ANTEPARTUM HAEMORRHAGE

INTRODUCTION

Antepartum hemorrhage is a serious complication of pregnancy occurring within the third

trimester. It is associated with significant maternal and fetal morbidity and mortality. Common
causes of antepartum hemorrhage are bloody show associated with labor, miscarriage, placental
previa, and placental abruption.

Normal Placenta During Child birth Process of placental growth and uterine wall changes
during pregnancy

1. The placenta grows with the placental site during pregnancy.

2. During pregnancy and early labor the area of the placental site probably changes
little, even during uterine contractions.
3. The semi rigid, non contractile placenta cannot alter its surface area.

Anatomy of the uterine/placental compartment at the time of birth

1. The cotyledons of the maternal surface of the placenta extend into the decidua basalis,
which forms a natural cleavage plane between the placenta and the uterine wall.
2. There are interlacing uterine muscle bundles, consisting of tiny myofibrils, around the
branches of the uterine arteries that run through the wall of the uterus to the placental
area.
3. The placental site is usually located on either the anterior or the posterior uterine wall.
4. The amniotic membranes are adhered to the inner wall of the uterus except where the
placenta is located.

In obstetrics, antepartum hemorrhage (APH), also pre partum hemorrhage, is bleeding from the
vagina during pregnancy from twenty four weeks gestational age to term.

It should be considered a medical emergency (regardless of whether there is pain) and medical
attention should be sought immediately, as if it is left untreated it can lead to death of the mother
and/or fetus .It can be associated with reduced fetal birth weight.

Bleeding without pain is most frequently bloody show, which is benign; however, it may also be
placenta Previa (in which both the mother and fetus are in danger). Painful APH is most
frequently placental abruption (which may also lead to adverse fetal and/or maternal outcomes)

DEFINITION:

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 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 first and second stage of labor are thus included). The 28th week
is taken arbitrarily as the lower limit of fetal viability. The incidence is about 3% amongst
hospital deliveries.

Wikipedia

INCIDENCE
APH occurs in 2% to 5% of all pregnancies. The primary causes of APH include:
 Abruptio placenta (1 in 100 pregnancies) 40%
 Placenta previa (1 in 200 pregnancies) 20%
 Unclassified 35%
 Lower genital tract lesion 5%

PHYSIOLOGY
In the non-pregnant state, the uterus receives approximately 1% of cardiac output. In the third
trimester, it receives approximately 20%. Uterine bleeding in the third trimester can be massive
and can quickly result in a hemodynamically unstable woman.

MORBIDITY AND MORTALITY

Placenta abruption and Previa account for slightly more than half of the cases of APH. They are
the two leading causes of perinatal morbidity and mortality in the third trimester. Globally, and
especially in developing countries where 99% of maternal deaths occur, 25% of these deaths are
due to haemorrhage. Placenta abruption and Previa account for 50% of haemorrhage-related
deaths. Postpartum haemorrhage accounts for the remaining 50% (de Swiet, 2000). It is critical
to rule out placenta Previa.

CAUSES:

The causes of antepartum hemorrhage fall into the following categories. The hospital
figures do not give a true picture of the incidence of the different varieties. However, on an
average, the incidence of placenta Previa, abruption placenta and the indeterminate group is
almost the same.

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 Cause of antepartum hemorrhage

A.P.H.

↓ ↓ ↓

Placental bleeding (70%) Unexplained (25%) Extra placental causes (5%)

↓ or Local cervico-vaginal lesions:

______________ Indeterminate - Cervical polyp

↓ ↓ (Excluding placental - Carcinoma cervix

Placenta Abruptio bleeding and local - Varicose vein

Praevia placentae lesions) - Local trauma

(35%) (35%)

PLACENTA PRAEVIA

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DEFINITION:

When the placenta is implanted partially or completely over the lower uterine segment it
is called placenta praevia. The term praevia (L, in front of) denotes the position of the placenta in
relation to the presenting part.

Dc. Dutta

INCIDENCE:

About one-third cases of antepartum hemorrhage 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 35, with high
birth order pregnancies and in multiple pregnancy. Increased family planning acceptance with
limitation and spacing of birth, lowers the incidence of placenta Previa.

ETIOLOGY

The exact cause of implantation of the placenta in the lower segment is not known. The
following theories are postulated.

 Dropping down theory: The fertilized ovum drops down and is implanted in the lower
segment. Poor decidua reaction in the upper uterine segment may be the cause. Failure of
zona pellucid to disappear in time can be a hypothetical possibility. This explains the
formation of central placenta praevia.

 Persistence of chorionic activity in the deciduas capsularis and its subsequent

development into capsular placenta which comes in contact with decidua vera of the
lower segment can explain the formation of lesser degrees of placenta praevia.

 Defective decidua, results in spreading of the chorionic villi over a wide area in the
uterine wall to get nourishment. During this process, not only the placenta becomes
membranous but encroaches onto the lower segment. Such a placenta praevia may invade
the underlying decidua or myometrum to causes placenta accrete, increta or percreta.

 Big surface area of the placenta as in twins may encroach onto the lower segment.

