diagnosis and management

1. Antepartum
hemorrhage
DR RAMESAN CK
MBBS,MS OBG,MCH GYNECOLOGIC ONCOLOGY

2. DEFINE ANTEPARTUM HEMORRHAGE
Bleeding from the genital tract after the period of viability and prior to
delivery of the baby.

3. WHAT ARE THE CAUSES OF APH?
Placenta previa
Abruptio placenta
Local lesions-cervical polp,erosions,malignancy
Vasa previa
Rupture of marginal sinus
Trauma to genital tract
unclassified

4. HOW DO YOU CLASSIFY APH?
Minor:<50ml
Major:50-1000ml
Massive:>1000ml

5. WHAT IS PLACENTA PREVIA?
Placenta previa is defined as placenta that is implanted over or adjacent
to internal os
INCIDENCE:
3-5/1000 at term

6. HOW DO YOU CLASSIFY PLACENTA PREVIA?
CLASSIFICATION OF PLACENTA PREVIA
Type I:in the lower uterine segment
Type II:upto internal os
Type III:placenta covers the internal os when cervix not dilated but only partially when the cervix is
dilated
Type IV:placenta completely covers the internal os even when the cervix is fully dilated.
SONOLOGICAL CLASSIFICATION:
Low lying placenta:placenta in lower uterine segment within 2cm from internal os and not covering it
Placenta previa:placenta partially or completely covers the internal os.

7. WHAT ARE THE RISK FACTORS FOR PLACENTA PREVIA?
Previous c-section
Previous curettage/intrauterine surgery
Previous placenta previa
Maternal smoking/cocaine use
Multiple pregnancy
Multiparity
Increasing maternal age.

8. Initial evaluation
Patients' vital signs?
Fetal heart sounds ?
Nature and duration of bleeding
Are there pain or contractions
What is the location of placental implantation

9. Key points in the clinical history
of antepartum haemorrhage
•Timing of onset of bleeding in relation to
presentation
• An estimate of the amount of observed
blood loss
• Presence and characterization of pain
• Previous episodes of bleeding in pregnancy
• Changes in fetal movements
• Medication history and history of substance
misuse (especially
cocaine)
• Smoking
• Cervical smear history
• Symptom of maternal compromise

10. HOW DO YOU CLINICALLY DIFFERENTIATE PLACENTA PREVIA
&ABRUPTION?
FEATURES PLACENTA PREVIA ABRUPTIO PLACENTA
HISTORY Painless vaginal
bleeding,recurrent episodes
Associated abdominal pain
Single episode
GENERAL E/O Shock proportionate to blood
loss
In concealed cases, shock out of
proportion to blood loss
P/A Uterine size=POG
Soft
Malpresentations common
Fetal parts well felt
FHR-normal
Uterine size>POG
Tense,tender
Uncommon
Difficult to palpate
abnormal
RENAL FAILURE &DIC Not common common
PLACENTA ACCRETA common Not common

11. WHAT IS PLACENTAL MIGRATION?
Majority of placenta previa (90%) diagnosed in 2nd trimester resolves by
term.This is known as placental migration.
It is due to –
differential growth of upper & lower uterine segment.
-growth of the placenta in the lower uterine segment toward the more
vascular upper segment.

12. WHAT IS THE ROLE OF USG?
TVS-100% accuracy in diagnosing placenta previa.
Rules out Placenta accreta spectrum
Rules out abruption
Can assess fetalgrowth,presentation.

13. CAN ABRUPTIONAND PLACENTA PREVIA CO-EXIST?
Yes, in around 10% of cases.

14. WHAT IS THE IMPORTANCE OF BLOOD GROUP?
-Blood transfusion
-for anti D if Rh negative

15. WHY DOES A PATIENT WITH PLACENTA PREVIA BLEED?
Antenally:
with formation of lower uterine segment & at the onset of contractions,there
is detatchment of placental tissues resulting in bleeding episodes.
After delivery:
lower uterine segment donot contract & hence bleeding from placental bed.

16. Triaging
Expectant management or a decision to expedite delivery
This decision is usually based on the likely diagnosis, maternal and fetal
conditions, and the gestational age

17. HOW WILL YOU MANAGE PLACENTA PREVIAAT DIFFENT GESTATIONAL
AGES?
For all
-assess maternal bloodloss and resuscitate with blood and blood
products if needed
-Anti D if rh negative.
-Assessment of fetal status with uss and nst.
-Rule out placenta accreta spectrum

18. In 2nd trimester:-IF MILD BLEEDING WITH SPONTANEOUS
CESSATION AND REASSURING FETAL STATUS
-reassure
-report if further episodes.
-repeat USS at 28 wks and then at 4weeks interval.

