R.G.

Kar Medical College and Hospital Department of Gynecology and Obstetrics

 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 1st and 2nd stages of labour are thus included). Causes: Placenta
Placental bleeding (70%) Praevia (35%) Abruptio Placentae (35%)

APH

Cervical polyp

Extra Placental Bleeding (5%)

Carcinoma Cervix

Varicose Vein

Local trauma

APH

Placental Bleeding

APH

Placenta Praevia
When the placenta is implanted partially or completely

over the lower uterine segment it is called placenta praevia. About 1/3rd cases of APH belong to Placenta Praevia. The incidence of Placenta Praevia ranges from 0.5-1% amongst hospital deliveries. In 80% cases, it is found to multiparous women. The incidence is increased beyond the age of 35yrs, with high birth order pregnancies and multiple pregnancy.

 Etiology: The exact cause of implantation of the placenta in the lower segment is not known. However some theories are postulated regarding this. They are as follows..
DROPPING DOWN THEORY PERSISTENCE OF CHORIONIC ACTIVITY DEFECTIVE DECIDUA BIG SURFACE AREA OF THE PLACENTA

 The high risk factors: Multiparity Increased Maternal Age Previous caesarean section Placental size and abnormality Scarring of the uterus Smoking Prior Curettage

APH

Types of Placenta Praevia: There are four types of placenta

praevia 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 internal os. TYPE-II: (marginal) The placenta reaches the margin of the internal os but does not cover it. TYPE-III: (partial central) The placenta covers the internal os when it is closed, but does not cover it when the os is open. TYPE-IV: (total) The placenta completely covers the internal os, even when the os is open.

APH

Each of the types are again subdivided into A and B

depending upon the implantation of the placenta on the anterior or the posterior wall of the uterus respectively. TYPE-IA, IB, and IIA are termed as MINOR DEGREE PLACENTA PRAEVIA. TYPE-IIB, IIIA, IIIB, and IV are termed as MAJOR DEGREE PLACENTA PRAEVIA. Dangerous placenta praevia is the name given to TYPE-IIB i.e. TYPE-II posterior placenta praevia.

APH

Because: 1.Due to the curved birth canal, major thickness of the placenta overlies the sacral promontory, thereby diminishing the anteroposterior diameter of the inlet and prevents the engagement of the presenting part. 2. Placenta is more likely to be compressed, if vaginal delivery is allowed. 3. More chances of cord compression or cord prolapse.

APH

Clinical Features:

Symptoms- 1. Painless and apparently causeless recurrent vaginal bleeding. 2. The blood is usually bright red in colour. 3. Subsequent bouts of bleeding may be alarming. 4. Earlier bleeding is more likely to occur in major degrees.
Signs1. General condition and anemia are proportionate to the visible blood loss

APH

Examination: General Examination- 1. Present with features of shock, which is proportional to the amount of blood loss. 2. Degree of anemia is also proportional to the amount of blood loss. 3. Pulse, Blood pressure are recorded. Hypotension and tachycardia are present, if the patient is in shock. Hypertension and gross edema is absent.

APH

Abdominal Examination-1. Height of the fundus usually corresponds to the period of gestation. 2. Uterus feels relaxed, soft, and elastic without any localized area of tenderness. 3. Persistence of malpresentation like breech or transverse or unstable lie. 4. The presenting part is high up. 5. The Fetal Heart Sound is usually present, unless there is major separation of the placenta with the patient in exsanguinated condition.

APH

Vulval Inspection: Only inspection is done to note whether bleeding id still occurring or has ceased, character of the blood. Confirmation of diagnosis :
Localization of placenta MRI Transabdominal ultrasound Transvaginal ultrasound Transperineal ultrasound Clinical By internal examination by double set up examination Direct visualization during caesarean section Examination of the placenta following vaginal delivery

Colour Doppler flow study

APH

Transabdominal Ultrasound

Colour Doppler Flow Study

APH

Transvaginal Ultrasound

Transabdominal Ultrasound

APH

Complications of Placenta Praevia: Maternal complication:

During pregnancy: Shock Malpresentation Premature Labour During labour: Early rupture of the membrane Cord prolapse Slow dilatation Intrapartum Haemmorrhage Increased incidence of operative interference Postpartum haemorrhage Retained placenta

APH

Puerperium: Sepsis is increased due to1. Increased operative interference 2. Placental site near to the vagina 3. Anemia and devitalized state of the patient Sub involution Embolism Fetal complication: Low birth weight Asphyxia Intrauterine death Birth injuries Congenital malformation

APH

Management: Prevention: 1.Adequate antenatal care to improve the health status of women and correction of anemia. 2.Antenatal diagnosis of low lying placenta at 20 weeks with routine ultrasound, and repeat the ultrasound examination at 34 weeks to confirm the diagnosis. 3.Significance of Warning haemorrhage should not be ignored. 4.Colour flow Doppler USG in placenta praevia is indicated to detect any placenta accreta.(Placenta accreta is a severe obstetric complication involving an abnormally deep attachment of the placenta, through the endometrium and into the myometrium)

APH

At Home: 1.Patient immediately put to bed. 2.Assess the blood loss by inspection of clothing soaked with blood and measuring pulse blood pressure and degree of anemia. 3.Quick but gentle abdominal examination. 4.Vaginal examination is not done ,only the inspection is done. Transfer to Hospital: Arrangement is made to shift the patient to an equipped hospital having facilities of blood transfusion, emergency caesarean section and neonatal intensive care unit.