The predisposing factors of placenta praevia are –

(a) Multiparty,
(b) Increased maternal age (> 35 years),
(c) History of previous caesarean section any other scar in the uterus (myomectomy or
hysterotomy),
(d) Placental size (mentioned before) and abnormality (succenturiate lobes),
(e) Smoking – causes placental hypertrophy to compensate carbon monoxide induced
hypoxemia.

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PATHOLOGICAL ANATOMY:

Placenta – The placenta may be large and thin. There is often a tongue shaped extension from the
main placental mass. Extensive areas of degeneration with infarction and calcification may be
evident. The placenta may be morbidly adherent due to poor decidua formation in the lower
segment.

Umbilical cord – The cord may be attached to the margin (battledore) or into the membranes
(velamentous). The insertion of the cord may be close to the internal or the fetal vessels may run
across the internal or in velamentous insertion giving rise to vasa praevia which may rupture
along with rupture of the membranes.

Lower uterine segment – Due to increased vascularity, the lower uterine segment and the cervix
becomes soft and more friable.

TYPES OR DEGREES:

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 onlyo
the lower margin encroaches onto the lower segment but not upto the os.

Type – II (Marginal): The placenta reaches the margin of the internal os but does not cover it.

Type – III (Incomplete or partial central): The placenta covers the internal os partially (covers
the internal os when closed but does not entirely do so when fully dilated).

Type – IV (Central or total): The placenta completely covers the internal os even after it is fully
dilated.

In the majority, the placenta lies either in the anterior or posterior wall, the latter is more
common. Type – III and IV constitute about one-third of the cases. For clinical purpose, the
types are graded into mild degree (Type-I and II anterior) and major degree (Type-II posterior,
III and IV).

Dangerous placenta praevia is the name given to the type – II posterior placenta praevia.
(1) Because of the curved birth canal major thickness of the placenta (about 2.5 cm) overlies the
sacral promontory, thereby diminishing the antero-posterior diameter of the inlet and prevents
engagement of the presenting to stop bleeding. (2) Placenta is more likely oto compressed, if
vaginal delivery is allowed. (3) More chance of cord compression or cord prolapse. The last two
may produce fetal anoxia or even death.

CAUSES OF BLEEDING:

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 As the placental growth slows down in later months and the lower segment progressively
dilates, the inelastic placenta is sheard off the wall of the lower segment. This leads to opening
up of utero-placental vessels and leads to an episode of bleeding. As it is a physiological
phenomenon which leads to the separation of the placenta, the bleeding is said to b e inevitable.
However, the separation of the placenta may be provoked by trauma including vaginal
examination, coital act, external version or during high rupture of the membranes. The blood is al
most always maternal, although fetal blood may escape from the torn villi specially when the
placenta is separated during trauma.

The mechanisms of spontaneous control of bleeding are : (1) Thrombosis of the open
sinuses. (2) Mechanical pressure by the presenting part. (3) Placental infarction.

Placental migration: Ultrasonography at 17 weeks of gestation, reveals placenta covering

the internal os in about 10% of cases. Repeat ultrasonography at 37 weeks showed no placenta
in the lower uterine segment in more the 90% of cases. During third trimester there is potential
growth of lower uttering segment compared to the placenta. Due to this disproportionate growth
there is apparent migration of placenta towards the fundus.

PATHOPHYSIOLOGY:

Painless Vaginal Bleeding

Ultrasound

Risk Factors

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Advanced Previous Uterine
Large Placenta
Surgery (Multiple Gestation, Erythroblastosis)
Maternal
Age Multiparity Smoking
 Complete Previa Marginal Previa
Partial Previa Low-lying placenta

Bleeding Stops
Fetus Stable

Bed Rest

Observe
↓ Urine Output Pale, cool skin

Hypotension (↓BP) ↑ Capillary refill

Bleeding continues
Maternal Hemorrhage Bleeding restarts Tachycardia (↑ Pulse)

Complications:

Congenital Anomalies
Maternal Mortality (rare)
Intrauterine Growth Retardation (IGR)

Cesarean Birth Vaginal or Cesarean birth

CLINICAL FEATURES

SYMPTOMS: The only symptom of placenta Preavia is vaginal bleeding.

 The classical features of bleeding in placenta Preavia are sudden onset, painless,
apparently causeless and recurrent.

 In about 5 % cases, it occurs for the first time during labour, specially in prim gravidae.
In about one-third of cases, there is a history of “warning hemorrhage” which is usually
slight.

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  The bleeding is unrelated to activity and often occurs during sleep and the patient
becomes frightened.

 Trauma or hypertension are usually absent. However, preeclampsia may complicate a

case of placenta preavia. The first bout of bleeding is usually not alarming but subsequent
bouts may be heavier than the previous one due to separation of fresh areas of placenta.

SIGNS: General condition and anaemia are proportionate to the visible blood loss. But in the
tropics, the picture is often confusing due to pre-existing anaemia.

Abdominal examination:

 The size of the uterus is proportionate to the period of gestation.

 The uterus feels relaxed, soft and elastic without any localized area of tenderness.

 Persistence of mal presentation like breech or transverse or unstable lie is more frequent.
There is also increased frequency of twin pregnancy.

