Vaginal bleeding in late pregnancy can be caused by placenta previa, placental abruption, or other local causes. Placental abruption occurs in about 1-2% of pregnancies and is a significant cause of perinatal mortality. Risk factors include hypertension, smoking, trauma, and sudden uterine decompression. Clinical features range from mild pain and bleeding to severe abdominal pain, heavy bleeding, and maternal shock. Management depends on fetal maturity, severity of bleeding, and presence of complications, and may include expectant monitoring, induction of labor, or caesarean section.

2. Vaginal Bleeding in
Late Pregnancy
Presented By
Nirsuba Gurung
Master in nursing
Women health and development

3. Obstetric Haemorrhage
 Ranks as the First cause of
maternal mortality accounting for
25 – 50 % of maternal deaths

4. APH: Epidemiology & Causes
 Magnitude: 4% of women may develop
APH.
 Causes:
 placenta previa (1/200)
 placental abruption (1/100)
 uterine rupture (<1% in scarred uterus)
 vasa previa (1/2000-3000)
 Local causes
 Cervical polyp
 Bloody show
 Cervicitis or cervical ectropion
 Cervical cancer

6. Vasa Previa

7. Velamentous Insertion of the
umbilical cord

8. ABRUPTIO PLACENTA
 Definition:
 Early separation of the normally
implanted placenta after 28/40 and
before the end of second stage of
labour
 Recurrence:
 The risk of recurrent abruption in a
subsequent pregnancy is high.

9. Epidemiology of Abruption
 Occurs in 1-2% of pregnancies
 20% of all third-trimester bleeders
 Recurrence risk
 10% in first pregnancy
 25% in second pregnancy

10. Epidemiology of Abruption
 It is a significant cause of perinatal
mortality – 15-20%
 Maternal mortality- 2-5%

11. Risk factors
Prevalence is high in
 Smoking or substance abuse (e.g.
cocaine)
 History of previous abruption
 High birth order
 Advancing maternal age
 Poor-socioeconomic condition
 Malnutrition
 Placental insufficiency

12. Risk factors

13. Etiology
 Hypertension in pregnancy
• Spasm of utero-placental blood vessels
• Anoxic endothelial damage
• Rupture of vessels or
• Extravasations' of blood in decidual basalis

14. Trauma
 External cephalic version
 RTA
 Needle puncture during amoiocentesis

15. Sudden uterine decompression
 Delivery of first twins
 Sudden escape of liquor amnii in
hydraminous
 Premature rupture of membrane

16.  Short cord
 Supine hypotension syndrome
 Placental anomaly
 Sick placenta
 Folic acid deficiency
 Uterine anomaly
 Thrombophilias

17. Pathogenesis
Decidual hematoma leads to degeneration and necrosis
of decidua basalis and adjacent placental parts
Hemorrhage into decidua basilais initiate placental
separation
Etiological factors

18. Umbilical artery (UA)Umbilical vein
(UV)
Uterine
arteries
Uterine
veins
Abruption
Archer TL 2006 unpublished
Placental abruption: fetal
asphyxiation
(O2 supply is cut off).

19. Placental abruption with
trauma
Elastic myometrium
Liquid placenta
Placenta
shears off

20. Miller’s Anesthesia Occult hemorrhage in abruption

21. Features of retroplacental
clots
 Depression found in maternal surface
of placenta
 Area of infraction with varying
degree of organization

22. Abruptio placenta:
Classifications
Are based on
1. Extent of separation: Partial vs complete
2. Location of separation: Marginal Vs
central
3. Clinical presentation: Revealed, concealed
and mixed
4. Clinical Severity: Mild, Moderate and
Severe

23. Grade 1 Mildest form:
approx 40 of all
cases.
• No vaginal bleeding to
mild vaginal bleeding
• Slightly tender uterus
• Normal maternal BP
and heart rate
• No coagulopathy
(clotting problems)
• No fetal distress
Clinical Severity
Grade 2: moderate -
approx
45% of all cases.
• No vaginal bleeding to moderate
vaginal bleeding
• Moderate-to-severe uterine
tenderness with possible tetanic
contractions
• Maternal tachycardia with
orthostatic changes in BP and
heart rate
• Fetal distress or even death
• Low fibrinogen levels present
(causing clotting problems)
Grade 0: no clinical features
•Diagnosis made after placental exmaninatio

24. Grade 3: Severe form: Approx 15% of all cases.
• No vaginal bleeding to heavy vaginal bleeding
• Very painful tetanic uterus
• Maternal shock
• Coagulopathy
• Fetal death
Clinical Severity

25. Abruptio Placenta: Features
 Pain and tenderness
 Initially localized then becomes
generalized due to endometrial injury –
extravasations of blood
 Vaginal bleeding
 Maternal distress
 Often I.U.F.D

26. Clinical manifestation of
hemorrhage
 Concealed type: blood accumulates
behind placenta
 Revealed type: blood dissect
downwards between membranes and
uterine wall and ultimately escape
out through the cervix or may be kep
concealed by the pressure of fetal
head on the lower uterine segment

28. Clinical manifestation of
hemorrhage
 Blood may gain access to the amniotic
cavity after rupturing the membrane
 Couvelaire uterus : blood may
percolate through the layer of
myometrium

30. Couvelaire uterus
 Naked eye features
 Dark port wine color:patchy and
diffused
 Sub peritoneal petechial
hemorrhage
 Free blood may be present in
peritoneal cavity

