contractions
• Provoking factors, e.g. trauma or sexual intercourse
• Foetal movements since the bleeding has started
• Current pregnancy - Previous episodes of bleeding
• Review ultrasound examinations performed earlier -
placental site recorded on a 20-week (or later) scan
• Past-obstetric, gynaecological, medical and surgical history.

16. EXAMINATION
 General condition – pulse, BP, pallor, RS, CVS
 Abdominal palpation:
a) Checking for uterine tenderness,
b) Symphysis - fundal height,
c) Foetal lie and presentation.
 Vaginal examination with a speculum only, to assess the site
of bleeding.

17. BLOOD INVESTIGATIONS
• Collect blood for: Full blood count(FBC),
• cross-match at least two units in case the bleeding escalates
to a major APH.
• Blood group cross match
• KFT
• LFT
• COAGULATION PROFILE
• Urine Routine
• Blood sugar

18. FOETAL WELL-BEING ASSESSMENT
• Cardiotocogragh (CTG) or hand-held Doppler, if an
appropriate gestation has been reached.
• Ultrasound Scan - for placental location, to exclude placenta
praevia , R-P Clot
• An MRI may also be used for placental localisation

19. • Depending upon the underlying cause of the bleeding,
women who have experienced an APH that is non-life-
threatening, who are clinically stable, and depends upon the
underlying cause of the bleeding, may be discharged and
reviewed on an outpatient basis.
• This decision will be based upon the judgment of an
experienced clinician, in consultation with the woman and
also in view of her individual circumstances
• i.e. distance from an appropriate hospital, home support,
telephone and transportation access. This decision has
medico legal implications and hence relatives' signatures
should be taken in case they decide to take the patient home
or elsewhere.

20. PLACENTA PRAEVIA
• Placenta is inserted wholly or partially in the lower uterine
segment in third trimester of pregnancy (RCOG 2011).
• Classification (RCOG, 2011, SCOG-11)6-8
• Major placenta praevia: Placenta lying over the cervical os.
• Minor placenta praevia: Placenta not lying over the cervical
os but encroaching on the lower uterine segment.
• Diagnosis of a suspected placenta praevia is usually by
ultrasound.

21. INCIDENCE
• Approximately 0.5%
• Only 10% of low lying placentae diagnosed at 16-20 weeks
remain low at (Brick, Neilson, 2003)
• The incidence of placenta praevia is higher in women with a
pre Caesarean section and increases in prevalence with each
Caesarean section

22. RISK FACTORS
 Large placental area, e.g. multiple pregnancy
 Advanced age, high parity
 Uterine scar, submucous fbroids
 Endometritis,
 curettage,
 history of manual removal of placenta .
 History of smoking or tobacco use
• Anterior placenta praevia increases the risk of placenta
accreta
• 16% of cases of placenta praevia are associated with IUGR
(especially in case of multiple episodes of bleeding).'

23. CLINICAL FEATURES
• Painless, causeless vaginal bleeding, mostly fresh red blood,
and variable in amount
• Uterine tenderness and irritability unusual
• foetal malpresentation or high floating presenting part
• may be incidental finding on ultrasound.
• From the second trimester, a placenta praevia may be
suspected.
• It may be associated with vasa praevia, and therefore
localisation of the foetal vessels on a follow-up ultrasound
scan with colour doppler is advised.

24. MANAGEMENT
• “Expectant line of management“ - based on the fact that the
first haemorrhage is not likely to harm the mother and
foetus.
• The high maternal mortality was only in cases of severe
haemorrhage
• Foetal mortality was due to prematurity. Therefore, it was
essential to carry and support the pregnancy until at least
35-36 weeks.

25. • Major placenta praevia
• - Symptomatic: In-patient care
• - Asymptomatic: Out-patient or inpatient care
• Minor placenta praevia
• - Symptomatic: In-patient care
• - Asymptomatic: Out-patient or in-patient care.

