APH , bleeding in pregnancy, placenta previa , abruptio placenta , maternal mortality risk factors, early trimester bleeding

1. ANTEPARTUM HEMORRHAGE
NIVETHA C

2. DEFINITION
 APH is defined as bleeding from or into the genital tract after the
28th week of pregnancy but before the birth of the baby ( the first
and second stage of labor are thus included )
 28th week is taken arbitrarily as the lower limit of fetal viability
 Incidence – 3 %

3. CAUSES

4. PLACENTA PREVIA
 When the placenta is implanted partially or completely over the
lower uterine segment ( over and adjacent to the internal os ) is
called placenta previa
 The term previa ( L, in front of) denotes the position of the
placenta in relation to the presenting part
 Incidence- 0.5 to 1%

5. HIGH RISK FACTORS
 Multiparity
 Maternal age - >35 years
 Race – Asian women
 Maternal factors – infertility treatment
 Presence of uterine segment – C section, myomectomy, hysterectomy
 Prior curettage
 Prior placenta previa
 Multiple pregnancy
 Placenta size& abnormality – succenturiate lobes, big placenta
 Smoking – causes placental hypertrophy to composite CO induced hypoxemia

6. ETIOLOGY
 Dropping down theory- The fertilized ovum drops down and is
implanted in the lower segment. Poor decidual reaction in the upper
segment may be the cause. Failure of zona pellucida to disappear in
time can be a hypothetical possibility. This explains the formation of
central placenta previa
 Persistence of chorionic activity – in decidua capsularis and it’s
subsequent development into capsular placenta which comes in contact
with decidua vera of the lower segment
 Defective decidua
 Big surface area of the placenta

7. Placenta
 The placenta may be large and thin. This is often tongue shaped extension from the main placental
mass. Extensive areas of degeneration with infarction and calcification may evident.
 The placenta may be morbidly adherent due to poor decidual formation in the lower segment.
Umbilical cord
 The cord may be attached to the margin or into the membranes. The insertion of the cord may be close
to the internal os or the fetus blood vessels may run across the internal os in velamentous insertion due
to poor placental formation
Lower uterine segment
 Due to increased vascularity, the lower uterine segment and the cervix becomes soft and more friable.

8. TYPES

9. DANGEROUS PLACENTA PREVIA
 Dangerous placenta previa is the name given to the type-II posterior placenta
previa
 Because of curved birth canal major thickness of the placenta overlies the
sacral promontory, thereby diminishing the antero-posterior diameter of the
inlet and prevents engagement of the presenting part. This hinders effective
compression of the separated placenta to stop bleeding
 Placenta is more likely to compressed if vaginal delivery is allowed
 More chance of cord compression or cord prolapsed
 This may lead to fetal anoxia or even death

10. CAUSE OF BLEEDING
 As the placenta growth slows down in later months and the lower
segment progressively dilates, the inelastic is sheared off the wall
of the lower segment  opening up of uteroplacental vessels 
bleeding ( inevitable)
 Separation of the placenta may be provoked by trauma including
vaginal examination, coital act, external version or during high
rupture of the membranes
 The blood is almost always maternal, although fetal blood may
escape from the torn villi

11. PLACENTAL MIGRATION
The term placental migration could be explained in two ways:
 With progressive increase in the length of lower uterine segment,
the lower placental edge relocates away from the cervical os .
 Due to trophotropism (growth of trophoblastic tissue towards the
fundus), there is resolution of placenta previa.

12. SYMPTOMS
 Vaginal bleeding – sudden onset, painless, apparently causeless
and recurrent

13. SIGNS
Abdominal examination
 Size of the uterus is proportionate to the period of gestation.
 The uterus feels relaxed, soft and elastic without any localized
areas of tenderness.
 Persistence of malpresentations
 The head is floating in contrast to the period of gestation.

14.  The FHS is usually present unless there is major separation of the placenta.
Slowing of the FHS on pressing the head down into the pelvis which soon
recovers promptly as the pressure is released is suggestive of the presence of
low lying placenta specially of posterior type it is known as Stallworthy’s sign.
Vulval inspection :
 Only inspection is to be done to check whether bleeding is still occurring or has
ceased
 In placenta previa the blood is bright red as the bleeding occurs from the
separated uteroplacental sinuses close to the cervical opening and escape out
immediately.
 Vaginal examination must not be done outside the operation theatre in the
hospital

15. DIAGNOSIS
History and clinical features
 Painless and recurrent vaginal bleeding in the second half of pregnancy
should be taken as placenta previa unless provoked otherwise.
Placentography
 Sonographyhy
1. Transabdominal --The accuracy after 30th week of gestation is about 98%
2. Transvaginal(TVS)--The probe is very close to the target area. It is more
accurate than TAS
3. Transperineal(TPS)--It is well accepted by patients. Internal os is visualized
in 97-100% of cases.

16. Color doppler flow study
 Prominent venous flow in the hypo-echoic areas near the cervix is consistent
with the diagnosis of placenta previa.
MRI
 It is a non invasive method without any risk of ionizing radiation.

