APH

DEFINE ANTEPARTUM HEMORRHAGE

Bleeding from the genital tract after the period of viability and prior to delivery of the baby.
WHAT ARE THE CAUSES OF APH?

Placenta previa
Abruptio placenta
Local lesions-cervical polp,erosions,malignancy
Vasa previa
Rupture of marginal sinus
Trauma to genital tract
unclassified
HOW DO YOU CLASSIFY APH?

Minor:<50ml
Major:50-1000ml
Massive:>1000ml
WHAT IS PLACENTA PREVIA?

Placenta previa is defined as placenta that is implanted over or adjacent to internal os

INCIDENCE:
3-5/1000 at term
HOW DO YOU CLASSIFY PLACENTA PREVIA?

CLASSIFICATION OF PLACENTA PREVIA

Type I:in the lower uterine segment
Type II:upto internal os
Type III:placenta covers the internal os when cervix not dilated but only partially when the cervix
is dilated
Type IV:placenta completely covers the internal os even when the cervix is fully dilated.

SONOLOGICAL CLASSIFICATION:
Low lying placenta:placenta in lower uterine segment within 2cm from internal os and not
covering it
Placenta previa:placenta partially or completely covers the internal os.
 WHAT ARE THE RISK FACTORS FOR PLACENTA PREVIA?

Previous c-section
Previous curettage/intrauterine surgery
Previous placenta previa
Maternal smoking/cocaine use
Multiple pregnancy
Multiparity
Increasing maternal age.
HOW DO YOU CLINICALLY DIFFERENTIATE PLACENTA PREVIA
&ABRUPTION?

FEATURES PLACENTA PREVIA ABRUPTIO PLACENTA

HISTORY Painless vaginal Associated abdominal pain
bleeding,recurrent episodes Single episode
GENERAL E/O Shock proportionate to blood In concealed cases, shock out of
loss proportion to blood loss
P/A Uterine size=POG Uterine size>POG
Soft Tense,tender
Malpresentations common Uncommon
Fetal parts well felt Difficult to palpate
FHR-normal abnormal
RENAL FAILURE &DIC Not common common
PLACENTA ACCRETA common Not common
WHAT IS PLACENTAL MIGRATION?
Majority of placenta previa (90%) diagnosed in 2nd trimester resolves by term.This is known as
placental migration.
It is due to –
differential growth of upper & lower uterine segment.
-growth of the placenta in the lower uterine segment toward the more vascular upper segment.
WHAT IS THE ROLE OF USG?
TVS-100% accuracy in diagnosing placenta previa.
Rules out Placenta accreta spectrum
Rules out abruption
Can assess fetalgrowth,presentation.
CAN ABRUPTION AND PLACENTA PREVIA CO-EXIST?

Yes in around 10% of cases.

WHAT IS THE IMPORTANCE OF BLOOD GROUP?

-Blood transfusion
-for anti D if Rh negative
 HOW WILL YOU MANAGE PLACENTA PREVIA AT DIFFENT GESTATIONAL AGES?

For all
-assess maternal bloodloss and resuscitate with blood and blood products if needed
-anti D if rh negative.
-assessment of fetal status with uss and NST.
-rule out placenta accreta spectrum
In 2nd trimester:-IF MILD BLEEDING WITH SPONTANEOUS CESSATION AND
REASSURING FETAL STATUS

-reassure
-report if further episodes.
-repeat USS at 28 wks and then at 4weeks interval.
EARLY THIRD TRIMESTER-IF MILD BLEEDING WITH SPONTANEOUS CESSATION AND
REASSURING FETAL STATUS

Admit the patient.

