ANTEPARTUM

HEMORRHAGE > 20 WEEK

Definition

Antepartum bleeding is vaginal bleeding at a

gestational age above 22 weeks or more.

Placenta previa is the placenta that implants in the

lower uterine segment, which can cover part or even the entire
internal uterine os.

Placental abruption is the detachment of part

or all of the maternal surface of the placenta from its
implantation site before the baby is born.
 Etiology

Causes ( Abrubtio placenta)

Causes ( placenta previa) ● The primary cause of
● blastocyst attached to
placental abruption is
the bottom of the unknown, but there are
uterus several pathological
● Inadequate decidual
conditions that are seen
vascularization frequently with or
● endometrium in the
accompanying placental
fundus that is not abruption
ready to accept
implantation.
 abrubtio placenta

1. Vascular factors (80-90%), namely toxemia

gravidarum, chronic glomerulonephritis, and essential
hypertension.
2. Trauma factors: - Sudden wasting of the uterus in
hydramnios and tickling. - Pulling on the short
umbilical cord due to large/free fetal movement,
external version, or birth assistance.
3. Parity factor. More common in multi than primi.
Holmer notes that wa of 83 cases of placental
abruption found 45 multi and 18 primi.
4. Direct trauma such as falling, being kicked, and
others.
5. Use of cigarettes / nicotine
 Risk factor (Placenta Previa and
abrubtio placenta)

● Age and parity

● The corpus luteum reacts slowly
● History of previous cesarean
section
● Endometrial hypoplasia
● History of uterine surgery
Total placenta previa

Placental implantation completely covers the internal uterine OUI.

placenta previa classification

Partial placenta previa

Placental implantation partially covers OUI.

Marginal placenta previa

if the placenta implants around the internal uterine os, with its tip at the edge of
the OUI.

Low lying placenta previa

Placental implantation in the lower part of the uterus, the edge can be felt with
the fingers, the tip is about 4 cm from the OUI.
solusio/abrubtio placental classification
CMD PLASENTA PREVIA
Investigations for placenta previa

❖ Ultrasound: can be used to measure

the distance between the uterine os
and the placenta
❖ the accuracy of diagnosis with
transabdominal ultrasound
reaches 95 – 98%
❖ while the accuracy of transvaginal or
transperineal (translabial)
ultrasound is even higher
● MRI: is the GOLD STANDART for
measuring the boundaries of the
placenta with OUI
How to diagnose? SOLUSIO PLASENTA

Pemeriksaan Fisik
1. Shock, hypotension
2. Visible blood coming out of the vagina
3. the uterus feels tense and hard like a board
called uterus in bois (wooden uterus)
4. the parts of the fetus are difficult to
recognize because the stomach (uterus) is
tense
Anamnesis 5. gawat janin (fetal distress)
1. Vaginal black bleeding
2. Abdominal pain
3. There is a reason (ex: hypertension,
trauma, etc.)
4. Not recurrent
 Investigations for SOLUSIO PLASENTA
★ Ultrasound examination: you can find
retroplacental blood deposits of varying
sizes, the amniotic fluid looks cloudy
because it is mixed with blood
★ Laboratory examination : Decreased
Hb, check blood group, COT every 1
hour, qualitative fibrinogen test,
quantitative fibrinogen test (normal level
is 150 mg%)
General Management
★ Correct fluid/blood
deficiency by infusion of
intravenous fluids (0.9%
NaCl or Lactated
Ringer's).
★ Assess the amount of
bleeding.
Active Management
if the baby is full term, fetal
distress (+), active and profuse
bleeding
★ pervaginam -> if the
placenta is low and head
presentation
★ sisanya SC
TREADMENT PLASENTA PREVIA
Expectant Management
★Expectant therapy requirements:
➔ Preterm pregnancy with scanty bleeding that stops with or
without tocolytic treatment
➔ There is no sign of inpartu yet
➔ Mother's general condition is quite good (Hb levels within
normal limits)
➔ The fetus is still alive and the condition of the fetus is good
★Give tocolytics if there are contractions:
➔ MgSO4 4 g IV initial dose followed by 4 g every 6 hours, or
Nifedipine 3 x 20 mg/day
★Administration of tocolytics combined with betamethasone 12 mg
IV single dose for fetal lung maturation
★Correct anemia with ferrous sulfate or ferrous fumarate orally
60 mg for 1 month.
 TREATMENT SOLUSIO PLASENTA
If there is heavy bleeding (overt or occult) with the first signs of shock in the mother, initiate labor
immediately:
★ If cervical dilatation is complete, deliver by vacuum extraction
★ If the opening of the cervix is not complete, do labor with cesarean section
If the bleeding is light or moderate and there are no signs of shock, the actions depend on the fetal heart rate
(FHR):
❖ DJJ normal, do caesarean section
❖ DJJ is not heard but the mother's pulse and blood pressure are normal: consider vaginal delivery
❖ DJJ is not audible and the mother's pulse and blood pressure are problematic: rupture the
membranes with kokher
➔If the contractions are bad, correct them with oxytocin
➔If the cervix is supple, thick and closed, do a cesarean section
❖ DJJ Abnormal (less than 100 or more than 180/min): perform vaginal delivery immediately, or
cesarean section if vaginal delivery is not possible
Differential Diagnosis
Placenta previa: Placental implantation is located at the
bottom of the uterus
thus blocking the birth canal

