BRIEF DESCRIPTION ON APH, DIFFERENCE BETWEEN PLACENTA PREVIA AND ABRUPTIO PLACENTA

1. HAEMORRAGE IN
LATE PREGNENCY
By
Mrs.Jasmi Manu
Head of the department(OBS/GYN) Nursing
Rama college of Nursing
Rama University, Kanpur

2. ANTEPARTUM
HAEMORRHAGE
Definition
It is defined as bleeding from or into
genital tract after the 28th week of
pregnancy but before the birth of the baby.

3. Causes of antepartum haemorrhage
 A.P.H.
Placenta bleeding Unexplained(25%) Extra placental
causes(5%)
(70%) Or
Indeterminate Local
Abruptio placentae
Placenta praevia (35%) (35%)

4. PLACENTA PRAEVIA
Definition- When the placenta is
implanted partially or completely over
lower uterine segment it is called
placenta praevia .
Incidence- Placenta praevia occurs
approximately one of every 250 birth.
It is one in 200 in India. One third of all
antepartum haemorrhage occurs due
to Placenta praevia .

5. Causes-
Dropping down theory-
Multiple pregnancy-
Defective decidua–

6. Predisposing Factors
 Increased placental size,e.g.twin placenta
 Previous uterine scar,e.g. previous caesarean or
myomectomy scar.
 Multiparity
 Advanced maternal age, over 35 year
 Previous reproductive surgery,e.g. dilatation and
curratage.
 Placental abnormality, e.g. succenturiate lobe
 Congenital malformation of the uterus.
 Smoking-causes placental hypertrophy to
compensate carbonmonoxide induced
hypoxaemia.

7. TYPES OR DEGREES OF PLACENTA PRAEVIA
 TYPE-1 (low – lying);-
 TYPE-2 (Marginal);-
 TYPE-3(Incomplete or partial
central);-
 TYPE-4(Central or total);-

10. CLINICAL FEATURES
SYMPTOMS- vaginal bleeding, sudden onset,
painless, apparently causeless and recurrent
SIGNS-.
 The size of the uterus is proportionate to the period
of gestation.
 The uterus feels relaxed, soft and elastic without
any localized area of tenderness.
 Persistence of malpresentation like breech or
transverse or unstable lie is more frequent.
 The head is floating in contrast to the period of
gestation .
 Fetal heart sound is usually present.

11. CONFIRMATION OF DIAGNOSIS
1) LOCALISATIONOF PLACENTAL (PLACENTOGRAPHY)
 Sonography
-Trans abdominal ultrasound
-Transvaginal ultrasound
-Colour Doppler flow study
 Magnetic resonance imaging (MRI)
2) CLINICAL
-By internal examination (Double set up examination)
-Direct visualisation during caesarean section
- Examination of the placenta following vaginal
delivery

12. COMPLICATION
MATERNAL COMPLICATION
• During pregnancy
-Antepartum haemorrhage with varying degrees of shock.
-Malpresentatation is common.
-Premature labour
• During labor
-Early rupture of the membrane
-Cord prolapse.
- Slow dilatation of cervix
-Intrapartum haemorrhage
-Increased incidence of operative interference
-Postpartum haemorrhage
• Puerperium
-Sepsis
-Sub involution
-Embolism
FETAL
-Low birth weight
-Asphyxia
-Intrauterine death
-Birth injuries
-Congenital malformation

13. COMPLICATION
MATERNAL COMPLICATION
• During pregnancy
-Antepartum haemorrhage with varying degrees of shock.
-Malpresentatation is common.
-Premature labour
• During labor
-Early rupture of the membrane
-Cord prolapse.
- Slow dilatation of cervix
-Intrapartum haemorrhage
-Increased incidence of operative interference
-Postpartum haemorrhage
• Puerperium
-Sepsis
-Sub involution
-Embolism
FETAL
-Low birth weight
-Asphyxia
-Intrauterine death
-Birth injuries
-Congenital malformation

14. DIFFERTIAT POINT BETWEEN PLACENTA PRAEVIA AND ABRUPTIO
PLACENTAE
PLACENTA PRAEVIA ABRUPTIO PLACENTAE
 Clinical features
-Nature of bleeding a) Painless, apparently causeless and
recurrent
b) Bleeding is always revealed
a) Painful, often attributed to
preeclampsia or trauma and
continuous
b) Revealed, concealed or usually
mixed
-Character of blood Bright red Dark coloured
-General condition and anaemia Proportionate to visible blood loss Out of proportion to the visible blood
loss in concealed or mixed variety
-Features of pre-eclampsia Not Relevent Present in one- third cases
 Abdominal examination
-Height of uterus Proportionate height May be disproportionately enlarge in
concealed type
-Feel of uterus Soft and relaxed May be tense, tender and rigid
-Malpresentation Malpresentation is common. The head is
high floating
Unrelated ,the head may be engaged.
-F.H.S. Usually present Usually absent specially in concealed
type
 Placentography Placenta in lower segment Placenta in lower segment
 Vaginal examination Placenta is felt on the lower segment Placenta is not felt on the lower
segment. Blood clot should not be
confused with placenta

15. MANAGEMENT
 PREVENTION
√ Adequate antenatal care to improve the health
status of women and correction of anaemia.
√ Antenatal diagnosis of low lying placenta at 20
weeks with routine ultra sound need repeat ultra sound
examination at 34 weeks to confirm the diagnosis.
√ Significance of “Warning haemorrhage” should
be ignored or under-estimated.
√ Family planning and limitation of birth reduce the
incidence of placenta praevia.