31. Couvelaire uterus
 Microscopic appearance:
 Necrosed uterine muscles in the
affected part
 Blood infiltration between the
muscle bundle
 Blood vessels may show acute
degenerative changes
 Muscular dissociation occurs in
middle and outer muscle layer

32. Clinical features
Revealed Mixed(Concealed
features predominate)
Symptoms Abdominal bleeding and
discomfort followed by
bleeding
Acute, intense
abdominal pain followed
by slight bleeding
Character of bleeding Continuous dark color Continuous dark color or
blood stained serous
discharge
General condition Proportionate to the
visible blood loss, shock
is usually absent
Shock may be
pronounced which is
proportionate to the
visible blood loss
Pallor Related with visible
blood loss
Pallor is usually severe
and out of proportion to
the visible blood loss
Features of pre- May be absent Frequent association

33. Revealed Mixed(Concealed
features predominate)
Uterine height Proportionate to the
POG
May be
disproportionately
enlarged and globular
Uterine feel Normal feel with
localized tenderness,
contractions frequent
and local amplitude
Uterus is tense ,tender
and rigid
Fetal parts Can be identified easily Difficult to make out
FHS Usually present Usually absent

34. Laboratory test
Revealed Mixed(Concealed features
predominate)
Hemoglobin Low value proportionate to
the blood loss
Markedly lower than vi
Coagulation profile Usually unchanged Variable changes
•Clotting time increased(>6min)
•Fibrinogen level
low(<150mg/dl)
•Low platelet count
•^ Partial thromboplastin time
•^ FDP and D-dimer
Urine for protein
Confusion in diagnosis
May be absent Usually present
Confusion in diagnosis Placenta previa Acute obstretrical-
gynaecological –surgical
complication

35. Ultrasound - Abruption
 Abruption is a clinical diagnosis!
 Placental location and appearance
 Retroplacental echolucency
 Abnormal thickening of placenta
 “Torn” edge of placenta
 Fetal lie
 Estimated fetal weight

36. Large, extensive sonographic
preplacental collection beneath the
chorionic plate

37. Large, retroplacental sonographic
abruption between the placenta and
uterus.

38. Sonographic blood collection at the
placental margin

39. Laboratory - Abruption
 Complete blood count
 Type and Rh
 Coagulation tests + “Clot test”
 Kleihauer-Betke not diagnostic, but
useful to determine Rhogam dose
 Preeclampsia labs, if indicated
 Consider urine drug screen

40. Sher’s Classification -
Abruption
 Grade I
 Grade II
 Grade III with fetal demise
 III A - without
coagulopathy (2/3)
 III B - with coagulopathy
(1/3)
mild, often retroplacental
clot identified at delivery
tense, tender abdomen and
live fetus

41. Placental Abruption: Complications
 Shock
 Acute renal failure
 Cause: ?seriously impaired renal
perfusion 2° to ↓CO and intrarenal
vasospasm as in preeclampsia
 DIC
 Consumptive coagulopathy 2° to
hypofibrinogenemia along with elevated
levels of fibrinogen–fibrin degradation
products

42. Placental Abruption: Complications
 Fetal distress/demise
 PPH
 Couvelaire Uterus:
 Widespread extravasation of blood
into the uterine musculature and
beneath the uterine serosa.
 Sheehan syndrome
 Puerperal sepsis

43. Placental Abruption:
Management
 Prevention : Aim
 Elimination of the known factors
 Correction of anemia
 Prompt detection and institution of
the therapy to minimize
complication

44. Prevention of known
factors
 Early detection and effective therapy
 Needle puncture: USG guided
 Avoidance of trauma
 Avoid sudden decompression of the
uterus
 To avoid supine hypotension
 Routine administration of folic acid

45. Placental Abruption:
Management
 Management depends on:
 fetal maturity,
 degree of severity,
 viability of the fetus/fetal distress

46. Assessment of case
 Blood loss
 Maturity of fetus
 Whether patient is in labor or not
 Presence of complication
 Types and grade of abruption

47. Emergency measures
 Sent blood for Hb and hematocrit,
coagulation profile, ABO and Rh
grouping
 Urine for detection of protein
 IV RL drip with wide bore cannula and
arrangement for BT
 Close monitoring of maternal and
fetal well being

48. Treatment modalities
 Expectant management of
pregnancy
 Definitive management
 Induction/augmentation of labor
 Caesarean section

49. If patient in labor
 Low Rupture of membrane
 Augmentation
Bed site clotting time
 Done regularly

50. Vaginal delivery
 Limited placental abruption
 Reassuring FHS
 Facilities of continous FHS
monitoring
 Prospect of vaginal delivery is soon
 Placental abruption with dead fetus

51. The patient not in labor
 Bleeding continues
 > grade 1 abruption
 Delivery either by
• Induction of labor
• C/S

52. Placental Abruption: General Management
1. Delivery
 Resuscitation
 FFP, whole blood, IV fluids
 Monitor BP
 Catherization - monitor urine output

53. Placental Abruption: General Management
2. Caesarean Section
 Indications for Caesarean Section
 salvageable baby,
 Severe vaginal bleeding,
 Poor progress,
 Transverse lie, inadequate pelvis
 Post delivery -watch out for PPH
 Myometrial myofibrin loose contractility
 Failure to clot

54. Expectant management
 If bleeding stopped
 Grade 1
 Fetus reactive and remote from term
Goal :
 prolong pregnancy
 Meanwhile administer betamethasone
for fetal lung maturity