 The head is floating in contrast to the period of gestation. Persistent displacement of the
fetal head is very suggestive. The head cannot be pushed down into the pelvis.

 Fetal heart sound is usually present, unless there is major separation of the placenta with
the patient in exsanguinated condition. Slowing of the fetal heart rate on pressing the
head down into the pelvis which soon recovers promptly as the pressure is released is
suggestive of the presence of low lying placenta specially of posterior type (Stallworthy’s
sign). But this sign is not always significant because it may be due to fetal head
compression even in an otherwise normal case.

Vulval inspection: Only inspection is to be done to note whether the bleeding is still occurring or
has ceased, character of the blood – bright red or dark coloured and the amount of blood loss- to
be assessed from the blood stained clothing. In placenta praevia, the blood is bright red as the
bleeding occurs from the separated utero-placental sinuses close to the cervical opening and
escapes out immediately.

Vaginal examination must not be done outside operation theatre in the hospital, as it can provoke
further separation of placenta with torrential hemorrhage and may be fetal. It should only be
done prior to termination of pregnancy in the operation theatre under anesthesia, keeping
everything ready for caesarean section.

CONFIRMATION OF DIAGNOSIS

Diagnosis: Painless and recurrent vaginal bleeding in the second half of pregnancy should be
taken as placenta praevia unless proved otherwise. Ultrasonography is the initial procedure either
to confirm of to rule out the diagnosis.

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 I. LOCALISATION OF II. CLINICAL
PLACENTA
(PLACENTOGRAPHY)

 Sonography - By internal examination (double set

up examination).
 Magnetic resonance imaging (MRI)
- Direct visualization during caesarean
- Trans abdominal ultrasound ((TAS). section.

- Transvaginal ultrasound (TVS). - Examination of the placenta

following vaginal delivery.
- Transperineal ultrasound

- Colour Doppler flow study

PLACENTOGRAPHY

Sonography: It can precisely determine the extent of placental margin in relation to internal os .
It also provides information pertaining to maturity and wellbeing of the fetus for guiding the
management.

Transabdominal (TAS): The accuracy after 30th week of gestation is about 98 percent. Cases of
placenta praevia detected in earlier weeks should be subjected to repeat scan at 34 weeks or
earlier for detection of placental migration.

Transvaginal (TVS): Transducer is inserted within the vagina without touching the cervix. The
probe is very close to the target area and higher frequencies could be used to get a superior
resolution. It is safe, obviates the discomfort of full bladder and is more accurate than TAS.

Transperineal (TPS): This is well accepted by patients. Internal os is visulised in 97-100% of

cases.

Colour Doppler flow study: Prominent venous flow in the hypoechoic areas near the cervix is
consistent with the diagnosis of placenta praevia.

Magnetic Resonance Imaging (MRI): It is a noninvasive method without any risk of ionizing
radiation. Quality of placental imaging is excellent.

Advantages: (1) Diagnostic vaginal examination with the risk of causing hemorrhage can be
avoided. (2). Minimize prolonged and unnecessary hospital stay, (3) To diagnose placenta
praevia .

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Distinguishing features of placenta praevia and abruption placentae:

Placenta praevia Abruptio placentae

-Nature of bleeding (a)Painless apparently (a)Painful, often attributed to
causeless and recurrent. preeclampsia or trauma and
continuous.
(b)Bleeding is always revealed. (b)Revealed concealed or usually
mixed

Character of blood Bright red Dark coloured

General condition Proportionate to visible blood Out of proportion to the visible blood
and anemia. loss loss in concealed or mixed variety..

Features of pre- Not relevant Present in on-third cases.

eclampsia

•Abdominal
examination

Height of uterus Proportionate height May be disproportionately enlarged in

concealed type.
Soft and relaxed
May be tense, tender and rigid
Feel of uterus Mal presentation is
Unrelated, the head may be engaged.
common. The head is high
Mal presentation floating.

Usually present
Usually absent specially in concealed type
F.H.S. Placenta in lower segment.
Placenta in upper segment
Placentography Placenta is felt on the lower
segment Placenta is not felt on lower segment.
•Vaginal Blood clots should not be confused with
examination placenta

COMPLICATIONS

 Maternal

 Fetal

Maternal:

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During pregnancy:

- Antepartum hemorrhage with varying degrees of shock is an inevitable complication of

placenta praevia. The first bout of hemorrhage is seldom severe but torrential hemorrhage
can easily be provoked by injudicious and ill advised internal examination done outside
soon after the warning hemorrhage.

- Mal presentation is common. There is increased incidence of breech and transverse lie
and the lie often becomes unstable.

- Premature labour either spontaneous or induced is common.

During Labour: The following complications occur:

 Early rupture of the membranes.

 Cord prolapse is due to abnormal attachment of the cord.
 Slow dilatation of the cervix is due to the attachment of placenta on the lower
segment.
 Intrapartum hemorrhage may occur due to further separation of placenta with
dilatation of the cervix.
 Increased incidence of operative interference.
 Postpartum hemorrhage is due to:Imperfect retraction of the lower uterine
segment on which the placenta is im planted.Large surface area of placenta with
atonic uterus due to pre-existing anaemia. Occasional association (15%) of
morbidly adherent placenta (placenta accrete, increta percreta) on the lower
segment.Trauma to the cervix and lower segment because of extreme softness and
vascularity.
 It should be remembered that because of antepartum anaemic state, the patient
may become shocked with relatively small amount of blood loss.

