The document discusses two conditions that can cause bleeding in late pregnancy - abruptio placenta and placenta previa. Abruptio placenta involves the separation of the placenta from the uterus prior to delivery and common risk factors include hypertension and trauma. Placenta previa occurs when the placenta implants in the lower uterine segment over the cervical os. Management of both conditions involves monitoring for maternal and fetal stability and either emergency c-section or planned c-section depending on gestational age and severity of bleeding. Complications can include disseminated intravascular coagulation for abruptio placenta or placenta accreta if placenta previa occurs over a previous c-section

1. APH
By: Huzaifa Hamid

2. Definition
 is defined as vaginal bleeding from 24 weeks to
delivery of the baby.
 Or any bleeding occurring in the antenatal
period after 20 weeks gestation.
 It complicates 2–5% of pregnancies.
 It is associated with increased risks of fetal and
maternal morbidity and mortality

3. Causes
• Erosion
• Polyps
• Cancer
• Varicosities
• Lacerations
• Abraptio p.
• Placenta p.
• Vasa previa

4. Initial steps in management of late
pregnancy bleeding:
initial management:
 patient’s vitals
 FHM
 IV fluids
Order lab tests:
 CBC
 DIC workup (platelets, PT,
PTT, fibrinogen, and D-
dimer)
 Type and cross-match
 Ultrasound “The most
accurate”
further steps in management:
 Give blood transfusion for
large volume loss.
 Place Foley catheter and
measure urine output.
 Perform vaginal exam to rule
out lacerations.
 Schedule delivery if fetus is
in jeopardy or gestational
age is ≥ 36 weeks.
Never perform a digital or speculum examination in a patient with late
vaginal bleeding until a vaginal ultrasound first rules out placenta previa.
Apt, Kleihauer-Betke, and Wright’s stain tests
determine if blood is fetal, maternal, or both.

5. ABRUPTIO
PLACENTA

6. Introduction
 Definition:
It is the separation of the placenta from its site
of implantation before delivery of the fetus.
 Varieties:
- Total or partial
- Revealed or Concealed
 Incidence:
1 in 200 deliveries

7. Placental Abruption

8. Pathophysiology
Initiated by bleeding into the decidua basalis, the
bleeding splits the decidua, and a decidual
hematoma forms. The hematoma leads to
separation, compression, and destruction of the
placenta adjacent to it.
a. The process may be self-limited, with no further
complication to the pregnancy or may continue to
become catastrophic.
b. Bleeding insinuates between the fetal
membranes and uterus which may extravasate or
may remain concealed. Concealed abruptions can
often be more compromising to maternal
hemodynamic status since they are generally
underappreciated.

9. Risk Factors
 Increased age & parity.
 Hypertension.
 Preterm ruptured
membranes.
 Multiple gestation.
 Polyhydramnios.
 Smoking.
 Cocaine use.
 Prior abruption.
 Uterine fibroid.
 Trauma

10. Clinical presentation
 Vaginal bleeding.
 Constant and severe abdominal pain.
 Irritable, tender, and typically hypertonic
uterus.
 Evidence of fetal distress (if severe).
 Maternal shock.
 Disseminated intravascular coagulation.Up to 20% of placental abruptions can present
without vaginal bleeding because bleeding is
concealed.

11. U|S for Abruptio placenta

12. Abratio Placenta
Diagnosis:
Clinically:
 Late trimester painful bleeding
 Normal placental implantation
 Disseminated intravascular coagulopathy
(DIC)
Ultrasonography:

13. Management
Emergency
CS
Vaginal
Delivery
Conservative

14. Management
 Emergency cesarean delivery: if maternal or fetal jeopardy is
present as soon as the mother is stabilized.
 Vaginal delivery: if bleeding is heavy but controlled or
pregnancy is >36 weeks. Perform amniotomy and induce
labor. Place external monitors to assess fetal heart rate
pattern and contractions. Avoid cesarean delivery if the fetus
is dead.
 Conservative in-hospital observation: if mother and fetus are
stable and remote from term, bleeding is minimal or
decreasing, and contractions are subsiding. Confirm normal
placental implantation with sonogram and replace blood loss
with crystalloid and blood products as needed.