26. PLACE OF CARE
• Explain to the family that frequency and severity of
recurrent bleeding is unpredictable and carries the risk of
foetal and maternal complications,
• Immediate hospital care will be required if contractions start
and/or vaginal bleeding is profuse.
• Emergency transport and access to higher centre may be
needed
• Admit urgently in active bleeding
• Consider need for anti-D, and correction of anaemia with
oral or parenteral iron
• Ultrasound every 2 weeks for social growth and placental
localisation (colour Doppler in 3rd trimester to reassess
placental site/vasa praevia/placenta accreta

27. PLACENTA ACCRETA, INCRETA AND PERCRETA
• For placenta accreta - consultant anaesthetic and obstetric
inputs are vital in planning and conducting the delivery.
• MRI of the uterus gives an accurate diagnosis of the degree
of adherence. Percreta with bladder invasion carries the
greatest risk.
• These cases are to be managed in a tertiary care centre with
a multidisciplinary team consisting of an interventional
radiologist, urologist and intensivist with availability of ICU
care.

28. • If the women is multiparous - it is safest to plan for an
elective section with obstetric hysterectomy. However, then
uterine artery embolisation - if the uterus needs to be
conserved
• These procedures themselves carry great risk and can lead to
maternal mortality.
• Availability and affordability are important issues.
• APH can also lead to PPH - careful watch for at least 48
hours.

29. ABRUPTIO PLACENTAE
• Definition - the bleeding due to untimely situated placenta
from its attachment to the uterus (Neilson 2013).
• The abruptio placentae types:
 Concealed-20%
 Revealed-65-80%
 Mixed

30. INCIDENCE
• Perinatal mortality rate-119 per 1,000 (Neilson 2013)
• Risk Factors -
 It is mainly associated with pregnancy-induced hypertension
(PIH). There are some contributory factors such as:
 Prolonged rupture of membranes
 Increasing maternal age, parity
 Cigarette smoking or tobacco use
 Abdominal trauma
• Sudden decrease in the uterine volume (e.g. spontaneous
rupture of membrane (SROM) in polyhydramnios or after
delivery of the first twin)
• External cephalic version (ECV)

31. DIAGNOSIS
• With IUFD placental detachment is more than 50%.
• Approximately, 30% patients show evidence of
coagulopathy.
• Pritchard demonstrated that abruption has led to absent FHS
when average blood loss is more than 2500 ml.
• Renal tubular necrosis is a serious complication. It may lead
to permanent kidney damage.

32. MANAGEMENT
• Immediate management and investigations
• Coagulation profile, altered fibrinogen levels and a
prolonged PT are suggestive of DIC. These tests are required
on an emergency basis.
• The following principles should guide the need for blood
transfusion:
 Revealed loss is likely to underestimate total blood loss
 In the presence of a typical severe abruption (with foetal
death), the woman may require 4-6 units of blood due to the
concealed haemorrhage.

33. DELIVERY
• Will depend on period of gestation
1. At 37 weeks and above - Caesarean delivery if acute foetal
compromise or other obstetric indication
• Consider vaginal delivery with continuous electronic foetal
monitoeing and only if labour is already advanced.
2. At premature (32-37 weeks) gestations –
 Conservative considered for minor placental abruption.
 If danger to mother's or foetal compromise, delivery should
be expedited.
3. At very premature (28-32 weeks) and extreme preterm (<28
weeks) gestations - weigh the risks of the maternal condition and
prematurity against those of continuing the pregnancy.

34. • Time factor should be noted. If more than 6 hours have
lapsed after abruption the prognosis is guarded.
• In significant abruptions, neonatal morbidity is improved if
the decision to delivery time for Caesarean section is less
than 20 minutes, therefore, unnecessary delay should be
avoided.
• If foetal demise is due to abruption, DIC is highly likely and
delivery should be expedited
• Induction may be tried in a multifarious woman. Caesarean
may be necessary if the woman's condition is worsening.

35. FOLLOWING DELIVERY
• Recognise increased risk of PPH. Be ready for further blood
transfusion.
• Methergine/oxytocin combination preferred.
• Judicious use of uterotonic agents.
• Surgical intervention by suitably experienced personnel.
• Correction of coagulopathies.
• Clinically examine the placenta and retroplacental clots
• Send placenta for pathological examination
• Keep a watch on urine output and renal profile
• Maternal screen for thrombophilias.
•

36. CONCLUSION
• Haemorrhage, hypertensive
disorders and sepsis continue to be
the leading causes for maternal
mortality.
• Let every obstetrician be fully aware
of the responsibility to give the best
of care to the parturient under his or
her care.