Retained placenta and increased incidence of manual removal add further hazard to the
postpartum shock. Increased incidence of retained placenta is due to:

(1) Increased surface area and

(2) morbid adhesion.

Puerperium:

1. Sepsis is increased due to: (a) increased operative interference,

(b) placental site near to the vagina and
(c) anemia and devitalized state of the patient.
2. Sub involution.
3. Embolism.

Fetal:

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 - Low birth weight babies are quite common which may be the effect of preterm labour
either spontaneous or induced. Repeated small bouts of hemorrhage while carrying on the
expectant treatment can cause chronic placental insufficiency and fetal growth
retardation.

- Asphyxia is common and it may be the effect of – (a) early separation of placenta, (b)
compression of the placenta or (c) compression of the cord.

- Intrauterine death is more related to severe degree of separation of placenta, with

maternal hypovolemia and shock. Deaths are also due to cord accidents.

- Birth injuries are more common due to increased operative interference.

- Congenital malformation is there times more common in placenta praevia.

PROGNOSIS

Maternal:

(a) Early diagnosis

(b) Omission of internal examination outside the hospital
(c) Free availability of blood transfusion facilities
(d) Potent antibiotics
(e) Wider use of caesarean section with expert anaesthetist and
(f) Skill and judgement with which the cases are managed.
All these factors have led to reduction of maternal deaths from placenta praevia to less than
1% or even to zero in some centres
Fetal:
Caesarean section which greatly lessens the loss from anoxia and improvement in the neonatal
care unit. But still the perinatal mortality ranges from 10-25%. The causes of death are –
(a) prematurity,
(b) asphyxia
(c) congenital malformation.

MANAGEMENT

1. May be given drugs that can prevent premature labor or birth example is progesterone.
2. Ultrasound exams to determine migration of an early diagnosed previa or classification of
the previa as total, partial, marginal, or low-lying.
3. With a small first bleed, client may sent home on bed rest if she can return to hospital
quickly.
4. If bleeding is more profuse client is hospitalized on bed rest with BRP, IV access; labs:
Hgb and Hct, urinalysis, blood group and type and cross match for 2 units of blood hold,
possible transfusions; goal is to maintain the pregnancy fetal maturity.
5. No vaginal exams are performed except under special conditions requiring a double set-
up for immediate cesarean birth should hemorrhage result.

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 6. Low lying or marginal previas may allowed to deliver vaginally if the fetal head acts as
tamponade to prevent hemorrhage.
7. Cesarean birth, often with vertical uterine incision, is used for total placenta previa.
8. Steroid shots may be given to help mature the baby's lungs.

PLACENTAL ABRUPTION

DEFINITION

Placental abruption occurs when the placenta separates from the wall of the uterus prior to the
birth of the baby. This can result in severe, uncontrollable bleeding (hemorrhage).

Dc dutta

DEFINITION:

- Premature separation of the placenta from the uterine wall.

- Common cause of bleeding during the second half of pregnancy
- Usually occurs after 20 to 24 weeks of pregnancy but may occur as late as during first or
second stage of labor.

wikipedia

CAUSE:

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The cause of placental abruption is unknown. However, a number of risk factors have been
identified. These factors include:

• older age of the mother

• history of placental abruption during a previous pregnancy
• high blood pressure
• certain disease states (diabetes, collagen vascular diseases)
• the presence of a type of uterine tumor called a leiomyoma
• twins, triplets, or other multiple pregnancies
• cigarette smoking
• heavy alcohol use
• cocaine use
• malformations of the uterus
• malformations of the placenta
• injury to the abdomen (as might occur in a car accident)

RISK FACTORS:

- women with parity of 5 or more

- women over 30 years of age
- women with pre-eclampsia - eclampsia and renal or vascular disease.

Factors contributing to ABRUPTIO PLACENTA

- Multiple gestations
- Hydramnios
- Cocaine use
- Decreased blood flow to the placenta
- trauma to the abdomen
- Decreased serum folic acid levels
- PIH

The uterus is the muscular organ that contains the developing baby during pregnancy. The lowest
segment of the uterus is a narrowed portion called the cervix. This cervix has an opening (the os)
that leads into the vagina, or birth canal. The placenta is the organ that attaches to the wall of the
uterus during pregnancy. The placenta allows nutrients and oxygen from the mother's blood
circulation to pass into the developing baby (the fetus) via the umbilical cord.

During labor, the muscles of the uterus contract repeatedly. This allows the cervix to begin to
grow thinner (called effacement) and more open (dilatation). Eventually, the cervix will become
completely effaced and dilated, and the baby can leave the uterus and enter the birth canal. Under
normal circumstances, the baby will go through the mother's vagina during birth.

