Antepartum hemorrhage

1. ANTEPARTUM
HEMORRHAGE

2. DEFINITION
It is defined as bleeding from or
into the genital tract after the
period of viability but before the
birth of the baby.
2

3. 3
In India period of viability is
taken as 28 weeks and in
western countries it is taken as
24 weeks.

4. CAUSES
4
Placenta Previa (35%) Abruptio placenta (35%)

5. PLACENTA PREVIA
5

6. “
DEFINITION
When the placenta is implanted partially or
completely over the lower uterine segment it
is called placenta praevia.

7. Incidence
7
About one-third cases of antepartum haemorrhage belong to placenta praevia, the
incidence of placenta praevia range from 0.5% - 1% amongst hospital deliveries.
In 80% cases, it is found to multiparous women.
The incidence is increased beyond age of 35, with high birth order pregnancies
and in multiple pregnancy.

8. ETIOLOGY
8
The exact cause of implantation of the placenta in the lower
segment is not known. The following theories are posulated:
 Dropping down theory
 Persistence of chorionic activity
 Defective decidua
 Big surface area of the placenta

9. “
a) Multiparity
b) Increased maternal age (>35 years)
c) History of previous caesarean section or any other
scar in the uterus (myomectomy or hysterotomy)
d) Placental size and abnormality (succenturiate lobe)
e) Smoking
The predisposing factors for placenta
praevia are-

10. TYPES OR DEGREES
10

11. DANGEROUS PLACENTA PREVIA
11
This name is given to the type- II posterior 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.
2) Placenta is more likely to compressed if vaginal delivery is allowed.
3) More chances of cord compression or cord prolapse.

12. Clinical features
12
SYMPTOMS
Vaginal bleeding
Classical features of bleeding in
placenta previa are sudden onset,
painless, apparently recurrent and
causeless (without trauma, coitus, etc.)

13. 13
The bleeding is unrelated to activity and often occurs during sleep and the patient becomes
frightened on awakening to find herself in a pool of blood.
Bleeding without onset of labor is characteristics of placenta previa (4P’s: Painless and
profuse bleeding in placenta previa)

14. 14
SIGNS
General examination
 Pallor is proportionate to visible blood
loss.
 The patient may not be in shock depending
on the amount of bleeding.

15. 15
Abdominal examination
 Abdomen is soft
 Size of uterus is proportionate to the period of gestation.
 Uterus is relaxed, soft, elastic and non-tender corresponding to the period of
amenorrhoea.
 Malpresentation like breech, transverse or unstable lie are more common in
placenta previa (35% cases).

16. 16
 Fetal parts are easily felt and fetal heart is
usually normal.
 Presentating part is floating. A deeply engaged
presenting part usually rules out placenta previa
or points to only minor placenta previa.
 Fetal heart sound and placental souffle are
well auscultated.
 Stallworthy’s sign

17. 17
Vulval inspection
Inspection is done to note whether the bleeding is still occurring and the amount and
character of blood loss. It is usually fresh (bright red) as the blood quickly trickles
down through the cervix from the nearby placenta.

18. DIAGNOSIS
18
 Ultrasound
 Transabdominal ultrasound(TAS)
 Transvaginal ultrasound (TVS)
 Transperineal or translabial ultrasound
Vaginal examination is contraindicated

19. complications
19
MATERNAL

20. 20
 Vaginal bleeding
 Malpresentations
 Preterm labor both spontaneous
or iatrogenic is more common.
 Long hospital stay
 Anaemia
During Antenatal Period

21. 21
 Rhesus sensitization in Rh-negative woman.
 Haemorrhagic shock with hypotension
 Adult respiratory distress syndrome
 Disseminated intravascular coagulation
(rare)
 Acute renal failure (rare)

22. 22
 Premature rupture of membranes
 Cord prolapse
 Intrapartum hemorrhage
 Slow dilatation of cervix
 More operative interference
During Labor

23. 23
 Postpartum hemorrhage.
 Retained placenta
 Abruption of placenta can co-exist with placenta previa.
 Hysterectomy
 Air embolism

24. 24
Secondary postpartum hemorrhage
Puerperal sepsis
Non-involution and subinvolution of uterus
Venous thromboembolism
During Puerperium

25. complications
25
FETAL

26. 26
Perinatal mortality ranges from 7-25% and is three times higher than
the general population.
The causes of death are:
(a) Prematurity
(b) Asphyxia due to separation of placenta
(c) Congenital malformations
(d)Cord accidents
(e) Maternal hypovolemia and shock

27. 27
 Prematurity
 Low birth weight babies
 Fetal hypoxia
 Fetal injuries
 Congenital malformations
 Fetal malpresentations
 Fetal hypovolemia

28. 28
1. Universal institutional antenatal care of all women to improve their
general health and to correct anaemia.
2. Family planning and limitation of births reduce the incidence of
placenta previa.

