Obstetrics

2. CAUSES
 Placenta praevia
 Abruptio placenta
 Local causes like polyp,cancer cervix,varicose
veins and local trauma
 Circumvallate placenta
 Vasa praevia
 Unclassified or indeterminate haemorrhage

3. ABRUPTIO PLACENTA
DEFINITION
• It is defined as hemorrhage
occuring during pregnancy due to
separation of normally situated
placenta.
• Also called accidental hemorrhage
or premature separation of
placenta.

4. GRADING
Sher and statland’s grading
It is of prognostic significance and
differentiates between a live and
dead fetus.
GRADE 1:Unrecognised clinically
before delivery,but evidence of
retroplacental clots on examining
the placenta

5. GRADE 2:Intermediate with
classical signs of abruption,but no
maternal distress and live fetus
GRADE 3:severe abruption with the
fetus dead
A.with coagulpathy
B.without coagulopathy

6. INCIDENCE
1% and is leading cause for perinatal
mortality

7. AETIOLOGY
The following are some of the risk
factors that are implicated
1.Medical factors
Preeclampsia and hypertension are
associated in 50% cases
Another strong correlation is with
chorioamnionitis secondary to
preterm premature rupture of
membranes

8. 2.Thrombophilias
Congenital and acquired thrombophilias
are associated with abruption.
Aquired type is antiphospholipid
syndrome-thrombosis,recurrent
miscarriage,early onset of preeclampsia
and fetal growth restriction in addition to
abruption
Congenital ,includes prothrombin gene
mutation factor v mutation protein C and S
deficiency are also associated with
abruption

9. 3.Hyperhomocystinaemia
Elevated levels of homocysteine-damage
vascular endothlium-causes abruption
This is the basis for association noticed
in women with folate deficiency
4.trauma
Blunt trauma to the abdomen
Amniocentesis
External cephalic version
Sudden uterine
decompression(hydramnios and
following delivery of 1st twin)

10. 5.Other associations
Previous abruption
Smoking and cocain abuse
Raised serum α fetoprotein level
Myomas esp. submucus myomas

11. CLASSIFICATION
Vasospasm→myometrial
contraction→venous engorement and
arteriolar rupture into decidua basalis
→dev. of decidual hematoma→
seperation of placenta
Abruption is divided into 3 based on
the type of hemorrhage:
Revealed(60%):
effused blood dissects the membranes
away from the uterine wall and make
its way through cervix into vagina.

12. Concealed(35%):
blood is retained in the uterus
Due to loss of tone of uterine muscle and
absence of uterine contractions
Uterus distends to accommodate the
blood
Sometimes amnion may rupture and
there is bleeding into amniotic sac
Concealed type is more likely to lead to
couvelaire uterus and cause fetal demise
and maternal complications

13. Mixed(5%):
In this partly revealed and partly concealed

14. COUVELAIRE UTERUS
 There can be extensive extravasation of blood into uterine
musculature beneath serosa esp. in concealed type.
 uterus show ecchymoses and tubes and ovaries drain blood.
 Peritoneal cavity is also filled with blood.
 This is called couvalaire uterus or uteroplacental apoplexy.
 Already there is fetal hypoxia due to placental seperation
 Tetanic contraction brought about by the seepage of blood
into myometrium in abruption cause ↑sed intrauterine
pressure.
 this cuts off placental blood flow adding to fetal
hypoxia.thus sudden fetal death is common.
 Concealed abruption is more likely to lead to couvelaire
uterus and cause fetal demise and maternal complications

16. DIAGNOSIS
 SYMPTOMS
Severe and constant abdominal
pain(more in concealed and less in
revealed)
Bleeding is present in revealed and
mixed types but may be absent in
concealed type.

17.  SIGNS
Pallor which is out of proportion to the
extent of bleeding
Hypertension(if there is associated
preeclampsia)
Uterus larger than the expected for the
period of amenorrhoea
Uterus may be tense and tender and
even rigid(woody hard)
Difficulty in palpating underlying fetal
parts easily
Fetal distress or absent FHS.