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During a normal labor and delivery, the baby is born first. Several minutes to 30 minutes later,
the placenta separates from the wall of the uterus and is delivered. This sequence is necessary
because the baby relies on the placenta to provide oxygen until he or she begins to breathe
independently.

Placental abruption occurs when the placenta separates from the uterus before the birth of the
baby. Placental abruption occurs in about one out of every 200 deliveries. African-American and
Latin-American women have a greater risk of this complication than do Caucasian women. It
was once believed that the risk of placental abruption increased in women who gave birth to
many children, but this association is still being researched.

SYMPTOMS
 symptoms of placental abruption include
 bleeding from the vagina,
 severe pain in the abdomen or back,
 tenderness of the uterus.
 Depending on the severity of the bleeding, the mother may experience a drop in blood
pressure, followed by symptoms of organ failure as her organs are deprived of oxygen
 . Sometimes, there is no visible vaginal bleeding. Instead, the bleeding is said to be
"concealed." In this case, the bleeding is trapped behind the placenta, or there may be
bleeding into the muscle of the uterus.
 Many patients will have abnormal contractions of the uterus, particularly extremely hard,
prolonged contractions.
 Placental abruption can be total (in which case the fetus will almost always die in the
uterus), or partial.
 Placental abruption can also cause a very serious complication called consumptive
coagulopathy. A series of reactions begin that involve the elements of the blood
responsible for clotting.
 These clotting elements are bound together and used up by these reactions. This increases
the risk of uncontrollable bleeding and may contribute to severe bleeding from the uterus,
as well as causing bleeding from other locations. (nose, urinary tract, etc.).
 Placental abruption is risky for both the mother and the fetus. It is dangerous for the
mother because of blood loss, loss of clotting ability, and oxygen deprivation to her
organs (especially the kidneys and heart).
 This condition is dangerous for the fetus because of oxygen deprivation, too, since the
mother's blood is the fetus' only source of oxygen. Because the abrupting placenta is

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 attached to the umbilical cord, and the umbilical cord is an extension of the fetus'
circulatory system, the fetus is also at risk of hemorrhaging.
 The fetus may die from these stresses, or may be born with damage due to oxygen
deprivation. If the abruption occurs well before the baby was due to be delivered, early
delivery may cause the baby to suffer complications of premature birth.

PATHOPHYSIOLOGY OF ABRUPTIO PLACENTAE

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CLINICAL MANIFESTATIONS:

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Covert (severe)/ Mild separation/ Mild Abruptio Placenta

The placenta separates centrally and the blood is trapped between the placenta and the
uterine wall.

Signs and Symptoms:

1. No overt bleeding from vagina

2. Rigid abdomen
3. Acute abdominal pain
4. Decresed . BP
5. Increseased. pulse
6. utero placental insufficiency

Overt (partial)/ Moderate separation/ Moderate Abruptio Placenta

The blood passes between the fetal membranes and the uterine wall and escapes
vaginally. May develop abruptly or progress from mild to extensive separation with external
hemorrhage.

Signs and Symptoms:

1. vaginal bleeding
2. Rigid abdomen
3. Acute abdominal pain
4. Decreased. BP
5. Increased. pulse
6. Uteroplacental insufficiency

Placental Prolapse/ Severe separation/ Severe Abruptio Placenta

Massive vaginal bleeding is seen in the presence of almost total separation with possible
fetal cardiac distress.

Signs and Symptoms:

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 a. Massive vaginal bleeding
b. Rrigid abdomen
c. Acute abdominal pain
d. Shock
e. Marked uteroplacental insufficiency

DIAGNOSIS

 Diagnosis of placental abruption relies heavily on the patient's report of her symptoms
and a physical examination performed by a health care provider.
 Ultrasound can sometimes be used to diagnose an abruption, but there is a high rate of
missed or incorrect diagnoses associated with this tool when used for this purpose.
 Blood will be taken from the mother and tested to evaluate the possibility of life-
threatening problems with the mother's clotting system.

TREATMENT

 The first line of treatment for placental abruption involves replacing the mother's lost
blood with blood transfusions and fluids given through a needle in a vein.
 Oxygen will be administered, usually by a mask or through tubes leading to the nose.
 When the placental separation is severe, treatment may require prompt delivery of the
baby. However, delivery may be delayed when the placental separation is not as severe,
and when the fetus is too immature to insure a healthy baby if delivered.
 The baby is delivered vaginally when possible. However, a cesarean section may be
performed to deliver the baby more quickly if the abruption is quite severe or if the baby
is in distress.

PROGNOSIS

The prognosis for cases of placental abruption varies, depending on the severity of the abruption.
The risk of death for the mother ranges up to 5%, usually due to severe blood loss, heart failure,
and kidney failure. In cases of severe abruption, 50-80% of all fetuses die. Among those who
survive, nearly half will have lifelong problems due to oxygen deprivation in the uterus and
premature birth.

