a) Placental abruption
b) Placenta praevia
c) Uterine rupture
Bleeding at > 24weeks (<24 weeks is miscarriage)
Placental abruption: part of the placenta becomes detached from the
Placenta Praevia: The placenta is inserted wholly or in part into the lower
segment of the uterus and therefore lies in front of the presenting part.
** AVOID PV exam; placenta
praevia may bleed catastrophically **
HOW WILL U DIFFERENTIATE BETWEEN
ABRUPTION AND PLACENTA PREVIA?
Painful third trimester bleeding.
Associated with PIH
1:120 pregnancies, approx. 1%.
Recurrence rate of 10%.
Port wine stained amniotic fluid.
Mark line at top of fundus at presentation and follow
fundal height serially.
Painless third trimester vaginal bleeding
1:200 - 1:250 pregnancies average
1:50 grand multiparas,1:1500 nulliparas
Undiagnosed third trimester bleeding, consider a
double set-up in the OR.
Biggest risk factor is prior C-section, which confers a
Signs and symptoms
Placental abruption Placenta praevia
Shock out of keeping with visible
Shock in proportion to visible loss
Pain constant No pain
Tender, tense uterus (hypertonic) Uterus not tender (hypotonic)
Normal lie and presentation Both may be abnormal
Fetal heart absent/distressed Fetal heart usually normal
Coagulation problems Coagulation problems rare
Beware pre-eclampsia, DIC, anuria Small bleeds before large
USG plays major role
Delivery is generally indicted unless the fetus is very
premature and both the mother and fetus are stable
DIC occurs in 4-10% of cases and usually is apparent by
8 hours after onset if symptoms
Renal failure is the most common cause of maternal
Total - needs operative delivery.
Partial and Marginal - may consider a vaginal delivery
as the baby’s head may tamponade the placenta during
Consider fetal hemorrhage in addition to maternal
Called for a woman who has just given birth
Delivery performed by new midwife
Upon Arrival patient is pale and the bed is soaked in
Case 2 Continued
P 165, BP 80/p, R 32, SaO 98% on NRB
Continuous hemorrhage noted as you move her to the
WHAT IS THE DIAGNOSIS ?
WHAT R THE CAUSES ?
HOW WILL U MANAGE ?
1. Call for help
b) Large bore IV access x 2
c) FBC, coag, cross match
d) Urinary catheter
3. Identify cause(s) of PPH
4. Control bleeding
5. Replace the blood loss
stages in management in vaginal
1. Ensure 3rd stage complete – if not
2. Rub uterine fundus to stimulate
contraction +/- bimanual compression if
required to stop uterine bleeding
3. Assess for cervical/vaginal wall/perineal
tears – if present, repair
stages in management
4. Medical management of atony with
5. Surgical management
a) Intra uterine balloon device
b) B lynch suture if at Caesarean section
c) Uterine artery embolisation/ligation
UTERINE COMPRESSION SUTURES
Cho JH, Jun HS, Lee CN: Haemostatic Suturing Technique For uterine Bleeding during
Cesarean Section delivery. Obstet Gynecol 200 0 96:129-131
A Straight needle is passed anterior
to posterior and passed over fundus
and ligated anteriorly.
Multiple square sutures are
Passed intramurally and tied
Selective Artery Embolisation
Useful in Haemorrhage associated with Placenta
Requires 24hr availability of radiological expertise.
Patients must be stable
Complications include: Necrosis of uterine wall,
contrast adverse effects, local haematoma formation
Recombinant Activated Factor VII
Novoseven is FDA approved for bleeding episodes in
It has been effective in nonhemophiliac patients with
extensive organ damage, hemorrhage and
coagulopathy that did not respond to transfusion
ROLE OF HYSTERECTOMY ?
HYSTERECTOMY LAST BUT