This document discusses antepartum hemorrhage, specifically placenta previa and abruption placentae. It defines each condition, describes their causes, clinical features, complications, types or degrees in the case of placenta previa, management, and prevention. Placenta previa is defined as a low implantation of the placenta in the uterus causing it to lie alongside or in front of the presenting part, often causing painless bleeding in the third trimester. Abruptio placentae is the premature separation of a normally situated placenta, which can result in both revealed and concealed bleeding. Management of both aims to prevent bleeding through antenatal care, diagnosis and hospitalization for

1. Antepartum Hemorrhage
Mrs. P. Christena
M.Sc-OBG Nursing
RNRM
Assistant Professor

2. DEFINITION
It 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)

4. PLACENTA PRAEVIA

5. DEFINITION
• A low implantation of the placenta in the uterus causing it to lie alongside
or Infront of the presenting part
• ANNAMMA JACOB
• Placenta implanted to lower uterine segment ,often causing painless
profuse third trimester bleeding
• UN PANDA

6. CAUSES
• UNKNOWN
• 3 POSTULATED THEORIES,
1
• DROPPING DOWN THEORY
2
• MUTLIPLE PREGNANCY
3
• DEFECTIVE DECIDUA

7. PREDISPOSING FACTOR
• Increased placental size
• Previous caesarian section
• Multiparity
• Advanced maternal age
• Previous reproduction surgery
• Placental abnormality
• Leiomyomas distorting the
uterine cavity
• Congenital malformation of
uterus

8. PATHOLOGICAL ANATOMY
• Placenta—The placenta may be large and thin. There is often a tongue shaped
extension from the main placental mass. Extensive areas of degeneration with
infarction and calcification may be evident. The placenta may be morbidly adherent
due to poor decidua formation in the lower segment.
• Umbilical cord—The cord may be attached to the margin (battledore) or into the
membranes (velamentous). The insertion of the cord may be close to the internal os
or the fetal vessels may run across the internal os in velamentous insertion giving
rise to vasa previa, which may rupture along with rupture of the membranes.
• Lower uterine segment—Due to increased vascularity, the lower uterine segment
and the cervix becomes soft and more friable

9. TYPES OR DEGREES
There are four types of placenta previa depending upon the degree of
extension of placenta to the lower segment.
Type—I (Low-lying): The major part of the placenta is attached to the
upper segment and only the lower margin encroaches onto the lower
segment but not up to the os.
Type—II (Marginal): The placenta reaches the margin of the internal os
but does not cover it.
Type—III (Incomplete or partial central): The placenta covers the internal
os partially (covers the internal os when closed but does not entirely do so
when fully dilated).
Type—IV (Central or total): The placenta completely covers the internal
os even after it is fully dilated.

11. Dangerous
placenta previa is
the name given to
the type-II posterior
placenta previa

12. Reasons for calling out Dangerous
placenta previa
• (1) Because of the curved birth canal major thickness of the placenta (about 2.5 cm)
overlies the sacral promontory, thereby diminishing the anteroposterior diameter of
the inlet and prevents engagement of the presenting part. This hinders effective
compression of the separated placenta to stop bleeding.
• (2) Placenta is more likely to be compressed, if vaginal delivery is allowed.
• (3) More chance of cord compression or cord prolapse. The last two may produce
fetal anoxia or even death.

13. CLINICAL FEATURES
• The only symptom of placenta previa is vaginal bleeding
• sudden onset, painless, apparently causeless and recurrent
• The bleeding is unassociated with pain unless labor starts simultaneously
• In majority of cases, bleeding occurs before 38 weeks and earlier bleeding is more likely to
occur in major degrees.
• SIGNS: General condition and anemia are proportionate to the visible blood loss
• Abdominal examination: The size of the uterus is proportionate to the period of gestation.
• The uterus feels relaxed, soft and elastic without any localized area of tenderness.

14. • Persistence of malpresentation
• There is also increased frequency of twin pregnancy.
• Persistent displacement of the fetal head is very suggestive. The head cannot be pushed
down into the pelvis.
• Fetal heart sound is usually present
• (Stallworthy’s sign) Slowing of the fetal heart rate 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 especially of posterior type .But this sign is not always
significant because it may be due to fetal head compression even in an otherwise normal
case.

15. • Vulval inspection: Only inspection is to be done to note whether the
bleeding is still occurring or has ceased
• In placenta praevia, the blood is bright red as the bleeding occurs from
the separated utero-placental sinuses close to the cervical opening and
escapes out immediately.
• Vaginal examination must not be done outside the operation theater in
the hospital, as it can provoke further separation of placenta with
torrential hemorrhage and may be fatal

18. COMPLICATIONS OF PLACENTA
PREVIA
MATERNAL:
• During pregnancy—
• Antepartum hemorrhage with varying degrees of shock
• Co-existent placental abruption is about 10%.
Malpresentation: There is increased incidence of breech presentation
and transverse lie. The lie often becomes unstable.
Premature labor either spontaneous or induced is common.

19. During labor
• Early rupture of the membranes
• Cord prolapse due to abnormal attachment of the cord
• Slow dilatation of the cervix due to the attachment of placenta
on the lower segment
• Intrapartum hemorrhage due to further separation of placenta
with dilatation of the cervix.
• Increased incidence of operative interference.
• Postpartum hemorrhage
• Retained placenta

20. Puerperium:
(1) Sepsis is increased due to :
(a) increased operative interference
(b) placental site near to the vagina and
(c) anemia and devitalized state of the patient.
(2) Subinvolution
(3) Embolism.

