APH

Bleeding from or into the genital tract after 28th

week of gestation but before the birth of the baby

Placental bleeding: Placenta Previa (35%) &

Placenta abruption(35%)
Causes of third trimester bleeding
Cervicitis
Cervical erosions
Endocervical Polyp
Cancer of cervix
Vulvar ,vaginal,cervical varicocities
Vaginal infections
Foreign bodies
contd
Genital lacerations
Bloody show
Degenerating leiomyoma
Vasa Previa
ABRUPTIO PLACENTAE
 Definition
Abruptio Placentae( placental
abruption):

Premature separation of the

normally implanted placenta from the
uterine wall before the birth of the
fetus.
1% of all deliveries.

0.52-1.29% severe enough to cause fetal death.

Increases with gestational age.

VARIETIES
REVEALED: Following separation of the placenta, the
blood insinuates downwards between the membranes
and the decidua, the blood comes out of the cervical
canal to be visible externally. This is the commonest
type.
CONCEALED: Blood collected behind the separated
placenta. Concealed hemorrhage carries much greater
maternal and fetal hazards.
MIXED: some part of the blood collects inside
(concealed) and a part is expelled out (revealed). Usually
one variety predominates over the other. This is quite
common.
Pathology
 Etiology
Mechanism: Hemorrhage into the decidua
basalis. The hematoma formed separates the
placenta from maternal vascular system
causing impairment in fetal oxygenation and
nutrition.
ETIOLOGY

•Maternal hypertension: Spasm of the vessels

in the uteroplacental bed( decidual spiral
artery)anoxic endothelial damage  Rupture
of vessels or extravasation of blood in the
decidua basalis(retroplacental haematoma)
•Trauma
Sudden uterine decompression (diminished surface
area of the uterus adjacent to the placental
attachment)
1)premature rupture of fetal membranes
2)Polyhydramnios
3)Delivery of Ist twin
Etiology
•Advanced maternal age
•Malnutrition, Smoking
•Risk of recurrence is 17% with one & 25% with
more than one
•Thrombopholias
•Hyperhomocystenemia
Pathology
Placental abruption is initiated by hemorrhage into
the decidua basalis.
Development of a decidual hematoma that leads to
separation, compression, and ultimate destruction of
the placenta adjacent to it.
Inflammation—infection—may be a contributor to
causal pathways.
Decidual spiral artery ruptures to cause a
retroplacental hematoma, which as it expands,
disrupts more vessels to separate more placenta.
Because the uterus is still distended by the products
of conception, it is unable to contract sufficiently to
compress the torn vessels that supply the placental
site.
The escaping blood may dissect the membranes
from the uterine wall and eventually appear
externally or may be completely retained within
the uterus .
Concealed Hemorrhage
Retained or concealed hemorrhage is likely when:
There is an effusion of blood behind the placenta,
but its margins still remain adhered
The placenta is completely separated, yet the
membranes retain their attachment to the uterine
wall
.
Blood gains access to the amnionic cavity after
breaking through the membranes
The fetal head is so closely applied to the lower
uterine segment that blood cannot make its way
past.
Most often, however, the membranes are gradually
dissected off the uterine wall, and blood sooner or
later escapes
 diagnosis
• vaginal bleeding(78%)

•Tender uterus & Back pain(66%)

• Uterine hypertonicity &Uterine

contractions(17%)

•Fetal distress,fetal demise 25-35%

•DIC(13%)
Grades
Grade I
Clinical feature may be absent, Diagnosis after
inspection of placenta after delivery.(Retrospective)
Grade II
Fetus is alive.
Abnormal fetal heart patterns.
Grade III
Fetal demise is present

III A Presence of coagulopathy

IIIB Absence of coagulapathy

Ultrasonography:
Relatively large retroplacental clots may
be detected
Globular placenta with a diameter of at
least 6cm
Placental examination
The extent of placental abruption of the
maternal surface of the placenta on which
a clot is detected at the time of delivery.
Complication
DIC
Hypovolemic shock
Amnionic fluid embolism
Acute renal failure
DIC
Massive release of thromboplastin in the
circulation  Intravascular formation of fibrin 
Consumption of coagulation factors  Activation
of fibrinolytic system
Coagulation abnormalities
•Hypofibrinogenemia
•Increaseing levels of fibrin degradation
products
•decreasing platelet count
•Increasing prothrombin time and partial
thromboplastin time
•Decreasing other serum clotting factors
Couvelaire Uterus
•widespread extravasation of blood into the uterine
musculature and beneath the uterine serosa.
• First described by Couvelaire in the early 1900s as
uteroplacental apoplexy, it is now termed
Couvelaire uterus.
Naked eye features
Uterus dark port wine colour ,patchy or diffuse
Initially in the cornu
Sub peritoneal petechial hemorrhage
Free blood in the peritoneal cavity
Broad ligament hematoma
Management
Treatment for placental abruption varies depending
on gestational age and the status of the mother
and fetus.
With a fetus of viable age, and if vaginal delivery is
not imminent, then emergency cesarean delivery is
chosen by most clinicians
Prevention
(1) Elimination of the known factors likely to
produce placental separation
(2) correction of anemia during antenatal period
so that the patient can withstand blood loss and
(3) prompt detection and institution of the therapy
to minimise the grave complications namely shock,
blood coagulation disorders and renal failure.
(4) Avoidance of trauma—specially forceful
external cephalic version under anesthesia.
IN Labour

The labor is accelerated by low rupture of the

membranes.
Rupture of the membranes with escape of liquor
amnii accelerates labor and it increases the uterine
tone also.
Oxytocin drip may be started to accelerate labor
when needed.
Severe abruption with fetal
demise
With fetal demise

1. placental detachment is usually greater than

50%
2. 30% of patients will show evidence of
coagulopathy
3. 10% will develop acute renal failure.
4. Retroplacental blood loss is about 2500ml.
Transfusion of blood , IVF to maintain HCT of at
least 30% ,Urine output of 30ml/hr.

Delivery is necessary to decrease maternal

morbidity and mortality.
Management of coagulopathy
Transfusion of blood products(Platelets,
cryoprecipitate. FFP)

Delivery of fetus after assessment of fetal

lie,presentation.

Vaginal delivery safer, avoid trauma and

episiotomy.
Operative interfernces avoided if possible.
Caesarean section for malpresentations ,CPD.

Amniotomy as soon as possible.

Oxytocin
Alive fetus
With rigid uterus
Caesarean section as distress during labour is more
than 90%.

Soft uterus
Vaginal delivery
Caesarean section if fetal distress.
Future pregnancies
Spontaneous abortion in 14%

Repeated abortion 9.3%

Risk of recurrence is 17% with one & 25% with

more than one