● without pain,
● recurrent bleeding,
● without cause,
● vaginal touch (-)

Transvaginal
USG ( gold
standard)
 Differential Diagnosis

Placental abruption / detachment of the placenta from the site

implantation
abruptio placenta

- intense pain
- black blood
- history of trauma,
- hypertension

Transabdominal USG
(Retroplacental bleeding)
 Differential Diagnosis
vasa previa Etiology there is fetal distress
that is not proportional to the
number bleeding
● Occurs after the rupture
of the membranes,
● a sign of shock to the
mother and fetus
● fresh red blood,
● without pain
PATOFISIOLOGI PLASENTA PREVIA
PATOFISIOLOGI SOLUSIO PLASENTA
COMPLICATION
previa plasenta

The rhythmic formation/development of the uterine

segments causes recurrent bleeding so that the patient
can be anemia even with shock hypovolemic.
Because the placenta is in the lower uterine segment, it is
easy for invasion to occur into the myometrium and even
to the perimetrium, leading to placenta increta and
percreta. The mildest is placenta accreta.
Another complication that can be high risk for the
occurrence of placental abruption
PROGNOSIS PLASENTA PREVIA
The prognosis for placenta
● Maternal prognosis (maternal is usually good) previa depends on several
● reducing the number of pregnant women with factors:
high parity and high age due to socialization of 1. class level of bleeding
family planning programs - reducing the that occurs
incidence of placenta previa. 2. gestational age whether
● The baby's prognosis depends on its premature or term
gestational age, the fetus is still not free from 3. general condition of
complications of premature birth either maternal and fetus before
spontaneous birth or due to inversion of bleeding
cesarean section. 4. the ability of the hospital
to provide services
5. Number of previous
pregnancies.
Patient Education

● Placenta previa is the covering of the internal cervical os preventing

a safe vaginal delivery.
● Delivery should be performed from 36 to 37 full weeks, via
cesarean section, in uncomplicated cases.
● Bed rest, avoiding intercourse, and avoiding digital examinations
are recommended. Any manipulation of the placenta can lead to
hemorrhage.
● Patients with placenta previa should go to the emergency room if
they have any episodes of vaginal bleeding.

Anderson-Bagga FM, Sze A. Placenta Previa. 2022 Jun 21. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2023 Jan–. PMID: 30969640.
PROGNOSIS SOLUSIO PLASENTA

● Placental abruption has a poor prognosis

for the mother and even worse for the
fetus.
● Mild placental abruption has a better
prognosis for mother and fetus
● In moderate and severe placental
abruption, the prognosis also depends on
the speed and accuracy of medical
assistance obtained by the patient.
Patient Education
● the patient must be encouraged to stop smoking to lower the
risk. Another major risk factor is the abuse of cocaine,
which must be curtailed.
● Patients also need to be educated about risk factors,
discontinuation programs to prevent recurrence of placental
abruption in the future
● In patients who choose to undergo elective sectio caesarea
(SC), doctors need to explain that there is an increased risk
for the patient to experience retained placenta in subsequent
pregnancies.
● Apart from that, patients are also educated for periodic
control of the womb to health facilities.

Schmidt P, Skelly CL, Raines DA. Placental Abruption. 2022 Dec 19. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2023 Jan–. PMID: 29493960.
REFERENSI
 Anderson-Bagga FM, Sze A. Placenta Previa. 2022 Jun 21. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID:
30969640
 Schmidt P, Skelly CL, Raines DA. Placental Abruption. 2022 Dec 19. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–.
PMID: 29493960.
 Pengantar Kuliah Bstertetri. N.p.: Egc, (n.d.).
 Prawirohardjo Sarwono (2016). Buku Ilmu Kebidanan Edisi 4. Jakarta: PT Bina
Pustaka Sarwono Prawirohardjo
 Mochtar Rustam. 2011. Sinopsis obstentri Fisiologi dan Obstentri Patofisiologi.
 Edisi 3 Jilid I. Jakarta: EGC.
 Malia SM, Islamy N, Triyandi R, Kedokteran F, Lampung U, Obstetri B, et al.
Merokok Sebagai Faktor Risiko Terjadinya Solusio Plasenta Smoking As A Risk
Factor Of Placenta Abruption. 2023;13:162–5.