29. 29
3. Reducing the rising rate of cesarean deliveries as previous cesarean
delivery predisposes to placenta previa.
4. Universal targeted scan of all pregnant women at 18 weeks can
diagnose low lying placenta which can later become placenta previa.

30. 30
MANAGEMENT

31. management
31
At Home and Transfer to Hospital
Treatment at Hospital

32. 32
At Home and Transfer to Hospital
After quick history, general physical examination and gentle abdomen
examination (but no vaginal examination), once antepartum hemorrhage is
visible; patient is shifted in an ambulance to a suitable hospital where there
are adequate facilities for blood transfusion, 24 hour cesarean delivery and
nursery care. A health care personnel should be with the patient.

33. 33
An intravenous drip is started with Ringer lactate or dextrose saline
solution and is continued in the ambulance. Preferably relatives fit to
donate blood should also go with the patient. The woman should be lying
down during transfer.

34. 34
Treatment at Hospital
1. A quick note is made about the general condition of the patient and the
amount of blood loss (By inspecting the soiling of her clothes and bed sheets
and the blood stains on her thighs and legs. )
2. A detailed history is taken from her or reliable attendant about the events
before bleeding, any associated pain, backache, any previous bleeding,
feeling of fetal movements and date of last menstruation period.

35. 35
3. A brief clinical examination is performed about general physical
condition by noting pulse, blood pressure, respiration, anaemia and heart
and chest auscultation.
4. A light and gentle abdominal palpation is done for uterine tone,
tenderness, contractions, fetal presentation, and fetal heart is auscultated.
5. Blood sample is taken for hemogram, group and cross-matching and 2-4
units of blood depending upon blood loss are arranged.

36. 36
6. Intravenous access is secured using two wide bore cannula and a
crystalloid (saline or dextrose saline) or colloid (hemaccel) is started.
7. The senior member of team (consultant) should be informed about
such a patient.
8. If available, a bedside ultrasound of abdomen is performed to
localise placenta, fetal presentation and fetal heart.

37. 37
9. Some sedation and reassurance are given to calm her.
10. Further management depends on the gestational period, maternal
and fetal conditions and whether bleeding has stopped or not.
11. Vaginal examination is absolutely contraindicated.

38. 38
ExpectantManagement
The aim is to continue pregnancy in gestation less
than 37 weeks for fetal maturity without
compromising maternal health in a centre with
round-the-clock facilities for blood transfusion and
cesarean delivery by providing bed rest, iron and
calcium supplementation.
Expectant management is terminated if patient
goes into labor, persistent bleeding and at 37
completed weeks of gestation.

39. 39
Cesarean Delivery
Cesarean delivery without vaginal examination is treatment of choice
for major degree placenta previa.
It enables not only to reduce maternal risk but also to improve fetal
outcome.

40. 40
The indications of cesarean delivery
1. Major degree of placenta previa (Type 2 posterior, Type 3 and
Type 4) irrespective of fetal condition for maternal sake.
2. Minor degree of placenta previa with excessive bleeding
inspite of amniotomy with fetal distress.
3. Presence of other complicating factors with minor degrees of
placenta previa where vaginal delivery is unsafe.

41. PROGNOSIS
41
Use of expectant management, more liberal use
of blood and blood products, avoiding vaginal
examination and liberal use of cesarean section
(delivery) has significantly improved maternal
and perinatal outcome in placenta previa.

42. ABRUPTIO
PLACENTA
42

43. “
DEFINITION
Abruptio placenta is antepartum
hemorrhage from premature separation of
normally situated placenta in the upper
uterine segment.

44. TYPES
44
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.

45. TYPES
45
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.

46. TYPES
46
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.

47. Incidence
47
The overall incidence is about 1 in 200 deliveries. Depending on the extent
(partial or complete) and intensity of placental separation, it is a significant
cause of perinatal mortality (15–20%) and maternal mortality (2–5%). More
and more cases of placental abruption are being diagnosed in the recent years.

48. ETIOLOGY
48
 Hypertension in pregnancy is the most important
predisposing factor. Pre-eclampsia, gestational
hypertension and essential Hypertension, all are associated
with placental abruption.
The association of pre-eclampsia in abruptio placenta varies
from 10-50 percent.
Spasm of the vessels in the utero placental bed (decidual
spiral artery) → anoxic endothelial damage → rupture of
vessels or extravasation of blood in the decidua basalis
(retroplacental hematoma).

