Antepartum Haemorrhage

ANTEPARTUM BLEEDING e.
c
PLACENTA PREVIA
Rosydaniah Zaskia 'Avif
B23. RSUD Jombang
Identitas
Ny.Nurul Komariah
28 th, IRT
pendidikan terakhir SLTA
alamat: Jombang Jogoroto
ANTEPARTUM HAEMORRHAGE
Obstetric Haemorrhage
Ranks as the First cause of maternal

mortality accounting for 25 50 % of
maternal deaths
APH: Epediology & Causes
Magnitude: 4% of women may develop APH.
Causes:
placenta previa (1/200)
placental abruption (1/100)
uterine rupture (<1% in scarred uterus)
vasa previa (1/2000-3000)
Local causes
Unknown origin
Vasa Previa
Velamentous Insertion of the umbilical

cord
I. ABRUPTIO PLACENTA
Definition:
Early separation of the normally implanted

placenta after 28/40 and before the end of
second stage of labour
Recurrence:
The risk of recurrent abruption in a

subsequent pregnancy is high.
Abruptio placenta: Classifications

Are based on
1.
Extent of separation: Partial vs complete
2.
Location of separation: Marginal Vs central
3.
Clinical presentation: Revealed, concealed and

mixed
4.
Clinical Severity: Mild, Moderate and Severe
Clinical Severity
Class 2: moderate -approx
27% of all cases.
Class 1 Mildest form:

approx 48% of all cases.
No vaginal bleeding to
mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and
heart rate
No coagulopathy
(clotting problems)
No fetal distress
No vaginal bleeding to moderate

vaginal bleeding
Moderate-to-severe uterine
tenderness with possible tetanic
contractions
Maternal tachycardia with
orthostatic changes in BP and heart
rate
Fetal distress
Low fibrinogen levels present
(causing clotting problems)
Clinical Severity
Class 3: Severe form: Approx 24% of all cases.
No vaginal bleeding to heavy vaginal bleeding
Very painful tetanic uterus
Maternal shock
Coagulopathy
Fetal death
I. Abruptio placenta: Risk factors
Hypertensive Disease
Multiple pregnancy
Trauma
PPROM
I. Abruptio placenta: Risk factors
Anaemia
Polyhydramnios sudden
intrauterine pressure
Short cord
Uterine leiomyoma: esp if located

behind the placental implantation
site, predispose to abruption
Abruptio Placenta: Features
Pain and tenderness
Initially localized then becomes

generalized due to endometrial injury
extravasations of blood
Vaginal bleeding
Maternal distress
Often I.U.F.D
Placental Abruption: Complications
Shock
Acute renal failure
Cause: ?seriously impaired renal perfusion 2

to CO and intrarenal vasospasm as in
preeclampsia
DIC
Consumptive coagulopathy 2 to
hypofibrinogenemia along with elevated
levels of fibrinogenfibrin degradation
products
Placental Abruption: Complications
Fetal distress/demise
PPH
Couvelaire Uterus:
Widespread extravasation of blood into the uterine

musculature and beneath the uterine serosa.
Sheehan syndrome
Puerperal sepsis
Placental Abruption: Management
Management depends on:
fetal maturity,
degree of severity,
viability of the fetus/fetal distress
Treatment modalities
Expectant management of pregnancy

Induction/augmentation of labor
Caesarean section
Placental Abruption: General Management
1. Delivery
Resuscitation
FFP, whole blood, IV fluids
Monitor BP
Catherization - monitor urine output
ARM
Induce/Augment labour
Oxytocin infusion or prostaglandin if

necessary to induce contractions
Bed site clotting time
Done regularly

2. Caesarean Section
Indications for Caesarean Section
salvageable baby,
Severe vaginal bleeding,
Poor progress,
Transverse lie, inadequate pelvis
Post delivery -watch out for PPH
Why?
Myometrial myofibrin loose contractility
Failure to clot
PLACENTA PRAEVIA - DEGREES

1.
Total placenta praevia

The internal cervical os is covered
completely by placenta.
2.
Partial placenta praevia

The internal os is partially covered
by placenta.
PLACENTA PRAEVIA - DEGREES

3. Marginal placenta praevia
The edge of the placenta is at the margin of the
internal os.
4.
Low-lying placenta
The placenta is implanted in the lower uterine
segment such that the placental edge actually
does not reach the internal os but is in close
proximity to it.
PLACENTA PRAEVIA: Predisposing factors
Multiparity
Advanced maternal age
Prior C/S or other uterine surgery
Prior placenta previa
Placenta Previa: Diagnosis
Painless vaginal bleeding in 2nd/3rd trimester
Confirmed by ultrasound
Up to 10% may have simultaneous abruption
Maternal shock is uncommon with 1st

presentation of bleeding
Placenta Previa: Obstetric Management
Vaginal exams are avoided
If possible, delay delivery until fetus is mature.
34 weeks - buy time for steroids
Prevent contractions with tocolytics -indocid
Mobilize blood donors
Placenta Previa: Obstetric Management
i.
Resuscitate - IV fluid and blood,

Monitor BP and amount of bleeding
Delivery
Mild non persistent bleeding
GA 34 weeks
ii.
Buy time for steroids and hospitalization.

