Ante Partum Bleeding

General Instructional Goal

• Understanding the etiology,

pathophysiology, diagnosis, and
management of bleeding during the late
stages of pregnancy / ante partum
bleeding, perform first-aid and make
reference obstetrical bleeding cases.
 Obstetrical Bleeding

 Bleeding during the time of pregnancy

 Bleeding after labor

 Bleeding during the time of
pregnancy

Non-obstetrical cause:

 Vagina : traumatic, ruptured varices, malignancy

 Cervix : cervicitis, erosion, polyp, malignancy

 Obstetric Cause
Earlier stage of pregnancy
 Abortion
 Ectopic pregnancy  20 weeks
 Hydatid mole

Later stage of pregnancy

 Placenta previa > 20 weeks
 Solutio placenta
 Uterine rupture
 Etc.
 Ante partum bleeding.
= ante partum hemorrhage

– Definition:
Vaginal bleeding after 20 weeks of pregnancy to labor before
childbirth

• Incidence:
– 2 – 5 % of all pregnancy.
– Cause:
• Placenta previa 20 %
• Solutio placenta 40 %
• Unclassified 35 %
• Etc. 5%
 Placenta Previa
Definition:
Implantation of the placenta in the lower uterine segment,
with the placenta either overlying or reaching the cervix,
usually in advance of the fatal presenting part.

Incidence:
+ 1 in 200-300 labors
Affected by: Age
Parity -Nulliparas 1:1500
-Grande multiparas 1:20
 Etiology:

• Specific cause is unknown

• Possibilities:
• Endometrial atrophy
• Abnormal endometrial vascularization
• Delayed Ovulation/Nidation
• Prior trauma to the endometrium/myometrium
After such operation, 6x increase in chances of
incidence
 Categorized into 3 types:

Total Placenta Previa

Partial Placenta Previa- Lateralis

- Marginalis

Low lying placenta.

 Clinical Feature:
• 28 weeks/more of Pregnancy
• Vaginal bleeding:
– Painless
– Fresh Blood
– Repeated
• General condition according to bleeding
• Presenting part of the fetus still high
• Usually there are abnormal presentation
• Fetus is usually still alive
• The fundal high according to gestational age
• The consistency of the uterine is normal
• Parts of the fetus easily palpable
 Diagnosis:
• Clinical feature.
• Determine the location of placenta:
– Ultrasonography
– Inspeculo
– DSU (Double Set Up) :
• Vaginal examination in operating theatre with
preparation for Caesarean Section
 Management.
• Passive/Conservative:
The aim to maintain the pregnancy, to
decrease perinatal mortality due to
prematurity

The condition are:

• Premature fetus weight less than 2000g
• Normal FHR
• No congenital anomalies
• The bleeding stops or minimal
• Not in labor
 Conservative Management
Includes:
 Bed rest and observation until 24 hours in delivery
room
 Improving the general condition
 Corticosteroid for fetal lung maturity
 If bleeding stops-> refer to obstetric ward
 If bleeding occurs again-> the conservative
management has failed-> active management
Active Management
If the condition for conservative management is not
fulfilled or conservative management has failed:
- Heavy Bleeding
- Fetal Distress or Fetal Death
- Patient in labor

 The pregnancy must be terminated

 Mode of the delivery :
-Vaginal delivery
DSU-> Amniotomy-> Spontaneous delivery
-Abdominal delivery-> Caesarean Section
 PLA C. PREVIA
Bleeding << Bleeding >>

Premature Aterm
Active
USG Other PP Management
Live Fetus Dead Fetus DSU
Total PP AMNIOTOMY

Passive Bleeding >> Bleeding  / stop

MAnagement Fetal distress Normal FHR

Wait until Aterm

Bleeding Observation Caesarean Section Wait for 12hrs
Bed rest
 Location of the placenta Not Progress
(USG)
PERVAGINAM
 Complications:
• Mother :
– Hemorrhage  shock, anemia.
– Placental Retention
– Infection
– Uterine Rupture

• Fetus :
– Asphyxia
– IUFD
– Prematurity
 Solutio placenta/
Abruptio Placenta.
• Definition :
Detachment of the placenta from its normal
implantation part or all before the fetus deliver
on more than or equal to 20 weeks of
pregnancy

• Incidence :
± 1 : 200 deliveries
• Etiology :

