2. Introduction
Death from hemorrhage still remains a leading cause of maternal mortality.
APH is defined as bleeding from the genital tract in pregnancy from the age of
viability(24 week’s gestation –WHO) and the onset of labour.
It affects 4% of all pregnancies. It is a medical emergency.
It is associated with increased risks of fetal and maternal morbidity and
mortality.
4. PLACENTA PREVIA
Is defined as the implantation of placenta partially or wholly in the lower
uterine segment.
About one-third cases of antepartum hemorrhage belong to placenta previa.
The incidence of placenta previa ranges from 0.5–1% amongst hospital
deliveries. In 80% cases, it is found in multiparous women.
5. Etiology
The exact cause of implantation of the placenta in the lower segment is not
known.
The following risk factors are identified:
• Advancing maternal age
• Multiparity
• Multifetal /multiple gestations
• Prior caesarean delivery
• Smoking
• Prior placenta previa
• Uterine structural anomaly
• Assisted conception
6. Types or degrees
Type—I (Low-lying): the placental edge is in the lower uterine segment but
does not reach the internal os
Type—II (Marginal): The placenta reaches the margin of the internal os but
does not cover it. Divided into anterior and posterior.
Type—III (Incomplete or partial central): The placenta covers the internal os
partially (covers the internal os when closed but does not entirely do so when
fully dilated).
Type—IV (Central or total): The placenta completely covers the internal os
even after it is fully dilated.
7.
8.
9. Cause of bleeding
Bleeding results from small disruptions in the placental attachment during
normal development and thinning of the lower uterine segment
As the placental growth slows down in later months and the lower segment
progressively dilates, the inelastic placenta is sheared off the wall of the
lower segment. This leads to opening up of uteroplacental vessels and leads
to an episode of bleeding.
10. Clinical features
Bleeding: usually mild but it could be severe; recurrent, painless and
causeless.
Soft and non-tender uterus
Normal fetal heart rate (unless there is severe bleeding or associated
abruption).
High presenting part.
Fetal malpresentation (breech/transverse/oblique).
General condition and anemia are proportionate to the visible blood loss
11. Abdominal examination
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. There is also increased frequency of twin
pregnancy.
The head is floating in contrast to the period of gestation. The head cannot
be pushed down into the pelvis.
Fetal heart sound is usually present.
Vulval inspection: the blood is bright red as the bleeding occurs from the
separated utero-placental sinuses close to the cervical opening and escapes
out immediately
Vaginal examination is contraindicated
12. DIAGNOSIS: Painless and recurrent vaginal bleeding in the second half of
pregnancy should be taken as placenta previa unless proved otherwise.
Ultrasonography is the initial procedure either to confirm or to rule out the
diagnosis
. Localization of placenta
Sonography
o Transabdominal ultrasound (TAS)
o Transvaginal ultrasound (TVS)
o Transperineal ultrasound
o Color Doppler flow study
Magnetic resonance imaging (MRI)
Clinical
By internal examination (double
set up examination)
Direct visualization during
caesarean section
Examination of the placenta
following vaginal delivery
13. Management
PREVENTION:
o Adequate antenatal care
o Antenatal diagnosis at 20th week
o Significance of “warning hemorrhage” should not be ignored
TREATMENT ON ADMISSION
IMMEDIATE ATTENTION: Overall assessment of the case is quickly made as regards:
(1) Amount of the blood loss — by noting the general condition, pallor, pulse rate and
blood pressure;
(2) Blood samples are taken for group, cross matching and estimation of hemoglobin;
14. (3) A large-bore IV cannula is sited and an infusion of normal saline is started and
compatible cross matched blood transfusion should be arranged;
(4) Gentle abdominal palpation to ascertain any uterine tenderness and
auscultation to note the fetal heart rate
(5) Inspection of the vulva to note the presence of any active bleeding.