MANAGEMENT:
- Monitoring of maternal vital signs, fetal heart rate (FHR), uterine contractions and
vaginal bleeding
- Likelihood of vaginal delivery depends on the degree and timing of separation in labor
- Cesarean delivery indicated for moderate to severe placental separation
- Evaluation of maternal laboratory values
- F & E replacement therapy; blood transfusion

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 - Emotional support

NURSING INTERVENTIONS:
 Assess the patient’s extent of bleeding and monitor fundal height q 30 mins.
 Draw line at the level of the fundus and check it every 30 mins (if the level of the fundus
increases, suspect abruptio placentae)
 Count the number of pads that the patient uses, weighing them as necessary to determine
the amount of blood loss
 Monitor maternal blood pressure, pulse rate, respirations, central venous pressure, intake
and output and amount of vaginal bleeding q 10 – 15 mins
 Begin electronic fetal monitoring to continuously assess FHR
 Have equipment for emergency cesarean delivery readily available:
o Prepare the patient and family members for the possibility of an emergency CS
delivery, the delivery of a premature neonate and the changes to expect in the
postpartum period
o Offer emotional support and an honest assessment of the situation
 if vaginal delivery is elected, provide emotional support during labor
o Because of the neonate’s prematurity , the mother may not receive an analgesic
during labor and may experience intense pain
o Reassure the patient of her progress through labor and keep her informed of the
fetus’ condition
 tactfully discuss the possibility of neonatal death
o Tell the mother that the neonate’s survival depends primarily on gestational age, the amount
of blood lost, and associated hypertensive disorders
Aassure her that frequent monitoring and prompt management greatly reduce the risk of
death.

o Encourage the patient and her family to verbalize their feelings

o Help them to develop effective coping strategies, referring them for counseling if necessary.

Goals of Care:

1. Blood loss is minimized, and lost blood is replaced to prevent ischemic necrosis of distal
organs, including kidneys
2. DIC is prevented or successfully treated.
3. Normal reproductive functioning is retained
4. The fetus is safely delivered
5. The woman retains a positive sense of self-esteem and self-worth.

Prevention

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Some of the causes of placental abruption are preventable. These include cigarette smoking,
alcohol abuse, and cocaine use. Other causes of abruption may not be avoidable, like diabetes or
high blood pressure. These diseases should be carefully treated. Patients with conditions known
to increase the risk of placental abruption should be carefully monitored for signs and symptoms
of this complication.

PLACENTA ACCRETA

DEFINITION

Placenta accreta is the abnormal adherence of the placenta with villus attachment to the
myometrium. Normally there is tissue called the decidua basalis between the chorionic villi and
the myometrium. In placenta accreta these vascular processes grow directly into the
myometrium. Placenta accreta can progress into placenta percreta. In placenta percreta, the
vascular processes of the chorion (the chorionic villi) may invade the full thickness of the
myometrium. The chorionic villi may grow through the myometrium and the outside covering of
the uterus (serosa) and result in complete rupture of the uterus.

INCIDENCE

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Placenta accreta should be considered in every woman with placenta previa. The incidence of
accreta has increased tenfold in the past 50 years and is now 1 in 2500 pregnancies largely due to
the increase in cesarean section deliveries..28, 29 In the presence of placenta previa, the risk of
accreta rises to approximately 5%. With placenta previa and prior cesarean section, the risk rises
to approximately 20% and increases further with increasing numbers of previous cesarean
sections or uterine surgeries.27,29,30

RISK FACTORS

o Risk factors for placenta accreta include placenta previa with or without previous uterine
surgery, prior myomectomy, prior cesarean section, Asherman’s syndrome, uterine
fibroids and maternal age greater than 35 years.

Diagnosis
o It is ideal to diagnose placenta accreta during the antenatal period. Strong clinical suspicion
is required in the presence of risk factors. The clinician should aim to rule out an accreta
before proceeding to attempting a vaginal delivery. Women with placenta accreta should be
delivered in facilities with adequate resources and personnel to manage complications
including intrapartum haemorrhage and hysterectomy.

o Transabdominal and transvaginal ultrasound.31-33 can detect up to 85% of placenta

accreta. Further additional investigations using ultrasound Doppler34-37 and magnetic
resonance imaging (MRI)38-41 may be helpful to further identify these women, where
this technology is available.
o In most cases, the placenta accreta will be encountered unexpectedly. If the placenta
cannot be delivered at the time of caesarean section or following vaginal delivery, one
management option is to leave the placenta in situ (in place) without further attempts at
delivery if the woman is not actively bleeding.

Important considerations related to placenta accreta:

1. The incidence of placenta accreta has increased significantly, mainly due to increased
caesarean section surgery rates.
2. Accreta should be suspected in the case of placenta Previa, especially if there is a history of
prior uterine surgery.
3. Ultrasound and MRI can be used for diagnosis (see Appendix 1 – Obstetrical Imaging).
4. The delivery should be done in a centre with comprehensive emergency obstetric care services
to manage complications including intrapartum haemorrhage and hysterectomy.

MANAGEMENT

 Consider hospitalization in the third trimester to provide proximity to facilities for

emergency cesarean delivery.

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  Fetal surveillance to detect compression of vessels.
 Antenatal corticosteroids to promote lung maturity.
 Elective cesarean delivery at 35 to 36 weeks of gestation.
 Immediate C/S.
 Avoid amniotomy as the risk of fetal mortality is 60-70% with rupture of the membranes.

