Bleeding before labour

1. ‫جنيه‬ ‫واحد‬
ANTEPARTUM HAEMORRHAGE
( APH)
Definition: It is defined as bleeding from or into
genital tract after the 28th week of pregnancy but
before the birth of the baby.
Incidence: The incidence is about 3% .

2. CAUSES:
Placental
Bleeding
(70%)
Placenta
previa
(35%)
Abruptio
placentae
(35%)
Unexplaine
d (25%)
APH
Extraplacental
Extrauterine
causes
(5%)
• Cervical polyp.
• Ca cervix.
• Varicose vein.
• Local trauma.
• Local trauma.

3. PLACENTA PREVIA
Definition: When the placenta is implanted partially or
completely over the lower uterine segment.
Incidence: It ranges from 0.5% to 1%.
Aetiology: The risk factors for placenta previa are:
 Multiparity.
 Increased maternal age (>35 years).
 History of previous c/s or any other scar in the uterus.
 Placental size and abnormality.
 Smoking.
 Prior curettage.

4. TYPES OR DEGREES:
Type 1 Lateral Placenta dipping into the lower
segment butt not reaching up to
the os.
Type 2 Marginal Placental edge reaches the internal
os.
Type 3 Incomplete central Placenta covers the internal os
when closed, but not when fully
dilated.
Type 4 Central
• Type 1 and 2 are called
minor degrees and type 3
and 4 called major degrees.
• Type 1 and 2 can be
anterior or posterior.
• Type 2 posterior placenta
Placenta covers the internal os
even when fully dilated.

5. PLACENTAL MIGRATION:
U/S at 17 weeks of gestation reveals placenta covering the
internal os in about 10% of cases. Repeat u/s at 37 weeks
showed no placenta in the lower uterine segment in more
than 90% of cases. Lower uterine segment expands from 0.5
cm at 20 weeks to more than 5 cm at term.
The term placental migration could be explained in two ways:
I. With the progressive increase in the length of lower
uterine segment, the lower placental edge relocates away
from the cervical os.
II. Due to tophotropism (growth of trophoblastic tissue
towards the fundus), there is resolution of placenta
previa.

6. FEATURES:
Symptoms: the only symptom of placenta previa is vaginal
bleeding.
The classical features of bleeding are:
Sudden onset, painless, apparently causeless and recurrent.
Signs:
 Pallor, if present, will be proportionate to the amount of
bleeding.
 Size of the uterus corresponds to the period of amenorrhoea.
 Uterus is soft and non tender.
 Malpresentations are common and if it is a cephalic
presentation, the head is usually floating.
 Fetal heart sounds will usually be heard. Slowing of the fetal
heart rate on pressing the head down into the pelvis and
prompt recovery on release of the pressure is termed
Stallworthy’s sign and is suggestive of posterior placenta
previa.
 Vaginal examination should not be suspected placenta previa.

7. DIAGNOSIS:
I. Localization of placenta:
 Sonography:
 TAS.
 TVS.
 Trans perineal U/S.
 Colour Doppler flow study.
 3D power Doppler study.
 MRI.
2. clinical:
 Double set examination.
 Direct visualization during c/s.
 Examination of the placenta following vaginal delivery.

8. DISTINGUISHING FEATURES OF PLACENTA
PREVIA AND ABRUPTIO PLACENTAE:
Parameters Placenta previa  Abruptio placentae
 Clinical features:
- Nature of bleeding
- Character of blood
- General condition
and anaemia
- Features of
preeclampsia
a) painless, causeless
and recurrent.
b) Bleeding is always
revealed.
Bright red
Proportionate to visible
blood loss
Not relevant
a) Painful. Often
attributed to
preeclampsia or
trauma and
continuous.
b) Revealed,
concealed or
usually mixed.
Dark coloured
Out of proportion to
visible blood loss in
concealed or mixed
variety
Present in one-third
cases

9. COMPLICATIONS OF PLACENTA PREVIA:
Maternal:
During pregnancy:
• Malpresentation.
• Premature labour.
During labour:
• Early rupture of the membranes.
• Cord prolapse.
• Slow dilatation of the cervix.
• Intrapartum haemorrhage.
• Increased incidence of operative interference.
• PPH.
• Retained placenta.
Puerperium:
• Sepsis.
• Subinvolution.
• Embolism.

10. FETAL COMPLICATIONS IN PLACENTA PREVIA:
 Low birth weight.
 Asphyxia.
 Intrauterine death.
 Birth injuries.
 Congenital malformation.
 Maternal and fetal morbidity and mortality.
Maternal death due to massive bleeding during the
antepartum, intrapartum or postpartum period.

