1. Bleeding in late
pregnancy
DR.KHALED AL GHAIDANY

2.  Vaginal bleeding in the third trimester
 Complicates 4 % of all pregnancies
Antepartum hemorrhage

3. 1. Placenta previa(PP)
2. Abruptio placenta(AP)
3. Uterine rupture
4. Fetal vessel rupture
5. Cervical lesions lacerations
6. Vaginal lesions lacerations
7. Congenital bleeding disorders
8. Unknown
Causes of APH

4.  Painless vaginal bleeding in a previously
normal pregnancy
 Usually at age of 30 weeks (13 occurs
before 30
 Mechanism of bleeding:
development and thinning of the lower
uterine segment in the 3rd trimester 
disruption of the placental attachment
Placenta previa

5.  Incidence : 0.5 % (20 % of all APH)
 Presentation:
1. Painless vaginal bleeding (70 %)
2. Bleeding with contractions (20 %)
3. incidental diagnosis “by US or at term”
(10 %)
Placenta previa

6.  Multiparty
 Increasing maternal age
 Prior placenta previa
 Multiple gestation
 Previous history of PP (4-8 % risk)
PP: Predisposing factors

7.  According to the relationship of the
placenta to the internal cervical os:
1. Total “ complete” = centralis
2. Partial
3. Marginal “ marginalis”
4. Low implantation “ lateralis”
PP: Classification

8.  The most accurate tool is US
 Transabdominal US (95 % sensitivity)
 Transvaginal US: ( 100 % sensitivity, it
should be done in hospital !!!)
 Double set-up examination (???)
PP: Diagnosis

9.  4 -6 % of patients have some degree of
previa on US before 20 weeks gestation
 With the development of the lower uterine
segment, there is a relative upward
placental migration, with 90 % of these
resolving by 3rd trimester
 However, only 10 % of complete PP
resolve
PP: prognosis

10.  Initially stabilize the patient
 The goal is to obtain fetal maturation
without compromising the mother’s health
 Expectant management
 Elective CS after 36 wks gestation
(Blood loss might reach >1500 ml)
PP: Management

11.  Premature separation of the normally
implemented placenta
 Complicates 0.5 to 1.5 % of all
pregnancies
 Result in fetal death in 1 per 500
deliveries
Abruptio placenta (AP)

12.  Hypertension (the most common)
 Trauma
 Polyhydramnios with rapid decompression
on membrane rupture
 Cocaine use
 Tobacco use
 Preterm premature rupture of membrane
 A short umbilical cord
AP: Predisposing factors

13.  Hemorrhage into the decidua basalis 
formation of a decidual hematoma 
placental separation further
separation and destruction of placental
tissue
 2 types:
1. Concealed hemorrhage (20%): when
blood dissect upward toward the fundus
2. Revealed(external) hemorrhage: if
extend downward toward the cervix
AP: pathophysiology

14.  Primarily a clinical one
 Vaginal bleeding in association with
uterine tenderness, hyperactivity, and
increased tone
 Increased fundal height
 Abdominal pain (66% of cases)
 Fetal distress (60%)
 US will detect only 2% of abruptions
 Do US only to detect the coexisting PP
AP: diagnosis

15.  Perinatal mortality rate: 35 %
 Accounts for 15% of 3rd stillbirths
 15% of live born infants have significant
neurological impairment
 AP is the most common cause of DIC in
pregnancy (20% of cases)
 Recurrence risk: 10 % after one AP,
and 25 % after 2 AP
AP: Maternal-fetal risks

16.  Careful maternal hemodynamic
monitoring, fetal monitoring, serial
evaluation of the hematocrit and
coagulation profile, and delivery
 CS should be reserved for obstetric
indications only
 Active delivery is the treatment of most
cases
AP: Management

17.  Follow the guidelines in referring high
risk pregnancies
 Have a high index of suspicion
 Stabilize the patient before referral as
much as you can
 Remember “ information has no side
effects”
 Build up your safety netting
As a GP