ANTEPARTUM

HEMORRHAGE; PREVIA
&ABRUPTIO PLACENTA
NUR AYUNI BT AZMAN
EISYA RADHIAH
INTAN LYIANA
NUREEN HUMAIRAH
OUTLINES
1. Define and list types of APH
2. Define and list degrees of placenta previa/abruptio placenta
3. List the risk factors of placenta previa/abruptio placenta
4. List symptoms, signs and investigations of APH due to placenta previa/abruptio
placenta
5. Describe first line management and outline the treatment modalities
 ● APH is bleeding from genital tract

DEFINITION OF in pregnancy at 24 weeks of

gestation before onset of labour.
ANTEPARTUM ● It complicates 3-5% of

HAEMORRHAGE
pregnancies
○ Placenta previa
○ Placenta abruptio
○ Other causes
CLASSIFICATION OF ANTEPARTUM HAEMORRHAGE

1. Placental site bleeding

a. Placenta previa
b. Abruptio placenta
2. Extra placental bleeding/local causes
a. Vaginal trauma
b. Cervical ectropion
c. Cervical carcinoma
d. Vaginal infection
3. Others
a. Vasa previa
4. Indeterminate bleeding
HISTORY TAKING
● Per vaginal bleeding
○ Amount of bleeding - significant blood loss poses a risk of mortality and morbidity to mother and baby
○ Colour of blood
■ Placental abruption- dark red
■ Placenta previa- bright red
○ Triggering factors
■ Postcoital bleed
■ Trauma, history of fall, massages- placental abruption
● Associated symptoms?
○ Associated with pain or contractions?
■ Placental abruption - painful vaginal bleeding associated with tense rigid abdomen with uterine
contraction
■ Placenta previa- intermittent painless vaginal bleeding, irregular abdominal pain with uterine
contraction
■ Vasa previa- painless bleeding
● Fetal movement
○ Is the baby moving?
■ Placental abruption - absence or reduced fetal movement
● Others
○ Last cervical smear (date/ result normal or abnormal) - Cervical cancer
PHYSICAL EXAMINATION
● General examination
○ Tachycardia, pale, prolonged capillary refill time -placental abruption
● Inspection
○ Look for any scar presence- placenta previa associated with previous caesarean section (risk
factor)
● Palpation (is the uterus soft, tender or firm?)
○ Placental abruption- tense rigid and woody abdomen with tenderness
○ Placenta previa- soft abdomen
● Fetal heart auscultation/CTG
○ Placental abruption & placenta previa -evidence of fetal distress
● Speculum examination (after excluding placenta previa)
○ To assess degree of bleeding and possible local causes of bleeding
ABRUPTIO PLACENTA
DEFINITION

● Abnormal separation of a normally sited placenta

from the uterine wall before onset of labour
TYPES

1. Revealed 2. Concealed 3. Mixed

Premature separation of Blood remains in the uterus as a There is both external bleeding and
placenta with retroplacental retroplacental clot and there is evidence of retroplacental clot.
clot and vaginal bleeding. no external bleeding.
 Risk factor

★ Hypertension
★ Prior placental abruption
★ Trauma
★ Cocaine , smoking
★ Multiparity
★ Advanced maternal age
★ Preterm premature rupture
of the membranes(PPROM)
 Clinical Features
History:
- Classically, there is painful bleeding. (due to blood behind the placenta and
in the myometrium, and is usually constant with exacerbations)
- the blood is often dark.