– Predisposing factors:
• Later age
• Chronic Hypertension / pre eclampsia
• Trauma
• Multiparity
• Short Umbilical Cord
• Hydramnion
• Twin pregnancy, 2nd baby
 Clinical Feature

– Vaginal Bleeding – Dark Red

– Tense Uterine and Pain
– Uterine Fundal Higher than Gestational Age
– Part of the fetal is not palpable
– Fetal Heart Rate Negative/Fetal Death
– Presence of Blood in Amniotic Fluid
 Diagnosis :

• According to clinical feature

• Vaginal examination-> Amnion still intact
and bulging, if amnion rupture the amniotic
fluid will mix with blood
• Sometimes it is difficult, especially in mild
cases
• Retro placental Hematome
 Management :

• Time Dependent → Influence the

prognosis

• Fresh blood transfusion

• Amniotomy → Immediately performed

– Reduce Intra Uterine Pressure
– Induction / Acceleration Delivery
– Reduce Bleeding
• Immediately Deliver before 6 hrs

– Fetus “viable” & living → Immediately CS

– Fetus non viable / dead → vaginal delivery.

• Uterine contraction < inadequate → oxytocin
drip
• Secondary arrest / more than 6 hrs no
delivery→ CS
 Solutio plac.

amniotomy
Living fetus and Dead fetus or
viable not viable
Latent Active
Phase Phase

Obs 30 ‘

Oxy Drip His < His >

6 hrs Blood
Coagulation Obs

Caesarean Vaginal Delivery

Section
 Complication
• Mother :
– Hypovolemic Shock → Kidney failure
– Post Delivery Bleeding ( HPP ).
• Uterine couvelaire / Uterine Atonia
• Hemostasis Disorder ( hypofibrinogenemia o0r DIC
).
• Fetus :
– Asphyxia to death
 Prognosis :
• Mother prognosis influenced by :
– Amount of bleeding
– Concealed bleeding
– Degree of coagulation disorder
– Presence of concomitant disease – HT / pre
eclampsia
– Time Interval
– Availability of blood transfusion
 UTERINE RUPTURE

• Rupture of the womb which causes a direct

connection between the amnion cavity and
the peritoneal/abdominal cavity

• Rupture of the uterine is the most serious

complication. It can be life-threatening for
both mother and infant
• Incidence:

– Developing countries > Developed

countries

– Developed countries: + 1:15.000 childbirth

(1996).

– Indonesia: 1:294 – 1:93.

• Etiology:

– Defect on the womb:

• Scarring from CS, myomectomy, hysterorraphy.
– Trauma:
• Abdominal trauma
• Medical procedure: external version, version
and extraction, extraction with forceps, etc.
– Complications on childbirth:
• Dystocia ( passage, passenger )
• Induction and accelerated childbirth
• High risks:
– Uterine defect:
• Prior CS:
– Corporil CS (classic)
– Low segment CS
• Prior myomectomy
– Grande multi gravida.
– Malpresentation.
– CPD – FPD.
– Dystocia.
– Induction and accelerated childbirth
– Childbirth by vaginal operative procedure
Patophysiology
 Classification:

• Anatomy:
– Complete
– Incomplete, serous layer still intact
• Causes:
– Spontaneous
– Violenta :
• Manipulation or Medical Procedure
• Abdominal trauma
• Wholeness of the womb:
– On intact uterus
– On ‘defective’ uterus:
• Prior CS, myomectomy.

• Time:
– During pregnancy:
• Scars prior CS, trauma
– During labor:
• Stage I – Stage II
 Clinical diagnosis:

• Ruptura Uteri Imminens ( RUI )

– Pain
– Bandl ring (+).
• Bleeding
– Intra abdominal: sign of free fluid (+)
– Vaginal bleeding: APB.
• Shock :
– T ↓ , P ↑ , Hb. ↓ .
• Palpation:
– Signs of free fluid (+).
– Uterine contraction (-). (1)
– Parts of the fetus easily palpable (2)
• Auscultation :
– Fatal heart rate (-). (3)
– 1,2,3 usually mentioned as trias rupture
• VT :
– Lower part of the fetus moved upwards
– Sometimes the margin of the rupture is
palpable
 Management:
• Prevention is better than cure.

– Resuscitation:
• A. B. C.
• Improve/Stabilize the patient’s general
condition
– Antibiotics.
– Laparatomy:
• Hysterectomy.
• Hysterorrhaphy. (special condition)
 Complications:

• Hypovolemic shock:
• And all the consequences

• Infection --- sepsis.