Antepartum haemorrhage

- Complicates 2-5% of pregnancies

- Defined as bleeding from 20 weeks until birth
- Symptomatic placenta praevia occurs in 0.4-0.8% of pregnancies
- Placenta praevia is a coincidental finding in 10% of abruption cases
- Approx 2-3% of women with a placenta praevia at 20-25 will still have a praevia at
delivery

Placental abruption

- 3-6 per 1000 pregnancies

- 70% of abruptions in low risk pregnancies
- the perinatal mortality can be as high as 48%
- occurs when there is premature separation of a normally sited placenta

There are two potential mechanisms for placental abruption:

- acute inflammation
- chronic vascular dysfunction

Bleeding begins in the decidua basalis and leads to the separation of the placenta from its
attachment to the uterine wall.
This sepration can be partial or self limiting, or can extend until there is fetal hypoxia and
ultimately demise
A Couvelaire uterus occurs when large pressure during contractions forces blood into the
myometrium. The uterus appears severely bruised and is infiltrated with blood and will
contract poorly leading to PPH.

Symptoms/signs

- Vaginal bleeding- 70-80%

- Abdominal pain- 50%
- Uterine tenderness- 70%
- Uterine contractions- 35%
- Fetal distress- 65% or IUD 15%
- Shock/DIC

Fibrinogen <2 signifies severe abprution.

DIC is present in in 20% of patients with severe abruption
PT will be increased in severe abruption

Kleihauer is not useful for diagnosing abruption but can help in Rh –ve mothers to
determine level of anti D required

Cocaine- vasoconstriction causes distruption of placental blood flow and there is an

incidence of 2-15% abruption in cocaine users
 Smoking- associated with a 90% increase in the risk of placental abruption

PPROM- infection and inflammation can cause placental abruption. <20 weeks 50%, 20-
24 weeks 44% and 29-32 weeks 13%

Recurrence- 10X more likely if previous abruption. After two pregnancies affected, the
chance of recurrence is between 19-25%

Other risk factors include:

- Increased maternal age
- First trimester bleeding
- Low BMI
- Pregnancy following ART

Placenta praevia

- For LLP diagnosed at 20 weeks, further TVS should be booked for 32 weeks, if still
low lying then further TVS booked for 36 weeks if asymptomatic

Grade I- lower edge outside lower uterine segment

Grade II- lower edge reaching internal os
Grade III- placenta partially covering os
Grade IV- placenta completely covering os

For pregnancies >16 weeks, the placenta should be reported as ‘low lying’ when the
placental edge is less than 20mm from the internal os and normal when placental edge is
>20mm from the internal os on TAS or TVS

- The incidence of placenta praevia at term is 1 in 200 pregnancies (0.5%)

Risk of placenta praevia with previous CS

(relative risk)
One previous- 4.5
Two previous- 7.4
Three previous- 6.5
Four previous -44.9

In 35% of cases of placenta praevia the fetus is malpositioned

Risks for women with placenta praevia:

- 11 in 100 women will require emergency hysterectomy (very common)

- need for further laparotomy 75 in 1000 (common)
- VTE- 3 in 100 (common)
- Bladder or ureteric injury 6 in 100 (common)
 - Future praevia 23 in 1000 (common)
- MOH 21 in 100 (very common)

In women with placenta praevia and previous caesarean section

Emergency hysterectomy 27 in 100 (very common)

In women with accrete should be advised emergency hysterectomy highly likely

Antenatal steroids

- Recommended between 34+0 and 35+6 for all women with low lying placenta.
- Appropriate prior to 34 weeks if high risk for preterm delivery.

Timing of delivery

- In uncomplicated praevia, delivery should be considered between 36+0 and 37+0

Indications for birth before 36 weeks:

- Onset of labour
- Fetal distress
- Severe growth restriction
- IUD
- Severe bleeding

Placenta accreta

It is believed that the decidua basalis is damaged during previous surgery. This is the layer
that prevents the trophoblastic cells from invading deeper.

Placenta accreta: chorionic villi attach directly to the myometrium in the absence of decidua

Placenta increta: placental villi invade deeper into the myometrium but do not extend to
the outermost layers of the uterus

Placenta percreta: chorionic villi penetrate through the myometrium up to the serosa. The
neo-vascularisation caused by the growing placenta percreta may soften the tissues of
adjacent organs and stimulate invasion
 Link between number of previous caesarean sections and risk of placenta accreta,
placenta praevia and hysterectomy

Incidence of
Previous Women with
Wome placenta accreta Hysterectomie
caesarean placenta
n with placenta s
sections accreta
previa

0 6201 15 (0.24%) 3% 40 (0.65%)

1 15 808 49 (0.31%) 11% 67 (0.4%)

2 6324 36 (0.57%) 40% 57 (0.9%)

3 1452 31 (2.13%) 61% 35 (2.4%)

4 258 6 (2.33%) 67% 9 (3.5%)

5 89 6 (6.74%) 67% 8 (8.9%)

The majority of placenta accreta are undiagnosed in 50-63% prior to delivery

Placenta accrete carries a mortality rate of 7%.

Management of placenta accreta

- Elective admission from 34 weeks with antenatal steroids.

- Aim for delivery between 35-36+6 weeks

Vasa praevia

- Fetal vessels crossing the internal cervical os through the free placental membranes
- Unprotected by whartons jelly or the umbilical cord, they are likely to rupture during
active labour or at ARM.
 - The prevalence varies from 1:1200 to 1:5000 pregnancies and the associated fetal
mortality is 60%.
- Approx 60% of women with vasa praevia at delivery have a placenta praevia
identified during 2nd trimester ultrasound.

There are two types of vasa praevia:

Type 1: occurs secondary to a velamentous cord insertion (90% of cases)

Type 2: occurs when fetal vessels connect lobes of the placenta, for example when
succenturiate lobe is present (10% of cases)

IVF is a risk for vasa praevia increasing risk to 1:250 for type 1

Management of vasa praevia

- RCOG recommend considering hospitalisation from 30-32 weeks particularly if

multiple pregnancy, antenatal bleeding or TPTL.
- Elective CS at 34-36 weeks with steroids from 32 weeks in asymptomatic patient.
- If bleeding, deliver immediately due to risk of fetal blood loss.

Uterine rupture

- Full thickness loss of integrity of uterine wall and visceral peritoneum.

- Uterine scar dehiscence foes not involve the visceral peritoneum and the placenta
and fetus remains in the uterine cavity.
- Most cases occur during labour following previous caesarean section or other
uterine surgery such as myomectomy.

- The risk of scar rupture after one caesarean section is 1:200 with spontaneous birth
however increase 2-3 fold with IOL and augmentation.

- Uterine rupture is rare with unscarred uterus, affecting 0.5-2 per 10,000

- Previous uterine rupture carries a 5% risk of previous rupture

- CTG abnormalities associated with 55-87% of rupture