Examination:
- Tachycardia suggests profound blood loss
- Hypotension only occurs after massive blood loss.
- Evidence of shock
- The uterus is tender and often contracting (In severe cases, the uterus is
‘woody’ hard and the fetus is very difficult to feel.)
- Fetal heart tones are often abnormal or even absent
 Classification based on severity of abruption
SYMPTOMS FETAL EFFECTS

CLASS 0 Asymptomatic None

CLASS 1 ● Absent or slight vagina None

bleeding
● Abdominal pain may or may
not present
● Uterus irritable

CLASS 2 ● Mild to moderate vaginal Fetal distress

bleeding
● Significant uterine
tenderness with tetanic
contractions

CLASS 3 ● Heavy vaginal bleeding Fetal death

● Painful tetanic contractions
● Maternal shock
 Investigations
● Ultrasound examination
- To determine placental location and identify retroplacental hematoma
- To assess fetal well-being
- To exclude placenta praevia
● Full blood count
- To assess maternal anemia
● Clotting profile
● Klethauer-Betke test
- To detects fetal blood in maternal circulation especially in Rh-negative
● Blood type and crossmatch
- If blood transfusion is necessary
● Urea and electrolytes (BUN)
- To evaluate changes in maternal’s status
● Cardiotocograph
- To assess fetal well being
 MANAGEMENT
Resuscitation of mother

1. Check airway, breathing, circulation (ABC approach) and give oxygen

2. Insert 2 large-bore intravenous cannulae :
● take blood
-for full blood count (FBC) to evaluate haemoglobin and hematocrit
-for coagulation profile to evaluate fibrinogen level, Prothrombin time, Activated Partial Thromboplastin Time and
Platelet count
-for urea and elctrolytes evaluation
-cross match (for ABO grouping and Rh grouping) as patients may be at risk for hemorrhagic shock so they may need
blood transfusion ( if mother is Rh- , give anti-D immunoglobulin )

● start IV crystalloid to treat hypovolemia

3. Insert urine catheter for monitoring urine output and proteinuria

Assessment of fetal health

- Use cardiotocography (CTG) to monitor fetal heart rate

- Ultrasound to assess fetal well-being and determine placental location

 Expectant management Emergent management

= Indications : For minor abruptions, stable maternal = Indications : presence of maternal and fetal
and fetal condition compromise and require immediate delivery, fetal demise

For pregnancy <37 weeks ; aim to prolong pregnancy ● Plan :

1) Patient in labour : vaginal delivery
Plan :
(amniotomy may be required to expedite delivery)
1) Admitted to antenatal ward
- Maternal parameter monitoring (vitals, FBC, pad
2) Patient is not in labour :
chart)
- Fetal CTG assessment Induction of labour with amniotomy + with or
- Corticosteroid for <34 weeks gestational age to without oxytocin
accelerate lung maturity OR
2) Discharged when symptoms settle (“high risk”) Caesarian section if severe abruption, amniotomy
- Immediately come to hospital if the symptoms cannot be done, amniotomy cannot control
recur bleeding, fetal distress
3) Plan for vaginal delivery when >37 weeks
( C-section if contraindicated to vaginal delivery) 3) Fetal demise : give blood products + Amniotomy
(with or without oxytocin) OR C-section if
contraindicated for vaginal delivery
Postpartum management

- Blood transfusion may be required

- Retained placenta should be removed
- Monitor urine output, hemoglobin concentration

(DC Dutta’s Textbook of Obstetrics 8th Edition)

PLACENTA PREVIA
DEFINITION ● Partially or completely implanted placenta over the lower
uterine segment (over or adjacent to internal os)

RISK FACTORS ● Multiparity

● Increased maternal age
● Prior placenta previa
● Multiple gestation
● Cesarean delivery
TYPES

Type 1 (low lying placenta) : Major part of placenta is attached to upper segment, not reach internal os
Type 2 (marginal) : The edge of placenta extends to margin of internal os
Type 3 (incomplete/partial central) : Placenta partially covers internal os
Type 4 (central/total) : Placenta completely covers internal os
 CLINICAL FEATURES
-ON PALPATION-
Bright red, painless Uterus is soft & non tender
vaginal bleeding
Blood are not retained in the uterus → not
- Growth of the lower uterine segment increased the tonicity of uterus → uterus
→ disrupts placenta vessels → is not rigid (soft) & non tender
bleeding