APH

Admission to Hospital: All Cases of APH should be admitted in hospital. Treatment on Admission: Immediate Attention: 1.Amount of the blood loss 2.Blood samples are taken for group, cross matching and estimation of hemoglobin. 3.A large-bore IV cannula is sited and an infusion of normal saline is stated and compatible cross matched blood transfusion should be arranged. 4.Gentle abdominal palpation. 5.Inspection of the vulva. Formulation of the line of treatment: Depends upon the duration of pregnancy, fetal and maternal status and the extent of the haemorrhage

APH

Expectant management: Prerequisites: 1. Availability of blood for transfusion whenever required. 2. Facilities for caesarean section should be available throughout 24 hrs. Selections of Cases: 1. Mother is in good health status, i.e. Hb>= 10 gm%, Haematocrit>30% 2. Duration of pregnancy is less than 37wks. 3. Active vaginal bleeding is absent. 4. Fetal well being is assured by USG.

APH

Conduct of expectant treatment:

1. Bed rest. 2. Routine blood investigation. 3. Periodic inspection of the vulval pads and fetal surveillance with USG at interval of 2-3 wks. 4. Supplementary haematinics should be given and the blood loss is replaced by adequate cross matched blood transfusion. if patient is anemic. 5.When the patient is allowed out of bed(2-3days after the bleeding stops), a gentle Cuscos speculum examination is made to exclude local cervical and vaginal lesions for bleeding. However, their presence does not negate placenta praevia.

APH

6. Use of tocoloysis (magnesium sulphate) can be done if vaginal bleeding is associated with uterine contractions. 7. Use of cervical circlage to reduce bleeding and to prolong pregnancy is not helpful. 8. Rh immunoglobulin should be given to all Rh negative(unsensitised) women. Expectant management is ideal in hospital, but considering the cost of prolonged hospitalization and psychological morbidity, home care may be allowed is some. They are Patient living close to hospital. 24 hrs transportation is available. Bed rest assured and patient is well motivated to understand the risks.

APH

Definitive management: Indications: 1. Bleeding occurs at or after 37 wks of pregnancy. 2. Patients is in labour. 3. Patient is in exsanguinated state on admission. 4. Bleeding is continuing and of moderate degree. 5. Baby is dead or known to be congenitally deformed. Management: Caesarean section: It is done for all woman with sonographic evidence of placenta praevia where placental edge is within 2cm from the internal os. Vaginal delivery: Its may be considered where placental edge is clearly 2-3cm away from the internal cervical os.

APH

SCHEME OF MANAGEMENT OF PLACENTA PRAEVIA IN HOSPITAL

All APH patients are to be admitted

Expectant Treatment No active bleeding Pregnancy <37 wks

Ultra sonography

Active Interference bleeding continues pregnancy >37wks

Placental edge is clearly 2-3 cm Away from the internal os.

placental edge within 2cm of the internal os or placenta praevia.

Vaginal delivery
Caesarean delivery

Caesarean delivery

APH

Abruptio Placentae
Definition: It is a form of ante partum haemorrhage where the bleeding occurs due to premature separation of normally situated placenta. Etiology: The exact cause of separation of normally situated placenta remains obscure in majority of cases. 1. Trauma 2. Sudden uterine decompression 3. Short cord 4. Supine hypotension syndrome 5. Placental anomaly 6. Sick placenta

APH

6. Folic acid deficiency 7. Uterine factor 8. Torsion of uterus 9. Cocaine abuse 10. Thrombophilias 11. Prior abruption
High risk factors:

1. High birth order 2. advancing age of the mother 3. malnutrition, poor economic condition, smoking

APH

Types of Abruptio Placentae:

Clinical manifestation of haemorrhage Ultrasonographic localization of haemorrhage

The bleeding remains confined inside Retro placentalBetween placenta the uterus without any evidence of and myometrium. external bleeding. It is a severe form.Concealed type. The bleeding appears as vaginal Sub chorionicBetween the bleeding. It is a mild form.Revealed placenta and the membranes. type .

Both concealed and revealed type Mixed type.

Blood may percolate through the layers of myometrium upto serous coat Couvelaire uterus.

Pre placentalBetween placenta and the amniotic fluid.