MAC CAFEE JOHNSON REGIME-conservative management.
Correct anemia if present.
Antenatal corticosteroids for fetal lung maturity.
Arrange blood
Assess fetal growth.
Terminate if recurrent episodes/non reassuring fetal status.
TERMINATE THE PREGNANCY
If non reassuring fetal status
Recurrent bleeding while on conservative management.
By 37 weeks.
 MODE OF TERMINATION:

A double set up pervaginal examination can be done in cases if ceplalic presentation, placenta is
anterior &2cm from internal os-palpate in posterior fornix to feel for bogginess of placental
tissue & if no bogginess/excessive bleeding normal vaginal delivery can be tried with careful
monitoring of FHR.
Others-LSCS
PAS-classical c-section
WHAT ARE THE COMPLICATIONSTO BE ANTICIPATED DURING DELIVERY?
Vaginal delivery:
FHR decelerations.
PPH
Stallworthy’s sign:FHR decelerations in cases of posterior placenta due to head
compression
C-Section:
-Anterior placenta:
placenta might cut through & in that case baby should be delivered as soon as
possible.
find a plane beneath placenta(Ward technique)
-Malpresentations common:difficult in delivery of baby.
-Bleeding from placental bed:hemostatic sutures to be put to arrest bleeding.
-Non separation of placenta:if placenta accrete spectrum not ruled out
antenatally.
WHY DOES A PATIENT WITH PLACENTA PREVIA BLEED?
Antenally:
with formation of lower uterine segment & at the onset of contractions,there is detatchment
of placental tissues resulting in bleeding episodes.
After delivery:
lower uterine segment donot contract & hence bleeding from placental bed.
WHAT ARE THE COMPLICATIONS?
FETAL:
complications of preterm.
fetal growth restriction.
fetal hypoxia.
IUD.
MATERNAL:
hypovolemia & shock-transfusion,renal failure & DIC.
PPH
increased operative deliveries.
Placenta accrete spectrum-obstetric hysterectomy.
Increased maternal morbidity & mortality.
DEFINE ABRUPTIO PLACENTA & HOW DO YOU CLASSIFY IT?

Premature separation of a normally situated placenta after 24 weeks of gestation.

Acute & chronic
Concealed & revealed.

GRADES-SHER & STATLAND

-Grade 0:asymptomatic & incidental RP clots
-Grade 1:vaginal bleeding,abdominal pain,uterine tenderness with no fetal distress.
-Grade 2: vaginal bleeding,abdominal pain,uterine tenderness with fetal distress.
-Grade 3:A-IUD with no maternal coagulopathy
B-IUD with maternal coagulopathy.
WHAT ARE THE RISK FACTORS FOR ABRUPTION?

Rapid decompression of uterus:

-polyhydramnios
-multiple pregnancy
-PPROM
Shearing of placental vessels:
-abdominal trauma
-ECV
Vasospasm and placental hypoperfusion:
-hypertension,pre eclampsia
-thrombophilias
-smoking/cocaine use
Inadequate decidualization:
-increased maternal age/multiparity
-uterine anomalies,fibroid uterus
 ROLE OF USS IN DIAGNOSING ABRUPTION

More useful in diagnosing placenta previa rather than abruption.

Early RP clot may be hyper/isoechoic and may be interpreted as thickened placenta.
If a RP hematoma is identified ,it indicated a massive bleeding
Sensitivity is 25-50% only.
JELLO SIGN:intrauterine clots may be seen floating in amniotic fluid whichjijjle on bouncing with
transducer.
 WHAT WILL BE THE MODE OF TERMINATION?
Whenever abruption is diagnosed,termination of pregnancy is needed.
Ceserean section is done most of the times.
Vaginal delivery can be attempted if
-live fetus with normal FHR pattern and no maternal coagulopathy and delivery is
imminent
-dead fetus with no maternal coagulopathy.
WHAT IS VASA PREVIA?
Presence of umbilical vessels running through the membranes across the internal os below the
presenting part.
since these vessels are not protected by whartons jelly,they are prone to rupture and torrential
bleed during labour.
Types:
-1-associated with velamentous cord insertion
-2-vessels running between placenta and its succenturiate lobe.