- Bright red blood : bcs bleeding occur -ULTRASOUND-

close to the cervical opening → Low lying placenta
escape from cervix immediately
- Painless : bcs the blood are not
retained in the uterus Fetal head is not
engaged and high
- Can occur after 20 weeks of
gestation - It cannot enter the pelvis due to
obstruction by placenta
Irregular abdominal pain
associated with uterine Abnormal fetal lie
contractions - Transverse lie
- Breech presentation
 INVESTIGATIONS
1. Ultrasound
- To confirm the placenta site
- Assess fetal well being
- Determine fetal lie & position

2. Cardiotocography (CTG)
- To assess fetal heart rate

3. Transvaginal ultrasound
- Only use, if after transabdominal scan, the location of placenta is still
unsure (bcs it is an invasive procedure)
- It is more accurate as the probe will be closer to the target area
(women reproductive organ)
- Indications :
- If the placenta located at the posterior segment of the uterus
- Diagnose type 1 & type 2

4. Abdominal examination
- Do not palpate the abdomen
5. Laboratory investigations

- Full Blood Count (FBC) : to assess haemoglobin level

- Hb : to check for anemia

- Cross-matching test (for ABO grouping & Rh grouping)

- Due to the bleeding, patient may be at risk for haemorrhagic shock.
Hence, need blood transfusion ( if mother is Rh- , give anti-D
immunoglobulin after each episode of PV bleeding)

- Coagulation profile (when indicated)

- fibrinogen level, FDP, Prothrombin time, Activated Partial Thromboplastin
Time and platelet count
- patient had DIC secondary to haemorrhagic shock due to placenta previa
 MANAGEMENT
Placenta migration occur during 28-34 w d/t BLEEDING
development of lower uterine segment. Hence,
< 37 weeks :
before 28 w => low lying placenta
< 34 weeks + hemodinamically stable
NO BLEEDING - Sent patient back home
- Bed rest & no heavy work
< 28 weeks - Avoid abdominal massage
- Advice for pelvic rest (avoid squatting, - Avoid sexual intercourse
strenuous lower body activities, yoga) - Gives IM dexamethasone
- Advice for bleeding precautions - Immediately come to hospital if any
- Follow up ultrasound at 36 weeks of contraction pain happen
gestation (to reconfirm placenta location) - Arrange for elective caesarean at term
(37-38 weeks)
28-36 weeks
- Review ultrasound > 34 weeks
- Check if placenta previa resolved - Admit to the ward
- YES : vagina delivery - Bed rest
- NO : elective caesarean at term - Monitor CTG , ultrasound & vital signs
- Arrange for elective caesarean at term
> 36 weeks
- Elective caesarean > 37 weeks :
- Emergency caesarean
 Abruptio placenta vs placenta previa
PLACENTAL ABRUPTION PLACENTA PREVIA

General Abnormal separation of a normally Partially or completely implanted

sited placenta from the uterine wall placenta over the lower uterine
before onset of labour segment (over or adjacent to
internal os)

Risk factor ★ Hypertension ★ Prior C-section

★ Coccaine ★ Multiple gestation
★ Trauma ★ Increase maternal age
★ Multiparity ★ Prior placenta previa

Symptoms ❏ Painful vaginal bleeding ❏ Painless,bright red vaginal

❏ Uterine contractions bleeding

Diagnosis - Clinical suspicion - Transabdominal ultrasound

- Laboratory coagulopathy - Transvaginal ultrasound
REFERENCES
1. Obstetrics Ten Teachers 20th edition

2. Obstetrics & Gynaecology : Lawrence Impey & Tim Child, 5th Edition

3. Oxford Handbook of Obstetric & Gynaecology

4. DC Dutta’s Textbook of Obstetrics

5. Obstetric and Gynaecology at a Glance, 4th edition

6. Obstetric Illustrated

7. Hacker & Moore’s Essentials of Obstetrics & Gynaecology 6th Edition

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