16. AT HOME
 The patient is immediate put to bed.
 To assess the blood loss
 To note the pulse, blood pressure and
degree of anaemia.
 Quick but gentle abdominal examination to
mark the height of the uterus,to auscultate
the fetal heart sound and to note any
tenderness on the uterus .
 Vaginal examination must not be done

17. TREATMENT ON ADMISSION
 IMMEDIATE ATTENTION
 FORMULATION OF THE LINE OF TREATMENT
IMMEDIATE ATTENTION
- Amount of blood loss
- Blood sample are taken
- An infusion of normal saline is started.
- Gentle abdominal palpation to ascertain any uterine tenderness
- Inspection of the vulva
FORMULATION OF THE LINE OF TREATMENT
 Expected treatment
 Active interference

18.  Expected treatment Active interference
-No active bleeding - Bleeding
continues
-Preg.less than 37 week - Preg.>37
week
-Patient – stable haemodynamically -Pt. in
labour
-F.H.S.- good -
Exsanguinated
37 week
-CTG – reactive fetus - F.H.S-
absent
-Gross
fetal
37 week
Malformation
steroid
therapy- if
duration of preg.
<34week
Double set up examination C.S.
(Internal examination in O.T.) ( Without internal examination)

19. Double set up examination (Internal examination in
O.T.)
Type I,II Type II,III,IV
A.R.M Oxytocin
C.S
Satisfactory progress Bleeding
continues
Without any bleeding
Vaginal delivery C.S.

20. ABRUPTIO PLACENTA
 DEFINITION- It is one form of antepartum
haemorrhage where the bleeding occure due
to premature separation normally situated
placenta.
 INCIDENCE – The overall incidence 1 in
150 deliveries . depending on the extent (
partial or complete) and intensity of placenta
separation ,it is a significance cause of
perinatal mortality (15-20%) and maternal
mortality(2-5%).

21. CLINICAL TYPES
Revealed- Following separation of the placenta, the blood
insinuates downwards between the membranes and the
deciduas.

22. Concealed- The blood collect behind the separation
placenta or collected in between the membranes and
deciduas.

23.  Mixed –In this type ,some part of the
blood collect inside (Concealed) and a
part is expelled out (Revealed) . usually
one variety predominates over the other
.this is quite common

25. ETIOLOGY
 Hypertensive disorders of pregnancy(HPD)
–Preeclampsia , essential hypertension, renal
hypertension.
 Trauma- Fall, forceful external cephalic
version, sudden decompression in hydromnios,
short cord in labour
 Vascular accident- supine hypotensive
syndrome due to compression of inferior vena
cava by gravid uterus.
 Nutritional and social factor- Grande
multiparty, advancing age, malnutrition, folic
acid deficiency, poverty, hard work, cigarette
smoking, and uterine fibroid . recurrence(10%)
occur in this group.

26. CLINICAL FREATURES OF ABRUPTIO PLACENTA
REVEALED TYPE CONCEALED TYPE
Symptoms
1) Vaginal bleeding Usually slight, continous, dark red,
rarely severe bleeding
Absent but present in mixed type
2)Abdominal pain No severe pain but discomfort Acute agonizing pain present
3) Precending symptoms of PIH Oedema, headache, vomiting may be
rarely present
This may be present
4)Past history of PIH, essential
hypertension, chronic renal disease
May be present May be present
SIGN
1) Shock absent Shock in an outstanding feature
2)anaemia Usually absent Always present-moderate to severe
3)evidence of preeclampsia May be present Present in higher incidence
4)Per abdomen-uterus Localized uterine tenderness; foetal
presentation as useul; foetal heart heard
Tense, tender . hard with rising fundal
height and increasing abdominal girth;
foetal part and FHS not easily audible
5)Vulval inspection Usually slight bleeding Bleeding is absent
6)Vaginal examination in an operating
theatre
No placenta felt at lower uterine
segment but friable
No placenta felt at the lower uterine
segment
7)Placental sonography Can be useful for differentiation from
placenta praevia
Can diagnose sonoluscent retro
placental clot in upper segment
8)Laboratory test blood Hb%
coagulation profile urine
Hb% low undisturbed proteinuria absent Clotting time increased- platelet count
low fibrinogen low FDP increases
usually present

27. SCHEME OF MANAGEMENT OF ABRUPTIO PLACENTAE
ABRUPTIO PLACENTAE
-General & abdominal examination
- Fetal status
- Assessment of blood loss
- Hb% ,Haematocrit,coagulation profile
-ABO& Rh group
-Resuscitation
Revealed Concealed
Resuscitation

28.  -Blood transfusion
- Periodic Coagulation
Pt. in labour Pt. not in labour Profile
-Urine output
-Fetal
>37 week <37week monitoring
A.R.M Oxytocin A.R.M Oxytocin- If
needed
-No
response
-Falling fibrinogen
Level
A.R.M Oxytocin- If needed - Oliguria
- Fetal distress
C.S
Hysterectomy(rare)

29. Bleeding stops Bleeding P.V.continuing
CTG:Reactive fetus
Expected treatment A.R.M
Try continue the pregnancy Oxytocin
Upto 37 week

30. BIBLIOGRAPHY
1)Bobak, Jenson, Maternity nursing 3rd edition Missouri,mosby publication
p.p 639-649
2)D.C.Datta, textbook of obstetrics 6th edition 2004,new central book
publication Calcutta p.p 221-228
3)Down C.S. pictorial & practical undergraduate &postgraduate textbook
of obstetrics,neonatology &reproductive &child health
education, revised sixteenth edition 2004,Down book,
kolkatta p.p 126-135.
4)B.T. Baswanthappa, text book of midwifery and reproductive health
nursing, 1st edition, jaypee brother medical publishes( p) liet,
P.P.-540-543
5)Bunnet V.Ruth ,brown linda ,k. Myles text book of midwives,
12th edition, hongkong P.P-309-315
6) WWW.Google.com