49. 49
 Trauma: Traumatic separation of the
placenta usually leads to its marginal
separation with escape of blood outside. The
trauma may be due to:
 Attempted external cephalic version specially
under anesthesia using great force
 Road traffic accidents or blow on the
abdomen
 Needle puncture at amniocentesis.

50. 50

Sudden uterine decompression: Sudden
decompression of the uterus leads to
diminished surface area of the uterus
adjacent to the placental attachment and
results in separation of the placenta. This
may occur following—
(a) delivery of the first baby of twins
(b) Sudden escape of liquor amnii in hydramnios
and
(c) Premature rupture of membranes.

51. 51
 Sick placenta: Poor placentation, evidenced
by abnormal uterine artery
 Folic acid deficiency even without evidence
of overt megaloblastic erythropoiesis
 Uterine factor: Placenta implanted over a
septum (Septate Uterus) or a submucous
fibroid.

52. 52
 Supine hypotension syndrome: In this condition which occurs in
pregnancy there is passive engorgement of the uterine and placental
vessels resulting in rupture and extravasation of the blood.
 Short cord, either relative or absolute, can bring about placental
separation during labor by mechanical pull.
 Placental anomaly: Circumvallate placenta.

53. 53
 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

54. 54
pathophysiology

55. 55
Depending upon the etiological factors
Premature placental separation is initiated by hemorrhage into the decidua basalis.
The collected blood (decidual hematoma) at the early phase hardly produces any
morbid pathological changes in the uterine wall or on the placenta.
Depending upon the extent of pathology, there may be degeneration and necrosis of
the decidua basalis as well as the placenta adjacent to it.
Rupture of the basal plate may also occur, thus communicating the hematoma with
the intervillous space.
The decidual hematoma may be small and self limited; the entity is evident only after
the expulsion of the placenta (retroplacental hematoma).

56. 56
Clinical features
of abruptio
placenta

57. 57
eclampsia

58. 58

59. COUVELAIRE UTERUS
▸ It is a pathological entity in
which there is extensive
intravasation of blood into
uterine muscles in association
with severe concealed abruptio
placenta.
59

60. CLINICAL CLASSIFICATIONS
60

61. 61
DIAGNOSIS

62. 62
 Complete hemogram including Hb estimation, platelet count, leucocyte
count and peripheral blood smear
 Serum fibrinogen level. Prothrombin time (PT), partial thromboplastin
time (PTT), Fibrin degradation products (FDP) levels, platelet count,
bleeding and clotting time, D-dimer (fibrinolytic activity) levels.
General

63. 63
General
 Serum electrocyte, blood urea and liver function
tests.
 Arterial blood gas analysis
 Blood group and crossmatching
 The Kleihauer-batke test, if available

64. 64
ULTRASOUND
1. To rule out abruptio placenta
2. To reveal the state of the fetus
3. Retroplacental clots at previous placental site is
helpful.
4. Jello sign- Placenta may jiggle when sudden
pressure is applied by transducer.

65. complications
65
MATERNAL
In revealed type—maternal risk is
proportionate to the visible blood loss and
maternal death is rare.
In concealed variety—The following
complications may occur either singly or in
combination.

66. 66
 Hemorrhage
 Shock
 Release of thromboplastin into the maternal
circulation results in DIC or there may be amniotic
fluid embolism
 Blood coagulation disorders
 Puerperal sepsis
 Postpartum hemorrhage due to –
a) atony of the uterus
b) increase in serum FDP

67. 67
 Oliguria and anuria due to—
(a) hypovolemia
(b) serotonin liberated from the damaged uterine muscle producing renal
ischemia and
(c) Acute tubular necrosis. a may lead to
(d) cortical necrosis and renal failure (in severe cases)

68. complications
68
FETAL

69. 69
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.

70. preventions
70
The prevention aims at—
(1) elimination of the known factors likely to produce placental separation
(2) correction of anemia during antenatal period
(3) Prompt detection and institution of the therapy to minimize the grave
complications namely shock, blood coagulation disorders and renal failure.

71. 71
 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—especially forceful external cephalic version
under anesthesia.

72. 72
 Avoid sudden decompression of the uterus— in acute or chronic
hydramnios, amniocentesis is preferable to artificial rupture of the
membranes.
 Avoid supine hypotension
 Routine administration of folic acid from the early pregnancy — of
doubtful value.

73. 73
MANAGEMENT

74. 74
The patient is to be treated as outlined in abruptio placenta and
arrangement should be made to shift the patient to an equipped maternity
unit as early as possible.
AT HOME

75. 75
AT HOSPITAL
Assessment of the case is to be done as regards:
(a) amount of blood loss
(b) maturity of the fetus and
(c) whether the patient is in labor or not (usually labor starts)
(d) presence of any complication and
(e) Type and grade of placental abruption.

