Welcome to all

Presentation by
A.Jalajarani
Principal Nursing Officer
MTPG&RIHS-Karaikal Branch
Ante partum Hemorrhage
Bleeding from the genital tract in pregnancy
between 20 to 24 weeks gestation and the
onset of labour.
It affects 4% of all pregnancies & it is a
MEDICAL EMERGENCY
It is associated with increased risks of fetal and
maternal morbidity and mortality.

causes
1. Placenta praevia-10%
2. Placental abruption-15%
3. Local causes:
- cervical ectropion/cervical trauma.
- local infection of the cervix/vagina.
- cervical polyps/cervical cancer.
4. Undetermined origin.
5. Rare cause: torn from vasa paevia (fetal
origin).



Placenta previa is defined as
a placenta that partially or wholly situated in the
lower uterine segment.
Grade 1: the placental edge is in the lower
uterine segment but does not reach the
internal os (low implantation).
Grade 2: the placental edge reaches the internal
os but does not cover it.
Grade 3: the placenta covers the internal os when
it is close and is asymmetrically situated
(partial).
Grade 4: the placenta covers the internal os and
is centrally situated (complete)

Marginal placenta previa. The edge of the
placenta is at the margin of the internal os.

Low-lying placenta. The placenta is implanted in
the lower uterine segment such that the
placenta edge actually does not reach the
internal os but is in close proximity to it.

Predisposing factors:
Older multiparous women. Women > 40 years have 9-fold
greater risks than women < 20 years of age.
Multiple pregnancy.
Previous caesarean section. The risk increases with increasing
numbers of C/S
Smoking.
Associations:
Fetal abnormality (double in placenta praevia).
IUGR (multiple bleeds).
Placental abruption (co-exist in 10% of placenta praevia).
Placenta praevia
Clinical presentation

Bleeding: usually mild but it could be
severe; recurrent, painless and causeless.
Soft uterus.
Normal fetal heart rate (unless there is
severe bleeding or associated abruption).
High presenting part.
Fetal malpresentation
(breech/transverse/oblique).
Vaginal examination is contraindicated.
Diagnosis:
Clinical presentation.
U/S: Transvaginal is better than
transabdominal; the woman does not need full
bladder and can determine the placental edge
in posterior PP.
- MRI: expensive.
Examination in the theatre: if no facilities or in
doubt.
Management of Placenta Praevia
Asymptomatic and minor bleeding:
Admission (minor). Asymptomatic PP admitted at 36 weeks.
CBC, cross matching and preparation of blood.
Coagulation profile.
Maternal and fetal monitoring.
Correction of anaemia.
Anti-D if the mother is rhesus negative.
Tocolytic: safe, gain 13 days, other than B-agonist to be used.
Corticosteroids 48 hours before delivery ( at 38 weeks).
Vaginal delivery: placenta 4.5 cm from the internal os, low
head, no bleeding. Consider examination in theatre if in doubt .
C/S (of choice): grade 4, 3, placenta within 2 cm of the
internal os, high head, bleeding, presence of added factors.
Complications of Placenta praevia
Preterm delivery and its complications.
Preterm premature rupture of membranes.
IUGR (repeated bleeding).
Malpresentation; breech, oblique, transverse.
Fetal abnormalities (double in PP).
number of C/S.
Morbid placentae: placenta acreta(80%), increta and
percreta.
Postpartum haemorrhage: lower segment not contract
and retract, morbid placenta, C/S.
Placenta Abruption
It is on form of ante partum hemorrhage
where the bleeding occurs due to premature
separation of normally situated placenta after
the 20
th
week of gestation.

Types:

Revealed: Separation of the placenta, the blood
insinuates downwards between the membranes
and the deciduas. Ultimately, the blood comes
out of the cervical canal to be visible
externally. IT is commonest type.

Concealed: Blood collects behind the separated
placenta or collected in between the
membranes and deciduas. Collected blood is
preventing from coming out of the cervix by the
presenting part which presses on the lower
segment. This type is rare.

Mixed: This type, some part of the blood
collects inside (concealed) and a part is expelled
out (revealed). This is quite common.

Predisposing factors

Hypertension: PET (24%), chronic hypertension
( 9-fold).
Fetal abnormality: maternal serum -
fetoprotein, recurrence of abruption. ?? poor
placentation ( adhesiveness).
Thrombophilias: factor V leiden, prothrombin
gene, protein C & S deficiency, antiphospholipid
syndrome & homocysteinaemia.
Trauma: ECV, cordocentesis, road traffic
accidents.



Rupture membranes: rapid decompression in
polyhydramnios.
Folic acid deficiency.
Chorioamnionitis.
Previous abruption: 6 times to recur.
Multiple pregnancy.
Smoking.

Diagnosis
Clinical presentation:
Bleeding: revealed/concealed, so clinical picture is
important.
Pain on the uterus and this increases in severity.
Signs of shock (hypovolaemia): fainting and collapse.
Hard tender uterus ( uterine tetany).
Difficult to palpate the fetal parts and to hear the fetal heart.
The diagnosis is clinical.
U/S: is to
Confirm fetal viability, assess fetal growth & normality,
measure liquor, do umbilical artery Doppler velocities.
Exclude placenta praevia.

Complications
Premature delivery.
Fetal distress and death
Haemorrhagic shock.
Acute renal failure: acute tubular or cortical
necrosis.
DIC (release of tissue thromboplastin)
Uterine atony (Couvelaire uterus).
PPH.

Management of Placenta Abruption
Principle of management:
1. Early delivery (50% of abruption present in labour).
2. Adequate blood transfusion.
3. Adequate analgesia.
4. Detailed maternal and fetal monitoring.
Coagulation profile (30% develop DIC).
C/S: distressed baby, severe bleeding, alive baby & not in
advanced labour. Perinatal mortality rate is 15-20%.
Vaginal delivery: very low gestation, dead baby, cervix is
fully dilated (Ventouse delivery).
Conservative: small abruption, well mother and fetus, if the
gestational age < 34, give steroids.

Management of Placenta Abruption
Conservative: Time taken to achieve delivery depends on:
rate of the bleeding.
The rate of change in the clotting studies.
The clinical condition of the mother and fetus.
CTG: twice/day.
Serial U/S and umbilical artery Doppler waveform.
No conservative after 38 weeks gestation.
Anti-D if the mother is rhesus positive.
Anticipate PPH.
In cases of previous CS, discuss hysterectomy.
Initial management of APH
Admit
History
Examination
NO PV
Nurse on side
IV access/ resuscitate
Clotting screen
Cross match
Kleihauer-Betke test
Apt test
CTG
Observation
Placental localization
Speculum examination
when placenta previa
excluded
Anti-D if Rh-negative
Kleihauer-Betke test -Is a blood test used to measure the
amount of fetal hemoglobin transferred from a fetus to
the mother's bloodstream.
The test allows the clinician to determine whether the
blood originates from the infant or from the mother.
Place 5 mL water in each of 2 test tubes
To 1 test tube add 5 drops of vaginal blood
To other add 5 drops of maternal (adult) blood
Add 6 drops 10% NaOH to each tube
Observe for 2 minutes
Maternal (adult) blood turns yellow-green-brown; fetal blood
stays pink.
If fetal blood, deliver STAT.