Prevent contractions with tocolytics Mobilize blood donors
Oral haematenics
GA 37 weeks = consider Elective CS
Persistent bleeding requires immediate delivery

whatever the gestation
Placenta Previa: Management
Indications for delivery:
Persistent bleeding requires delivery whatever the

gestation
Active labor
Documented fetal lung maturity
37 weeks gestational age.
Excessive bleeding
Development of another obstetric complication
mandating delivery
Placenta Praevia
Elective caesarean if 37 weeks
? Never cut through the placenta
PLACENTA PRAEVIA
Lower segment may need to be

packed
Placenta previa may be assoc. with

placenta accreta, increta or percreta
PPH
PPH - 2 to poorly contractile nature of

the LS of uterus.
Comparison of Presentation of
Abruption v. Previa v. Rupture
Abruption
Previa
Rupture
Abdominal pain
present
absent variable
Vaginal blood
old
fresh fresh
DIC common
rare
rare
Fetal distress
common
rare
common
Vasa Previa
Umbilical vessels separate in the membranes

at a distance from the placental margin and
some of the vessels (fetal) cross the internal os
and occupy a position ahead of the presenting
part of the fetus.
ROM may cause fetal exsanguination.
High fetal mortality (50-75%)
Risk factor: multiple gestation (esp., triplets).
Vasa Praevia
Diagnosis
Moderate vag bleeding + fetal distress

Vessels may be palpable thru dilated cervix
Vessels may be visible on ultrasound
Difficult to distinguish clinically from

abruption.
Treatment
C/S,
Resuscitation of infant (volume)
Local & Unknown Causes of APH
Rupture of uterus
Carcinoma of cervix
Trauma
Cervical polyp
Bilharzia of cervix
Cervicitis

Antepartum Haemorrhage

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ANTEPARTUM BLEEDING e.

Ranks as the First cause of maternal

APH: Epediology & Causes

Magnitude: 4% of women may develop APH.

Velamentous Insertion of the umbilical

Early separation of the normally implanted

The risk of recurrent abruption in a

Abruptio placenta: Classifications

Extent of separation: Partial vs complete

Location of separation: Marginal Vs central

Clinical presentation: Revealed, concealed and

Clinical Severity: Mild, Moderate and Severe

Class 1 Mildest form:

No vaginal bleeding to moderate

I. Abruptio placenta: Risk factors

I. Abruptio placenta: Risk factors

Uterine leiomyoma: esp if located

Abruptio Placenta: Features

Pain and tenderness

Initially localized then becomes

Placental Abruption: Complications

Acute renal failure

Cause: ?seriously impaired renal perfusion 2

Placental Abruption: Complications

Widespread extravasation of blood into the uterine

Placental Abruption: Management

Management depends on:

Expectant management of pregnancy

Placental Abruption: General Management

FFP, whole blood, IV fluids

Catherization - monitor urine output

Placental Abruption: General Management

Oxytocin infusion or prostaglandin if

Bed site clotting time

Placental Abruption: General Management

Indications for Caesarean Section

Post delivery -watch out for PPH

PLACENTA PRAEVIA - DEGREES

Total placenta praevia

Partial placenta praevia

PLACENTA PRAEVIA - DEGREES

PLACENTA PRAEVIA: Predisposing factors

Advanced maternal age

Prior C/S or other uterine surgery

Prior placenta previa

Placenta Previa: Diagnosis

Painless vaginal bleeding in 2nd/3rd trimester

Up to 10% may have simultaneous abruption

Maternal shock is uncommon with 1st

Placenta Previa: Obstetric Management

Vaginal exams are avoided

If possible, delay delivery until fetus is mature.

34 weeks - buy time for steroids

Prevent contractions with tocolytics -indocid

Mobilize blood donors

Placenta Previa: Obstetric Management

Resuscitate - IV fluid and blood,

Buy time for steroids and hospitalization.

GA 37 weeks = consider Elective CS

Persistent bleeding requires immediate delivery

Placenta Previa: Management

Indications for delivery:

Persistent bleeding requires delivery whatever the