21. FETAL COMPLICATIONS IN PLACENTA PREVIA
• Low birth weight babies are quite common (15%)
• Asphyxia is common and it may be the effect of
(a) early separation of placenta
(b) compression of the placenta or
(c) compression of the cord.
• Intrauterine death
• Birth injuries
• Congenital malformation is three times more common in placenta
previa.

22. MANAGEMENT
• PREVENTION:
• Adequate antenatal care
• Antenatal diagnosis
• Significance of “warning hemorrhage” should not be ignored.
• Color flow Doppler USG in placenta previa is indicated to detect any placenta
accrete
• AT HOME:
• The patient is immediately put to bed
• To assess the blood loss
• (a) inspection of the clothing soaked with blood
• (b) to note the pulse, blood pressure and degree of anemia
• Quick but gentle abdominal examination
• Vaginal examination must not be done

23. • TRANSFER TO HOSPITAL:
• Arrangement is made to shift the patient to an equipped hospital having facilities of
blood transfusion, emergency cesarean section and neonatal intensive care unit
(NICU)
• ADMISSION TO HOSPITAL:
• All cases of APH, even if the bleeding is slight or absent by the time the patient
reaches the hospital, should be admitted.
• The reasons are:
(1) All the cases of APH should be regarded as due to placenta previa unless proved
otherwise
(2) The bleeding may recur sooner or later and none can predict when it recurs and
how much she will bleed.

25. ABRUPTIO
PLACENTAE
(Syn : Accidental
Hemorrhage.
Premature
Separation Of
Placenta)

26. DEFINITION:
It is one form of antepartum hemorrhage where the
bleeding occurs due to premature separation of normally
situated placenta. Out of the various nomenclatures,
abruptio placentae seems to be appropriate one.

27. VARIETIES
• (1) Revealed : Following separation of the placenta, the blood insinuates
downwards between the membranes and the decidua. Ultimately, the
blood comes out of the cervical canal to be visible externally. This is the
commonest type.
• (2) Concealed : The blood collects behind the separated placenta or
collected in between the membranes and decidua. The collected blood is
prevented from coming out of the cervix by the presenting part which
presses on the lower segment. At times, the blood may percolate into the
amniotic sac after rupturing the membranes. In any of the circumstances
blood is not visible outside. This type is rare.
• (3) Mixed : In this type, some part of the blood collects inside (concealed)
and a part is expelled out (revealed). Usually one variety predominates
over the other. This is quite common

29. ETIOLOGY:
• The exact cause of separation of a normally situated placenta
remains obscure in majority of cases.
• The prevalence is more with
(a) high birth order pregnancies with gravida 5 and above —
three times more common than in first birth
(b) advancing age of the mother
(c) poor socio-economic condition
(d) malnutrition
(e) smoking (vaso-spasm).

30. • Hypertension in pregnancy
• Trauma
• Sudden uterine decompression:
• Placental anomaly
• Uterine factor: Placenta implanted over a septum (Septate Uterus) or a
submucous fibroid. Torsion of the uterus leads to increased venous
pressure and rupture of the veins with separation of the placenta.
• Cocaine abuse is associated with increased risk of transient
hypertension, vasospasm and placental abruption.
• Thrombophilias inherited or acquired have been associated with
increased risk of placental infarcts or abruption.
• Prior abruption: Risk of recurrence for a woman with previous abruption
varies between 5 to 17%.

34. COMPLICATIONS OF ABRUPTIO
PLACENTAE• MATERNAL:
• In revealed type—maternal risk is proportionate to the visible
blood loss and maternal death is rare
• In concealed variety–
• Hemorrhage
• Shock
• Blood coagulation disorders
• Oliguria and anuria
• Postpartum hemorrhage
• Puerperal sepsis
• increased maternal death varies from 2–8%.
• There is failure of lactation (Sheehan’s syndrome) later on.

35. FETAL:
• In revealed type, the fetal death is to the extent of 25-30%.
• In concealed type, however, the fetal death is appreciably high,
ranging from 50-100%.
• The deaths are due to prematurity and anoxia due to
placental separation.
• With same degree of placental separation, the fetus is put to
more risk in abruptio placentae than in placenta previa.
• This is due to the presence of pre-existing placental
pathology with poor functional reserve in the former, in
contrast to an almost normal placental functions in the latter.

36. MANAGEMENT OF ABRUPTIO
PLACENTAE
• Prevention:
• The prevention aims at—
(1) elimination of the known factors likely to produce placental
separation
(2) correction of anemia during antenatal period so that the
patient can withstand blood loss and
(3) prompt detection and institution of the therapy to minimise
the grave complications namely shock, blood coagulation
disorders and renal failure.

37. • Prevention of known factors likely to cause placental separation are
• • Early detection and effective therapy of pre-eclampsia and other hypertensive
disorders of pregnancy.
• • Needle puncture during amniocentesis should be under ultrasound guidance.
• • Avoidance of trauma—specially forceful external cephalic version under
anesthesia.
• • To avoid sudden decompression of the uterus— in acute or chronic
hydramnios, amniocentesis is preferable to artificial rupture of the
membranes.
• • To avoid supine hypotension the patient is advised tolie in the left lateral
position in the later months of pregnancy.
• • Routine administration of folic acid from the early pregnancy — of doubtful
value.

39. ?????? DOUBTS
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