19. EARLY THIRD TRIMESTER-IF MILD BLEEDING WITH SPONTANEOUS
CESSATION AND REASSURING FETAL STATUS
Admit the patient.
MAC CAFEE JOHNSON REGIME-conservative management.
Correct anemia if present.
Antenatal corticosteroids for fetal lung maturity.
Arrange blood
Assess fetal growth.
Terminate if recurrent episodes/non reassuring fetal status.

20. TERMINATE THE PREGNANCY
If non reassuring fetal status
Recurrent bleeding while on conservative management.
By 37 weeks.

21. MODE OF TERMINATION:
A double set up pervaginal examination can be done in cases if ceplalic
presentation, placenta is anterior &2cm from internal os-palpate in
posterior fornix to feel for bogginess of placental tissue & if no
bogginess/excessive bleeding normal vaginal delivery can be tried with
careful monitoring of FHR.
Others-LSCS
PAS-classical c-section

22. WHAT ARE THE COMPLICATIONS TO BE ANTICIPATED DURING DELIVERY?
Vaginal delivery:
FHR decelerations.
PPH
Stall worthy's sign: FHR decelerations in cases of posterior placenta
due to head compression

23. C-Section:
-Anterior placenta:
placenta might cut through & in that case baby should be delivered as
soon as possible.
find a plane beneath placenta(Ward technique)
-Malpresentations common: difficulty in delivery of baby.
-Bleeding from placental bed: hemostatic sutures to be put to arrest
bleeding.
-Non-separation of placenta: if placenta accrete spectrum not ruled out
antenatally.

24. WHAT ARE THE COMPLICATIONS?
FETAL:
complications of preterm.
fetal growth restriction.
fetal hypoxia.
IUD
MATERNAL:
hypovolemia & shock- transfusion, renal
failure & DIC.
PPH
increased operative deliveries.
Placenta accrete spectrum-obstetric
hysterectomy.
Increased maternal morbidity & mortality.

25. DEFINE ABRUPTIO PLACENTA & HOW DO YOU CLASSIFY IT?
Premature separation of a normally situated placenta after 24
weeks of gestation.
Acute & chronic
Concealed & revealed.

26. ROLE OF USS IN DIAGNOSINGABRUPTION
More useful in diagnosing placenta previa rather than abruption.
Early RP clot may be hyper/isoechoic and may be interpreted as thickened
placenta.
If a RP hematoma is identified ,it indicated a massive bleeding
Sensitivity is 25-50% only.
JELLO SIGN: intrauterine clots may be seen floating in amniotic fluid on
bouncing with transducer.

27. Classification
GRADES-SHER & STATLAND
-Grade 0:asymptomatic & incidental RP clots
-Grade 1:vaginal bleeding,abdominal pain,uterine tenderness with no fetal
distress.
-Grade 2: vaginal bleeding,abdominal pain,uterine tenderness with fetal distress.
-Grade 3:A-IUD with no maternal coagulopathy
B-IUD with maternal coagulopathy.

29. WHAT ARE THE RISK FACTORS FOR ABRUPTION?
Rapid decompression of uterus:
-polyhydramnios
-multiple pregnancy
-PPROM
Shearing of placental vessels:
-abdominal trauma
-ECV
Vasospasm and placental hypoperfusion:
-hypertension, pre-eclampsia
-thrombophilia's
-smoking/cocaine use
Inadequate decidualization:
-increased maternal age/multiparity
-uterine anomalies, fibroid uterus

30. complications

31. WHAT WILL BE THE MODE OF TERMINATION?
Whenever abruption is diagnosed, termination of pregnancy is needed.
Cesarean section is done most of the times.
Vaginal delivery can be attempted if
-live fetus with normal FHR pattern and no maternal coagulopathy
and delivery is imminent
-dead fetus with no maternal coagulopathy.

32. WHAT IS VASA PREVIA?
Presence of umbilical vessels running through the membranes across the
internal os below the presenting part.
since these vessels are not protected by whartons jelly,they are prone to rupture
and torrential bleed during labour.
Types:
-1-associated with velamentous cord insertion
-2-vessels running between placenta and its succenturiate lobe.

33. Shock classification

34. shock index
Pulse rate/systolic blood pressure
Shock index of greater than 1.2 is a pointer to the severity of the blood
loss.
The normal shock index range is 0.7–0.9 in pregnant women

38. THANK
YOU