76. 76
EMERGENCY MEASURES

Blood is sent for hemoglobin and hematocrit estimation, coagulation
profile (fibrinogen level, FDP, prothrombin time, activated partial
thromboplastin time and platelets), ABO and Rh grouping and urine for
detection of protein

77. 77
 Ringer’s solution drip is started with a
wide bore cannula
 Arrangement for blood transfusion
 Resuscitation articles available.
 Close monitoring of maternal and fetal
condition is done.

78. 78
MANAGEMENT OPTIONS
Immediate delivery
Management of
complications if there is any
Expectant management
(rare)

79. 79
Immediate delivery
Vaginal delivery is favored in cases with:
 Limited placental abruption
 FHR tracing is reassuring
 Facilities for continuous (electronic) fetal monitoring is available
 Prospect of vaginal delivery is soon or
 Placental abruption with a dead fetus

80. 80
DISTINGUISHING
FEATURES OF
PLACENTA PREVIA
AND ABRUPTIO
PLACENTA

81. 81

82. 82
The exact cause of vaginal bleeding in late pregnancy is
not clearly understood in few cases. The diagnosis of
unclassified bleeding should be made after exclusion of
placenta previa, placental abruption and local causes.
INDETERMINATE BLEEDING
Rupture of vasa previa, marginal sinus
hemorrhage, circumvallate placenta, marked
decidual reaction on endocervix or excessive
show may be a possible cause of such
bleeding.

83. 83
EXTRA PLACENTAL
CONDITION

84. IMPLANTATION BLEED
▸ A small vaginal bleed can occur when the blastocyst embed in the
endometrium. This usually occurs 5-7 days after fertilization and if the
timing coincides with the expected menstruation this may cause confusion
over the dating of the pregnancy if the menstrual is used to estimate the
date of birth.
84

85. CERVICALPOLYPS
▸ These are small, vascular, pedunculated growths on the cervix, which
consist of squamous or columnar epithelial cells over a core of
connective tissue rich with blood vessels. During pregnancy, the
polyps may be a cause of bleeding but require no treatment unless
the bleeding is severe or a smear test indicates malignancy.
85

86. CARCINOMA OF CERVIX
▸ Carcinoma of the cervix is the most common gynaecological
malignant disease occurring in pregnancy with an estimated
incidence of 1 in 2200 pregnancies. The condition presents with
vaginal bleeding and increased vaginal discharge. On speculum
examination the appearance of the cervix may lead to a suspicious of
carcinoma, which is diagnosed following colposcopy or a cervical
biopsy.
86

87. CERVICAL ECTROPION
▸ Cervical ectropion is a condition in which the cells from the inside of
the cervical canal, known as glandular cells (or columnar
epithelium) are present on the outside of the vaginal portion of the
cervix.
▸ More commonly known as cervical erosion
87

88. 88
NURSING
MANAGEMENT OF
ANTEPARTUM
HEMORRHAGE

89. ASSESSMENT
▸Scant or profuse vaginal bleeding.
▸Uterine irritability, tenderness and rigidity.
▸Abdominal pain that is intermittent or continuous.
▸Signs of maternal shock- hypotension, rapid pulse, dyspnea
▸Violent fetal activity followed by inactivity
▸FHR- slow to absent
▸Late deceleration noted in monitor strip
▸May have blood stained amniotic fluid (port wine stain)
89

90. NURSING DIAGNOSIS
Risk for fetal injury
Risk for infection
Ineffective airway clearance
Actual/ risk for aspiration
Anxiety
90
 Anticipatory grieving
 Altered family process
 Actual/ risk for altered parenting
 Health seeking behavior

91. PLANNING
▸Promote safe care environment
▸Monitor for presence of pre-existing conditions.
▸Assess maternal – fetal status and initiative
emergency care
▸Provide encouragement and support.
▸Administer measures to treat shock and blood loss
91

92. IMPLEMENTATION
▸Monitor maternal and fetal vital signs.
▸Treat shock symptoms
▸Assess vital signs every 5-15 mins
▸Administer oxygen by face mask at 7-10 L/min
▸Increase IV flow rate
▸Administer blood
▸Monitor urinary output
92

93. IMPLEMENTATION
▸Monitor FHR continuously
▸Observe for signs and symptoms of coagulation
problems
▸Measure abdominal girth
▸Remain with woman
▸Monitor labor pattern continuously if allowed to
progress or prepare for cesarean section
.
93

94. EVALUATION
▸The woman and her spouse understand the treatment plan
▸The physiological status of the women and the fetus
remains within the normal limits.
▸The women and her spouse verbalize, decrease of anxiety
and feelings of support.
▸The women remain normotensive
▸The hemoglobin and Hematocrit levels are within normal
limits.
94

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