VASA PREVIA

DEFINITION
Vasa previa is the term commonly used when foetal blood vessels in the membranes run across
the cervix in front of the presenting part. However, if there are foetal blood vessels in the
membranes, they may rupture when the membranes rupture even if not directly in front of the

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presenting part. When foetal blood vessels are in the membranes they are not protected and are
therefore fragile and may easily rupture.
dc. dutta
INCIDENCE
Vasa Previa occurs 1 in 5000 pregnancies. Incidence is higher in twin pregnancies. Vasa Previa
is also associated with a placenta that is low in the uterus, velamentous insertion of the cord and
succenturiate lobe.

MORBIDITY AND MORTALITY

Foetal mortality is estimated to be as high as 50% to 70%.

DIAGNOSIS
 Prenatal diagnosis is unlikely, but may be made by observing foetal vessels crossing the
internal os on transvaginal sonography. An attempt to look for such vessels can be made
when scanning a woman vaginally for a low placenta. A prenatal diagnosis would
mandate closer observation of the woman and delivery prior to term via an elective
caesarean section.
 The clinical diagnosis should be considered when rupture of the membranes is associated
with acute painless vaginal bleeding and an abrupt change in the foetal heart rate
(tachycardia or bradycardia). Occasionally, the vessels may be felt on digital exam prior
to rupture of the membranes.
MANAGEMENT
When vasa Previa is suspected, the baby needs to be delivered quickly. The best course of action
will depend on the stage of labour. If the woman is fully dilated, operative delivery with vacuum
or forceps is indicated. A caesarean section should be performed if the woman is in labour and
not yet fully dilated, if expertise to use vacuum or forceps or the equipment is not available, or in
the case of failed operative delivery.
o The baby is likely to be compromised at birth. Health care providers should be present
who are able to resuscitate the baby.
o The woman and her family should be advised of the gravity of risk to their baby.
o Where available, an Apt test or Wright’s stain on vaginal blood to detect foetal
haemoglobin could suggest the diagnosis. A positive test would indicate that blood is of
foetal origin, while a negative test indicates that the blood is of maternal origin. In
practice, the Apt test may not be done when there is suspicion of vasa Previa, because the
time is often very short from onset of bleeding from ruptured blood vessels to foetal
collapse from vasa Previa.
o The modified Apt test differentiates foetal from maternal blood.
o Apt test technique:
o Collect bloody vaginal fluid.
o Add a small amount of tap water (haemolyses blood).
o Centrifuge or shake the sample.
o Add 1 cc of 1% sodium hydroxide for every 5 cc of the pink colored fluid (supernatant).
o Read in 2 minutes. Results: Pink sample = fetal hemoglobin (Hgb)

o Yellow–brown sample = adult (maternal) Hgb

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Overview of the Management of Antepartum Haemorrhage
If blood loss is significant:
 Call for HELP from an individual who is culturally appropriate to the community and the
family.
 REMEMBER ABCs (Airway, Breathing, and Circulation)
 Talk with the woman. Provide information and reassurance.
 Monitor vital signs (pulse, blood pressure, respiration, temperature).
 Elevate the woman’s legs to increase return of blood flow to the heart. If possible, raise
the foot end of the bed.
 Urgently mobilize all available health care providers.
 Turn the woman onto her side to minimize the risk of aspiration if she vomits and to
ensure that an airway is open.
 Keep the woman warm but do not overheat her as this will increase peripheral circulation
and reduce blood supply to the vital organs.
 Take a comprehensive history and perform a physical exam. Clinical differences will
give the first clues to the diagnosis.
 Determine hemodynamic stability.
 Evaluate uterine tone and activity.
 Assess the cervix for dilatation or any lesion. Avoid a vaginal exam until placenta Previa
has been ruled out.
 Perform an ultrasound, if possible prior to a speculum exam. Controversy exists
regarding performing a speculum exam in the absence of a prior ultrasound.
 Promptly evaluate foetal health. Ask the woman about changes in foetal movement.
Auscultate the foetal heart rate or use electronic foetal monitoring where available to
determine the health status of the foetus. Ultrasound will assist in assessment of foetal
well-being.

 Carefully monitor the maternal cardiovascular status. Estimate blood loss accurately,
taking into consideration the maternal ability to withstand haemorrhage and replace lost
fluid volume, as indicated.
 Where laboratory facilities exist, draw blood for:
 Type and cross match
 CBC, (haemoglobin, haematocrit, platelet count)
 PT (prothrombin time) or INR (International Normalized Ratio), PTT (partial
thromboplastin time), fibrinogen level
 A Kleihauer-Betke test2 may confirm an abruption and is advisable in all cases of
suspected abruption.
 Arrange for blood donors, if needed.
 Where available, Rh immune globulin should be given to all unsensitized Rh-negative
women with any bleeding or suspected concealed abruption. The dose may be adjusted
by the Kleihauer-Betke results. The usual dose is 300 μg of Rh immune globulin should