17. CLINICAL CONFIRMATION
• Double set up examination (vaginal examination)
• it is less frequently done these days.
 Indications are
1. Inconclusive USG report
2. USG revealed type I placenta previa
3. USG facilities not available

18.  Visualization of the placental implantation on the lower segment
can be confirmed during caesarean section.
 Examination of the placenta following vaginal delivery reveals;
1. a tongue shaped, thin segment of placental tissue projecting
beyond the main placental mass with evidences of degeneration.
2. Rent on the membranes on the margin of the placenta.
3. Abnormal attachment of the cord.

19. DIFFERENTIAL DIAGNOSIS
 Abruptio placentae
 Local cervical lesions ( polyp, carcinoma )
 Circumvallate placenta

21. COMPLICATIONS
During pregnancy
 APH with varying degrees of shock
 Malpresentation is common
 Premature labour: either spontaneous or induced
During labour
 Early rupture of membranes
 Cord prolase
 Slow dilatation of the cervix
 Intrapartum haemorrhage
 Increased incidence of operative interference
 Post partum haemorrhage
 Retained placenta

22. During puerperium
 Sepsis is increased due to operative interference.
▫ Placental site near the vagina
▫Anemia and devitalized state of the patien
 Subinvolution
 Embolism
Fetal
 Low birth weight
 Asphyxia:Early separation of placenta,Compressionon of the placenta orCompression of the cord
 Intrauterine death
 Birth injuries
 Congenital malformation

23. MANAGEMENT
1. Prevention
 Adequate antenatal care.
 Antenatal diagnosis of low lying placenta.
 Significance of “ warning haemorrhage”.
 Family planning and limitation of births.
2 .Management at home
 The patient is immediately put to bed.
 Assess the blood loss.
 Quick but gentle abdominal examination.
 Vaginal examination must not be done.

24. 3.Hospital treatment
 Shift the patient to an equipped hospital
 An intravenous dextrose saline drip.
 Patient should be accompanied by 2/3 persons fit for donation of blood if necessary.
 All cases of APH should be regarded as due to placenta previa unless proved otherwise
 The bleeding may recur sooner or later

25. TREATMENT ON ADMISSION
Immediate attention
 Amount of blood loss.
 Blood samples are taken for grouping, cross matching and Hb.
 A large bore IV cannula is sited and an infusion of normal saline is started.
 Gentle abdominal palpation.
 Inspection of the vulva.
 Confirmation of diagnosis.
Formulation of line of treatment
Expectant management
Active management

26. EXPECTANT MANAGEMENT
Vital prerequisites
 Availability of blood for transfusion
 Facilities for caesarean section
Selection of cases
 Mother is in good health status.(Hb >10 gm%, haematocrit >30%)
 Duration of pregnancy is <37 weeks.
 Active vaginal bleeding is absent.
 Fetal well being is assured by USG.

27. CONDUCT OF EXPECTANT TREATMENT
 Bed rest.
 Investigations.
 Periodic inspection.
 Supplementary haematinics.
 When the patient is allowed out of bed a gentle peculum examination is made to exclude local cervical
and vaginal lesions for bleeding.
 Use of tocolytics and cervical encirclage are not helpful.

28. Expectant management is done in home
 Patient lives close to hospital
 24 hour transportation is available
 Bed rest assured
 Patient is well motivated to understand the risks

29. Termination of the expectant treatment
 The expectant management is carried upto 37 weeks of pregnancy. By this time baby become mature.
 Premature termination is done in conditions such as
Presence of brisk haemorrhage and which is continuing.
The fetus is dead.
The fetus is found congenitally malformed on investigation.
Steroid therapy
 It is indicated when duration of pregnancy is <34 weeks. Betamethasone reduces the risk of respiratory
distress of the new born when preterm delivery is considered.

30. DELIVERY
Active management (Delivery)
 Bleeding occurs at or after 37 weeks of pregnancy.
 Patient is in labour
 Patient in exsanguinated state on admission.
 Bleeding is continuing and of moderate degree.
 Baby with non reassuring cardiac status/ dead/congenitally deformed.

31. DEFINITIVE MANAGEMENT
 Vaginal examination in OT followed by
Lower rupture of membranes or
Caesarean section
 Caesarean section without internal examination
Contraindications of vaginal examination
 Patient in exsanguinated state
 Diagnosed cases of major degrees of placenta preavia confirmed by USG.
 Associated complications like malpresentations, elderly primigravida, pregnancy with h/o previous
caesarean section, contracted pelvis etc

32. Low rupture of membranes
 Low rupture of membrane is done using long Kocher’s forceps in lesser degrees of placenta previa (type
I & type II anterior).
Precautions during vaginal delivery
 steps to restore the blood volume.
 Methergine 0.2 mg.
 Proper examination of the cervix should be done soon following delivery.
 Baby’s blood Hb level is to be checked.