11. MANAGEMENT OF PLACENTA PREVIA:
Expectant management (Called as Macaffee regime) :
Goal- is to carry pregnancy till term without putting mothers life
at risk with an aim to achieve fetal lung maturity.
• No active bleeding present.
• Hemodynamically stable.
• Gestation age <37 weeks.
• CTG-should be reactive.
• No fetal anomaly in U/S.
Active management- To terminate pregnancy immediately
irrespective of gestational age:
• If active bleeding is present.
• Hemodynamically unstable/shock.
• Gestational age >37 weeks and patient in labour.
• Fetal distress present/ FHS absent.
• USG shows fetal anomaly or dead fetus.

12. EXPECTANT MANAGEMENT:
 Hospitalization.
 Complete bed rest.
 Correction of anaemia.
 Antenatal steroids to promote fetal lung maturity.
 Anti D if patient is Rh negative.
 If uterine contractions present- Tocolytic can be give (
magnesium sulphate/ nifedipine).

13. INDICATIONS FOR C/S IN CASE OF PLACENTA PREVIA:
 Major degree of placenta previa (type 3 and 4).
 Type 2 posterior placenta.
 In cases where fetal head is not engaged.
 Severe bleeding irrespective of the type of placenta previa.
 Obstetrical contraindication of vaginal delivery.
Placenta accrete:
It is the attachment of placenta directly to the myometrium without
any intervening decidua basalis.

14. ABRUPTIO PLACENTAE ( SYN: ACCIDENTAL
HAEMORRHAGE, PREMATURE SEPARATION OF
THE PLACENTA):
Definition: It is one form of APH where the bleeding occurs due to
premature separation of normally situated placenta.
Varieties:
A. Revealed.
B. Concealed.
C. Mixed.
Bleeding is almost always maternal.
Incidence: The overall incidence is about 1 in 200 deliveries.
Risk factors:
• Increased maternal age.
• Increased parity.
• Pre eclampsia.
• Chronic hypertension.
• Preterm rupture membranes.
• Sudden uterine decompression of the uterus.

15.  Cigarette smoking.
 Thrombophilia.
 Previous abruption.
 External trauma.
 Folic acid deficiency.
 Uterine fibroid.
Clinical pictures of Abruptio placentae:
The clinical pictures depends on:
1. Degree of separation of the placenta.
2. Speed at which separation occur.
3. Amount of blood concealed inside the uterine cavity.

16. DISTINGUISHING FEATURES OF PLACENTA PREVIA AND
ABRUPTIO PLACENTAE:
Placenta previa Abruptio placentae
Symptoms:
Bleeding and pain Sudden, painless and
recurrent.
Always revealed.
Bright red.
Severe abdominal pain.
Revealed or concealed.
Signs:
Pallor :
Fundal height:
Palpation:
Fetal parts:
Head:
Malpresentation:
FHS:
Pre eclampsia:
Proportionate to loss.
Corresponds to GA.
Soft and relaxed
uterus.
Easily palpated.
High and floating head.
Common.
Usually normal.
May be out of
proportion.
May be more.
Tense, tender and rigid
.
Difficult to palpate.
Head usually fixed.
Uncommon.

17. COMPLICATIONS OF ABRUPTIO PLACENTAE:
Maternal:
In revealed type: Maternal risk is proportionate to the visible blood loss and
maternal death is rare.
In concealed type:
1) Haemorrhage.
2) Shock.
3) Blood coagulation disorders.
4) Oliguria and anuria due to: a) hypovolemia b) serotonin liberated from
the damaged uterine muscle producing renal ischemia and c) necrosis,
in severe cases may lead to d) cortical necrosis and renal failure.
5) Atony of the uterus.
6) Increase in serum FDP.
7) Puerperal sepsis.
8) Couvelaire uterus.
9) Sheehan’s syndrome.
Fetal mortality rate is high in abruptio placentae.

18. TREATMENT OF ABRUPTIO PLACENTAE:
 Assessment of the patient.
 Emergency measures.
 Management options:
1) Immediate delivery.
2) Management of complications.
3) Expectant management ( rare).

19. VASA PREVIA:
 The unsupported umbilical vessels in filamentous placenta, lie
below the presenting part and run across the cervical os. The
vessels are torn either spontaneously or during rupture of
membranes.
 Fetal mortality rate is high (about 50%).
 Detection of nucleated red blood cells or fetal haemoglobin is
diagnostic.
 Management depends on fetal GA, severity of bleeding,
persistence or recurrent bleeding.