18.  In revealed uterus fundal height may
correspond to period of gestation
FHS are present
Initial presentation may be as preterm
labour with an irritable uterus and there
should be a high index of suspicion
Due to association of preeclampsia BP
may be normal even with severe
abruption.Hence findng of a normal BP
is not always reassuring

19.  VAGINAL EXAMINATION
 Performed after ruling out placenta praevia
 Usually patient will be in labour with fixed
presenting part and on artificial rupture of
membranes,liquor will appear to be uniformly blood
stained
 ULTRASOUND
 Less significant role
 Mainly useful to rule out placenta praevia
 Sometimes retroplacental hematoma may be seen
 Negative findings do not exclude abruption
 Abruption is essentially a clinical diagnosis and not
an ultrasound diagnosis

20. DIFFERENTIAL DIAGNOSIS
 Placenta praevia
 Other causes of APH
 Preterm labour
 Acute polyhydramnios(absence of pallor and
ultrasound is diagnostic)
 Rupture uterus(esp. incomplete rupture)
 Red degeneation,pyelonephritis,and other causes
of acute abdomen

21. COMPLICATIONS
 MATERNAL
 1.shock
 2.renal failure
 3.disseminated intravascular coagulation
(liberation of thromboplastin from placenta →intravascular
coagulation→ consumption of all coagulation factors →
fall in fibrinogen level →bleeding).
4.Postpartum hemorrhage(due to atonicity and
coagulation failure)
FETAL
1.Prematurity
2.Hypoxia and fetal death

22. MANAGEMENT
 Immediade management
 Similar in all cases of APH
 Resuscitation with blood and crystalloids and prompt
delivery
 Blood transfusion
 Indwelling catheter introduced and monitered
 Central venous pressure line inserted
 Blood taken for Hb,PCV,grouping,cross matching and
coagulation profile
 Coagulation profile includes fibrinogen ,fibrin
degradation products , partial thromboplastin time,
prothrombin time and platelet count
 (best marker –fibrinogen)
 Clotting time,clot retracton test,stability of the clot is
also looked for
 Ultrasound to confirm normal placenta and live fetus

23.  Obstetric management
 Immediate delivery is vital in abruption
 Mode of delivery depends on gestational
age and condition of mother and fetus
 fetus is alive
 Ceasarian is the best method
 In mild cases of revealed
abruption,imminent vaginal dlivery is
carried out

24.  Fetus is dead
 Vaginal delivery preferred unless bleeding is so severe or
there are other obstetric complications
 Hence artificial rupture of membranes and immediate
infusion of oxytocin to hasten delivery
 If delivery is not imminent after reasonable
time,caesarean section may have to be resorted to
 Caesarean section
 Done by experienced person with the help of an expert
anaesthetist
 PPH must be anticipated
 Indications for caesarean section:
 Fetus is alive and capable of survival
 Severe bleeding and vaginal delivery is not imminent
 Failure to progress after artificial rupture of membranes
and oxytocin

25. o Coagulation failure
o It is treated by blood tranfusion
o Human recombinant activated factor
vii is best agent but very expensive
o Cryoprecipitate used if fibrinogen is
very low
o Vaginal delivery is preferred ,if
caesarean becomes
neccesary,coagulation defect is
corrected before proceeding.
o Plenty of cross matched bood should
be available

28. OTHER TYPES OF APH
 CIRCUMVALLATE PLACENTA
 In this condition chorionic plate which is on the fetal
side is smaller than than basal plate on maternal side
 Fetal surface of placenta presents a central
depression surrounded by thickened greyish white ring
 These pregnancies may be complicated by IUGR,↑sed
chance of fetal malformations
 Bleeding is usually painless
 Antenatal diagnosis is unlikely and diagnosis usually
made after examination of placenta post delivery

30. VASA PRAEVIA
 When the fetal vessels in the membrane cross the
region of the internal os and are ahead of
presenting part the condition is called vasa
praevia.
 Occurs in 2 situations
 Type 1-velamentous to cord insertion where cord
insertion is into the membranes
 Type 2-presence of fetal vessels running between
lobes of a placenta with one or more accessory
lobes
 these can remain undiagnosed and and it can
rupture during artificial rupture of membranes
leading to death of the fetus

32.  Apts test or singer’s alkali denaturation test can
be used to confirm vasa praevia
 Principle-fetal Hb more resistant to alkali
denaturation
 When water and blood are mixed with NaOH it
remains pink for longer if fetal in origin or turns
yellow brown in 2 min if maternal in origin
 Risk factors-
 Succenturiate lobe
 Multiple pregnancy
 IVF

33.  Sometimes vessels can b palpated on vaginal
examination
 Prenatal diagnosis is rarely possible by
ultrasound and doppler
 Vaginal bleeding associated with variable
deccelerations on cardiotocography alerts one to
diagnose vasa praevia

34. Unclassified or intermediate APH
 Exact cause of APH is unknown
 There is mild bleeding but no features of
abruption or placenta praevia
 Speculum examination may not reveal local
cause
 Apt test-exclude VP
 IUGR and poor perinatal outcome are
associated
 If there is recurrent bleeding and GA is 37
weeks or more,risk factors like fetal growth
restriction delivery is preferred
 In majority of cases marginal sinus rupture
is later found to be the cause