25
 be given for every 30 cc of fetal blood detected in maternal circulation (equivalent to 15
cc of packed red blood cells).
Unstable woman
 The two immediate objectives for women who are actively bleeding and
hemodynamically unstable are fluid replacement and delivery.
 While speeding up delivery or preparing the woman for transfer, the following
management steps should occur at the same time.
 Administer oxygen to all women who are hypotensive because oxygen consumption is
increased 20% in pregnancy and the foetus is sensitive to hypoxia.
 Monitor maternal oxygen saturation, where possible.
 Begin active fluid resuscitation and/or blood transfusion using two large bore (16-gauge
or largest available) intravenous lines. Rapidly infuse intravenous fluids (normal saline or
Ringer’s lactate) initially at the rate of 1 L in 15–20 minutes; give at least 2 L of these
fluids in the first hour. This is over and above fluid replacement for ongoing losses. Aim
to replace 2–3 times the estimated fluid loss.
 Perform an ongoing assessment of maternal vital signs, including urine output)
 Continuously monitor foetal well-being.

 If blood transfusion and caesarean section facilities do not exist, the woman should be
stabilized, if possible, and then transferred to an appropriate facility.
 A caesarean section is required if bleeding is due to a placenta Previa (partial or
complete) or abruption when maternal or foetal health is unstable, unless vaginal delivery
is imminent. If the cervix is dilated, operative vaginal delivery may be an option in cases
of placenta abruption.
 Disseminated intravascular coagulopathy (DIC) should be considered. The “bedside clot
test” may be helpful. Assessing clotting status is useful in determining if coagulopathy is
present.
Bedside clot test
 Take 2 mL of venous blood into a small, dry, clean, plain glass test tube (approximately
10 mm x 75 mm).
 Hold the tube in your closed fist to keep it warm (+37 °C).
 After 4 minutes, tip the tube slowly to see if a clot is forming. Then tip it again every
minute until the blood clots and the tube can be turned upside down.
 Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests
coagulopathy.
 If coagulopathy is present:
 Correct with fresh frozen plasma or cryoprecipitate, where available.
 Attempt to deliver as soon as clotting factors have been corrected and volume
replacement is adequate.
 The risk of DIC is increased if the woman presents with an intrauterine fetal death.
 Once maternal and fetal statuses are stable, consider transfer to a high-risk centre if
necessary.

Stable woman
 Continue maternal and fetal surveillance for 12 to 24 hours.

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  Appropriate attention should be paid to the maternal hemodynamic status. All women
with an APH are at risk for recurrent bleeding.
 If the woman has suffered abdominal trauma and is 20 weeks gestation, it is
recommended that she be monitored for a minimum of 4 hours after the trauma. If there
are ominous signs such as bleeding, uterine pain, or more than one contraction in 10
minutes, the duration of surveillance should be longer because abruptio placenta is seen
in about 20 % of such cases.
 If the fetus is preterm, expectant management may be appropriate depending on maternal
fetal status. Antepartum steroids are indicated for a gestational age of 24 to 34 weeks.
Consider the risk on significant subsequent bleeding against fetal maturity.
 Transfer to a high-risk centre may be indicated, based on the maternal and fetal status,
and local resources.
 There is insufficient information to recommend use of tocolytics.

NURSING DIAGNOSIS

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 1. Fluid Volume Deficit r/t massive vaginal hemorrhage due to secondary to complete
placental separation
2. Impaired gas exchange: fetal r/t insufficient maternal-fetal oxygen transfer and supply
secondary to premature separation of the placenta
3. Altered comfort: acute pain related to increase pressure in the abdomen and bleeding
between the uterine wall due to massive accumulation of blood clots behind the
4. placenta secondary to premature separation of the placenta
5. Risk for fetal injury r/t impaired maternal – fetal nutrition and oxygen transfer to the fetus
secondary to premature placental separation
6. Anxiety r/t maternal-fetal outcome due to the lack of knowledge about the effects of early
placental separation secondary Abruptio Placenta

SUMMARY
Today we have discussed regarding definition causes risk factors pathophysiology Antepartum
haemorrhage during pregnancy and management of antepartum haemorrhage
CONCLUSION
Pregnancy is crucial stage in women’s life so, during pregnancy health of women should be
maintained both physical and psychological changes. Physical changes like nausea a vomiting and
bleeding are common problems. If bleeding per vagina more than normal it lead to APH A standard
protocol for the management of APH is essential. A sample protocol is located at the end of this
chapter in Appendix 2 A medical or midwifery directive for nursing staff to initiate management
is recommended. The life-threatening nature of abruptio placenta and placenta previa for both
mother and fetus should be kept in mind, as should the potential for rapid evolution of these
conditions. Vigorous resuscitation should be undertaken when appropriate.
Ultrasound determination of placental location should precede vaginal examination, if it is
available. Ongoing surveillance and active management are required.

BIBLIOGRAPHY
1. “DC DUTTA “ obstetrics Elsevier’s publications seventh edition (2013) pg no 510-
515
2. “NIMA BHASKER” midwifery and obstetrical nursing emess publications 2 nd edition
(2017) pg no 530-560
3. “LOWDER MILK” maternity nursing emesss publications sixth edition (2012) pg no 600-650

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Internet
1. Wikipedia
2. w.w.w. scribd.com
3. w.w.w slides share.com

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