Antepartum haemorrhage (APH) is bleeding from the genital tract between 28 weeks of pregnancy until birth. Placental causes account for 70% of APH cases, with placenta previa being the most common cause, occurring in 35% of placental APH cases. Placenta previa is when the placenta implants partially or completely in the lower uterine segment. It is diagnosed using ultrasound and managed either expectantly until 37 weeks if mild, or through caesarean section, especially for posterior placenta previa or heavy bleeding. Management depends on the amount of bleeding, maternal and fetal condition, and gestational age.

1. ANTEPARTUM HAEMORRHAGE
Dr Poonam
Professor.
Department of Obst.& Gynae

2. APH
• Its bleeding from genital tract after 28weeks
of pregnancy but before the birth of the baby.
• After the Period of viability. (24/ 22weeks)
• Includes 1st and 2nd stage.
• 3% among hospital deliveries.

3. Causes of APH
Placental cause (70%)
Extra placental cause (5%)
Unexplained ( 25%)

4. Causes of APH
Placental
causes
Placenta
previa (35%)
Accidental
Haemorrhage
(35%)

5. APH
Extra placental causes:
– Cervical polyp
– Carcinoma cervix
– Varicose vein
– Local trauma.
Unexplained

6. Placenta previa
When placenta is implanted partially or completely
over the lower uterine segment.
Incidence: 0.5-1%
Risk factor: elderly pt.( >35yrs)
Multiparous
Multiple pregnancies.
Privious CS or any other scar in uterus.
Placental abnormality –size or
accenturiate lobe

7. Placenta previa

8. Placenta previa

9. Placental anomaly

10. Vasa previa

11. Lower uterine segment
• Anatomical definition: part developed from
antomical and hystological internal os.
thinner than upper segment.
passive part. Stretching and thinning occur.
(upper segment becomes thicker and smaller due
to contraction and retraction.
• Radiological diagnosis. Part behind bladder .5cm
above int os.
• Surgical :Behind loose peritoneum.
• Clinical: P/V 7.5 cm above ex os

12. Lower uterine segment

13. Lower uterine segment

14. Lower uterine segment

15. Lower uterine segment

16. Placenta previa
Etiology :not known
Theories
Drop down theory- embryo grow in the lower
part of uterus.
Persistent chorionic activity; in decedua
capsularis.
Defective decedua : membranous placenta
Big surface area; multiple pregnancy

17. Type or degrees of placenta previa

18. Type or degrees of placenta prev
• Type 1 : low lying
• Type2: marginal
• Type3: incomplete central
• Type4: complete central.
Clinical classification
Mild : type 1 and Type 2 anterior.
Severe : type 2 posterior. 3 and 4

19. Placenta previa
• Type 2 posterior is also called dangerous
placenta previa
– Thickness of placenta 2.5 cm prevents
engagement of head. Facilitate more bleeding.
– Placenta will be compressed if allowed to deliver
vaginaly.
– More chance of cord prolapse or compression

20. Placenta previa
Causes of bleeding in placenta previa
• As lower segment progressively dilates, in -
elastic placenta is sheared off from the wall of
the lower segments-opening of uteroplacental
vessels.
• Mechanical injury to placenta – examination,
ECV, rupture of membrane, coital act .
• Blood loss is mostly maternal.

21. Placenta previa

22. Placenta previa –clinical feature
• Symptoms
• Vaginal bleeding
–Sudden onset, painless, causeless, recurrent.
–5% during onset of labour
–50% have warning haemorrhage.
–Before 38weeks
–earlier bleeding in major degree.
• But in central placenta there may not be any
bleeding till labour starts.
• Diagnosed by routine USG

23. Placenta previa –clinical feature
Signs:
anaemia proportional to amount of blood
loss. (may be more in pre existing anaemia pt)
Abdominal examination
size of uterus: proportional to period of
gestation
soft, relaxed
mal-presentation common.
head free,not engaged.
FSH: +/-ve . Stallworthy’s sign

24. Placenta previa –clinical feature
NO VAGINAL EXAMINATION SHOULD BE DONE
Inspection : bright red . Clothing/ body blood
soaked.

25. Placenta previa –clinical feature
DIAGNOSIS:
Sonography- Abdominal USG .
May be difficult in obese, posterior placenta.
Overfull bladder . Myometrial contraction
How to diagnose L.S ?
Below the level of uterovesical fold of
peritoneum.
5cm above internal os

26. Placenta previa –clinical feature
• TVS: superior resolution
• Color doppler flow study: prominant venous
flow near int. Os.
• MRI: non invasive, no radiation. (excellent but
costly)

27. USG findings

28. USG findings

30. USG-colour doppler

31. Placenta previa –clinical feature
If USG not available /doubtful finding
Examination in OT under GA --Double setup
• Boggy mass felt through fornices.
• placenta feels tough and firm contrast to
blood clot feels soft and friable.
Differential diagnosis: accidental Haemorrhage,
local causes

32. Placenta previa
Complications:
Haemorrage leading to shock
Malpresentation
Premature labour.
Increase operative delivery
PPH due to –imperfect retraction of LUS, large
surface area, atonic uterus for associated
anaemia, placenta accreta
Retained placenta.
Sepsis

33. Placenta previa
Fetal complication:
Low birth wt.
Prematurity.
Birth asphyxia.
IUD
Associated with congenital malformation

34. Placenta previa –Management
Antenatal;(diagnosed in routine checkup)
Adequate ANC
Rpt USG at 34weeks
Rule out accreta.
Council pt for warning sign., hospital
admission. Need for blood transfusion,Need
for LSCS etc.

35. Placenta previa
• Plcental migration
• Lower segments expands from 0.5cm to 5cm by term.
• Placenta relatively grows away from os.
• Previa in early pregnancy may not be so at term

36. Placenta previa –Management
If comes with bleeding
 Quick assessment
 Sent blood sample, arrange blood
 Two Large bore IV canula, infuse fluid.
 All examination should be gentle .
 Confirmation of diagnosis-USG
 Decide further management.

37. Management
Management depends on
 amount of bleeding,
 condition of the pt,
 fetal condition and
 period of gestation
Immediate resuscitation and termination
 beyond 37weeks
 IUD /with gross congenital anomaly
 shock/ continuous bleeding

38. Management
Expectant management: (Macafee Regimen)
To continue pregnancy to achieve fetal
maturity without compromising mothers
health.
Pre requisit:
Availability of blood.
Facility for CS

39. Expectant management:
Pt selection
Good health .Hb% >10gm%. HCT >30,
<37weeks,
assured fetal wellbeing

40. Expectant Management
• Bed rest,
• Blood investigation
• Close monitoring of bleeding, fetal survillence,
haematinics.
• once bleeding stopped for 3-4days , gental
vaginal inspection to rule out any local cause.
• Steroid injection for lung maturity if<34weeks
• Anti D injection, if Rh negetive.

41. Management-mode of delivery
LSCS:
 Type 2 posterior./ type3 and Type 4
placenta.
 Pt in ex-sanguinated state,
 other obstetric indication like
malpresentation
Vaginal delivery: Minor degree PP. (Placenta 2-
3cm away from os)

43. Management-mode of delivery
• Difficulty during CS
• Excessive bleeding due to incision over placenta.
• Open sinuses of lower segments bleeds as lower
segment can not contract like upper segment.

44. Points to remember
• Definition.
• Causes of APH.
• Lower uterine segment
• Types of placenta previa
• Diagnosis
• Management.

45. Thank you