15. Complications
Maternal :
 Hypovolemia.
 DIC.
 Renal failure.
 Death.
 Uterine rupture
Fetal :
 Hypoxia.
 IUGR.
 IUFD.
 Anemia

16. PLACENTA
PREVIA

17. Introduction
Definition:
the placenta is implanted in the lower uterine segment.
Classification:
 Complete placenta previa: The placenta covers the
entire internal cervical os.
 Partial placenta previa: The placenta partially covers
the internal cervical os.
 Marginal placenta previa: One edge of the placenta
extends to the edge of the internal cervical os.
 Low-lying placenta: Within 2 cm of the internal
cervical os.
Incidence:
Complicates approximately 1 in 300 pregnancies.

18. Placenta Previa
Ultrasound performed in the second trimester may show a placenta previa in
5% to 15% of cases. However, as the lower uterine segment develops, over
90% of these previas will resolve. A repeat ultrasound should be performed at
28 weeks to confi rm the presence of a placenta previa.

19. Placental migration
 At 16 weeks 20%
 At 40 weeks 0.5%
 Why the difference?
 TrophoTropism
Placental migration

20. Mechanism of migration

21. Pathophysiology of bleeding
Avulsion of villi, stretching of
lower uterine segment

22. Risk Factors
 Multiparty
 Increased maternal
age
 Previous placenta
previa
 Multiple gestation
 Previous C/S
 Uterine anomalies
 Maternal smoking
ART!!!

23. Presentation & Diagnosis
 Late trimester bleeding
 Lower segment placental implantation
 No pain
 MRI or Double set-up
Transabdominal US
(95% accurate)

24. U|S Placenta Previa

25. Management
Emergency cesarean delivery
Conservative in-hospital observation
Vaginal delivery
Scheduled cesarean delivery

26. Management
 Emergency cesarean delivery: if maternal or fetal jeopardy
is present after stabilization of the mother.
 Conservative in-hospital observation: Conservative
management of bed rest is performed in preterm gestations if
mother and fetus are stable and remote from term. The initial
bleed is rarely severe. Confirm abnormal placental
implantation with sonogram and replace blood loss with
crystalloid and blood products as needed.
 Vaginal delivery: This may be attempted if the lower
placental edge is >2 cm from the internal cervical os.
 Scheduled cesarean delivery: if the mother has been
stable after fetal lung maturity has been confirmed by
amniocentesis, usually at 36 weeks’ gestation.

27. Complications of Placenta
praevia
 Preterm delivery.
 PPROM.
 IUGR
 Malpresentation
 Fetal abnormalities
 ↑ number of C/S.
 morbidly adherent placenta
 Postpartum haemorrhage

28. morbidly adherent placenta
Placenta accreta: The placenta is abnormally attached directly to the
myometrium.
Placenta increta: The placenta invades the myometrium.
If placenta previa occurs over a previous uterine scar the villi
may invade beyond Nitabuch layer resulting in PLACETNA
ACRETA

29. Summary
Abruptio Placenta Placenta Previa
Pain Yes No
Risk factors Previous
abruption
Hypertension
Trauma
Cocaine abuse
Previous previa
Multiparity
Structural
abnormalities
(e.g., fibroids)
Advanced maternal
age
Diagnosis:
Sonogram
Placenta in
normal
position ±
retroplacental
hematoma
Placenta implanted
over the lower
uterine segment

30. Summary
Abruptio Placenta Placenta Previa
Management 1. Emergent c-section: Best choice for placenta previa
or if patient/fetus is deteriorating.
2. Vaginal delivery if ≥ 36 weeks or continued bleeding.
May be attempted in placenta previa if placenta is > 2
cm
from internal os.
3. Admit and observe if bleeding has stopped, vitals and
fetal heart rate (FHR) stable, or < 34 weeks.
Complication Disseminated
intravascular
coagulation
Placenta accreta/
increta/percreta
→ hysterectomy

31. Any question?