• FORMULATION OF THE LINE OF TREATMENT:
• The definitive treatment depends upon the duration of pregnancy, fetal and
maternal status and extent of the hemorrhage.
15. Expectant management
The aim is to continue pregnancy for fetal maturity without compromising the
maternal health.
Conduct of expectant treatment:
Strict Bed rest; Investigations—like hemoglobin estimation, blood grouping and
urine for protein are done;
Periodic inspection of the vulval pads and fetal surveillance with USG at interval of
2–3 weeks;
Supplementary hematinics should be given and the blood loss is replaced by
adequate cross matched blood transfusion, if the patient is anemic;
Steroid for lung maturation if gestational age is less than 34 weeks
Use of tocolysis (magnesium sulfate) can be done if vaginal bleeding is associated
with uterine contractions;
Rh immunoglobin should be given to all Rh negative (unsensitized) women
16. Active management- delivery
Cesarean delivery is done for all women with sonographic evidence of
placenta previa where placental edge is within 2 cm from the internal os. It is
especially indicated if it is posterior or thick
18. ABRUPTIO PLACENTAE
It is one form of antepartum hemorrhage where the bleeding occurs due to
premature separation of normally situated placenta after the age of viability.
Occurs in 1-2% of all pregnancies
Perinatal mortality rate associated with placental abruption was 119 per 1000
births compared with 8.2 per 1000 for all others.
19. Types
(1) Revealed : Following separation of the placenta, the blood comes out of the
cervical canal to be visible externally.
(2) Concealed : The blood collects behind the separated placenta or collected in
between the membranes and decidua.
(3) Mixed : In this type, some part of the blood collects inside (concealed) and a
part is expelled out (revealed).
20. Clinical classification
Grade—0: Clinical features may be absent. The diagnosis is made after inspection
of placenta following delivery.
Grade—1 (40%): (i) Vaginal bleeding is slight (ii) Uterus: irritable, tenderness may
be minimal or absent (iii) Maternal BP and fibrinogen levels unaffected (iv) FHS is
good.
Grade—2 (45%): (i) Vaginal bleeding mild to moderate (ii) Uterine tenderness is
always present (iii) Maternal pulse ↑, BP is maintained (iv) Fibrinogen level may be
decreased (v) Shock is absent (vi) Fetal distress or even fetal death occurs.
Grade—3 (15%): (i) Bleeding is moderate to severe or may be concealed (ii)
Uterine tenderness is marked (iii) Shock is pronounced (iv) Fetal death is the rule
(v) Associated coagulation defect or anuria may complicate
21. Risk factors
The primary cause of placental abruption is unknown, but there are several associated conditions.
Increased age and parity
Preeclampsia
Chronic hypertension
Preterm ruptured membranes
Multifetal gestation
Hydramnios
Cigarette smoking
Folic acid deficiency
Thrombophilias
Cocaine use
Prior abruption
Uterine leiomyoma
External trauma
22. Clinical presentation
Bleeding: revealed/concealed, so clinical picture is important.
Pain on the uterus and this increases in severity.
Signs of shock (hypovolaemia): fainting and collapse.
Woody hard tender uterus ( uterine tetany).
Couvelaire uterus (Bluish uterus)
Difficult to palpate the fetal parts and to hear the fetal heart.
Normal fetal lie and presentation
Ultrasonography: is done to confirm fetal viability, assess fetal growth &
normality, measure liquor.
23. Management
Treatment for placental abruption varies depending on gestational age and
the status of the mother and fetus.
Hospitalize
History & examination
Assess blood loss
IV access, X match, DIC screen
Assess fetal well-being
Placental localization
24. Complications
MATERNAL: Shock, Blood coagulation disorders, Oliguria and anuria,
Postpartum haemorrhage, Puerperal sepsis, Acute renal failure: acute tubular
or cortical necrosis.
FETAL: IUGR, Anaemia, Premature delivery, Fetal distress and death