APH

Depending upon the degree of placental abruption.. Grade 0- clinical features absent. Grade 1- a) Vaginal bleeding is slight, b) Uterus is irritable tenderness may be minimal or absent, c) Maternal BP and fibrinogen levels unaffected, d) FHS is good Grade 2- a) Vaginal bleeding mild to moderate, b) Uterine tenderness is always present, c) Maternal pulse ,BP is maintained, d) Fibrinogen , e) Shock absen, f) Fetal distress or fetal death occurs Grade 3- a) Bleeding is moderate to severe or may be concealed, b) Uterine tenderness is marked, c) Shock is pronounced, d) Fetal death is the rule, e) Associated coagulation defect or anuria may complicate.

APH

Clinical Features:
Symptoms Character of bleeding Revealed type Concealed type

Abdominal discomfort and Continuous abdominal vaginal bleeding ( dark ). pain and slight bleeding.

General condition

Proportionate to visible Shock may be pronounced blood loss, shock is absent. which is out of proportion to visible blood loss.
Related to blood loss. May be absent. Proportionate to period of gestation. Present . Normal . Severe pallor. Frequent association. Disproportionately enlarged and globular. Absent . Usually diminished.

Pallor Features of preeclampsia Uterine height Fetal parts & FHS Urine output

APH

Laboratory Investigation:
Investigation Blood: Hb% Revealed type Low value proportionate to the blood loss. Usually unchanged. Concealed type Markedly lower, out of proportion to the visible blood loss. Clotting time increased Fibrinogen level low Platelet count low.

Coagulation Profile

Urine for protein

May be absent.

Usually present.

Confusion in Diagnosis

With placenta praevia.

With acute obstetrical gynecological surgical complication.

APH

Complications of Abruptio Placentae:

Maternal: 1. Revealed type: Maternal death is rare.

2. Concealed type: Haemorrhage Blood coagulation disorder Shock Oliguria and anuria Puerperal sepsis Postpartum haemorrhage due to atony of the uterus. Fetal: 1. Revealed type: Fetal death is to extent of 25-30% 2. Concealed type: Fetal death is high( 50-100%) due to prematurity and anoxia due to placental separation.

APH

Management of Abruptio Placentae:

Assessment of the case is to be done as regards: a)

amount of blood loss, b) maturity of the fetus, c) whether the patient is in labour or not, d) presence of any complication, e) type and grade of placental abruption. Emergency measures: a) Routine blood test, b) Ringers solution drip arrangement for blood transfusion. Management options are: a) immediate delivery, b) Management of complication if any, c) Expectant management.

APH

Definitive Treatment:
The patient is in labour The patient is not in labour

The labour is accelerated by Low Rupture of the Membranes. Vaginal delivery is favoured in cases with: i) Limited placental Abruption, ii) FHR tracing, iii) Continuous fetal monitoring is available, iv) placental abruption with a dead fetus.

Induction of labour is done by low rupture of membranes: Oxytocin may be added to expedite delivery. Inj.Oxytocin 10 IU IV(slow) is given with delivery of baby to minimize postpartum blood loss. Caesarean Section

APH

Abruptio Placentae Resuscitation Revealed Pt. in labour ARM+Oxytocin Vaginal delivery Pt. not in labour Delivery ARM+ Oxytocin Concealed Delivery ARM+Oxytocin Caesarean delivery Caesarean Sec.

Vaginal delivery

Vaginal delivery Oxytocics is continued to improve uterine tone along blood transfusion.

APH

Difference between placenta praevia & Abruptio placentae:

Points of discussion Nature of bleeding & character of blood General condition and anemia Features of preeclampsia Height of uterus Feel of uterus Malpresentation FHS Placenta praevia Painless, causeless and recurrent & bright red. Proportionate to visible blood loss. Not relevant. Proportionate to the gestational age. Soft and relaxed. It is common. Head is high. Present. Abruptio placentae Painful, continuous and dark coloured Out of proportion to the visible blood loss. Present in 1/3rd of cases. Enlarged and disproportionate. Tense, tender, rigid. Unrelated as head is engaged. Absent.

APH

Points of discussion Placentography (USG) Vaginal examination

Placenta praevia Placenta in lower segment.

Abruptio placentae Placenta in upper segment.

Placenta is felt on the lower Placenta is not felt in lower segment. segment.

A, Partial abruption with concealed hemorrhage. B, Partial abruption with apparent hemorrhage. C, Complete abruption with apparent hemorrhage.

APH

An extra placental cause of APH is suspected when placental

praevia and abruptio placentae are excluded from history, clinical examination and USG. A gentle speculum examination of the cervix and vagina helps to settle the diagnosis of local causes of bleeding in such cases. Benign conditions like cervical ectropion, cervical polyp are not treated during the pregnancy. A cervical polyp can however be removed, if recurrent bleeding persists. Cervical carcinoma in pregnancy requires special attention. If diagnosis is made in early 2nd half of pregnancy, the carcinoma is treated with usual management thus sacrificing the pregnancy. In the late pregnancy, often treatment is started after delivery. Caesarean section is necessary in such case.

APH