1. BLEEDING IN PREGNANCY
Early Pregnancy Bleeding – Antepartum Haemorrhage

2.  Spontaneous Abortion
• Threatened Miscarriage
• Inevitable Miscarriage
 Implantation Bleeding
 Decidual Bleeding
 Ectopic Pregnancy
EARLYPREGNANCYBLEEDING

3.  Spontaneous Abortion
• Threatened Miscarriage
• Inevitable Miscarriage
EARLYPREGNANCYBLEEDING

4. SpontaneousAbortion
 Defined as the involuntary loss of the
products of conception prior to 24 weeks
gestation
 It is thought that 15% of conceptions result in
miscarriage
 Majority occur within first trimester

5. Spontaneous
Abortion
Threatened
Pregnancy
Progresses
Birth of
Viable Infant
Missed
Carneous
Mole
Inevitable
Incomplete
Septic
Complete

6. SpontaneousAbortion
Causes
 Maldevelopment of the conceptus
 Most common cause
 Chromosomal abnormalities account for 70% of
defective conceptions
 Spontaneous mutations may still arise
 Defective Implantation
 Hydatidiform Mole
 Fibroids

7. SpontaneousAbortion
Causes
 Maternal Infection
 Due to high temperature relating to general
metabolic effect of fever
 Result of transplacental passage of viruses, e.g.
 Influenza
 Rubella
 Pneumonia
 Toxoplasmosis
 Cytomegalovirus
 Listeriosis
 Syphilis
 Brucellosis
 Appendicitis

8. SpontaneousAbortion
Causes
 GenitalTract Infections
 Bacterial vaginosis
 Vaginal mycoplasma infection
 Medical Disorders
 Diabetes
 Thyroid disease
 Hypertensive disorders
 Renal disease

9. SpontaneousAbortion
Causes
 Endocrine Abnormalities
 Poor development of the corpus luteum
 Inadequate secretory endometrium
 Low serum progesterone levels
 UterineAbnormalities
 Structural abnormalities implicated in 15% of early
pregnancy losses e.g.
 Double uterus
 Unicornuate, bicornuate, septate or subseptate uterus
 Failure of uterus to develop to adult size,
remaining infantile

10. SpontaneousAbortion
Causes
 Retroversion of the Uterus
 Does not itself cause abortion
 As uterus fails to enlarge into abdomen, vaginal and
abdominal manipulation to correct the retroversion
causes abortion
 CervicalWeakness
 Caused by laceration of cervix or undue stretching of
internal os as a result of previous medical abortion or
childbirth
 Membranes bulge through cervical canal and rupture
 Characterised by recurrent late pregnancy losses

11. SpontaneousAbortion
Causes
 Environmental Factors
 Environment teratogens such as lead and
radiation
 Ingested teratogenetic substances such as drugs
(namely cocaine) and alcohol
 Smoking
 Maternal Age
 Women in late 30’s and older at higher risk,
irrespective of previous obstetric history

12. SpontaneousAbortion
Causes
 Stress and Anxiety
 Severe emotional upset may disrupt hypothalmic
and pituitary functions
 Paternal Factors
 Poor sperm quality
 Source of chromosomal abnormalities
 Immunologocial Factors
 Maternal lymphocytes with natural killer cell
activity may affect trophoblast development
 Autoimmune diseases such as antiphospholipid
syndrome

13. SpontaneousAbortion
Causes
Despite detailed investigations,
no cause can be found for the
majority of cases of spontaneous abortion

14. SpontaneousAbortion
ThreatenedMiscarriage
 Signs and Symptoms
 Pain: Variable, possibly slight lower
abdominal pain or backache
 Bleeding: Scant, during first 3 months
 Cervical Os: Closed, no dilation
 Uterus: If palpable, soft and not tender

15. SpontaneousAbortion
ThreatenedMiscarriage
 No vaginal assessment as may provoke uterine
activity
 No evidence that bedrest is effective
 Woman should be referred for medical
attention straight away
 A pregnancy test is carried out and ultrasound
performed to assess viability
 Heavy or increased amount of bleeding in an
ominous sign and may precede inevitable
abortion

16. SpontaneousAbortion
InevitableMiscarriage
 Signs and Symptoms
 Pain: Severe, rhythmical
 Bleeding: Heavy, clots
 Cervical Os: Open with dilation
 Uterus: If palpable, smaller than expected

17. SpontaneousAbortion
InevitableMiscarriage
 As name indicates, it is unavoidable pregnancy
loss
 Gestational sac separates from uterine wall
and uterus contracts to expel the contents of
conception
 Midwife should attend at once when called as
woman may collapse from blood loss
 Speculum examination in hospital, input from
obstetrician or gynaecologist
 Oxytocic drug may be given after products
expelled

18. SpontaneousAbortion
IncompleteMiscarriage
 Signs and Symptoms
 Pain: Severe
 Bleeding: Heavy, profuse
 Cervical Os: Open with dilation
 Uterus: Tender and painful
 Other: Tissue present in cervix
Shock

19. SpontaneousAbortion
IncompleteMiscarriage
 Gestational sac is incompletely expelled, with
usually the placental tissue retained
 Static or slowly falling HCG levels
 Evacuation of retained products of conception
from the uterus carried out
 Medical management possible using
prostaglandin analogues such as misoprostol
 If surgical evacuation required, woman should
be screened for chlamydial infection
 Transfusion may be given if blood loss
excessive

20. SpontaneousAbortion
CompleteMiscarriage
 Signs and Symptoms
 Pain: Diminishing or absent
 Bleeding: Minimal or absent
 Cervical Os: Closed
 Uterus: If palpable, firm and contracted

21. SpontaneousAbortion
CompleteMiscarriage
 Gestational sac completely expelled
 History of abdominal pain, bleeding with
passing of clots and tissue
 Once miscarriage is complete, pain and
bleeding subside, cervix closes
 Ultrasound shows empty uterus coupled with
falling HCG levels

22. SpontaneousAbortion
MissedMiscarriage
 Signs and Symptoms
 Pain: Absent
 Bleeding: Some spotting possible, brown loss
 Cervical Os: Closed
 Uterus: If palpable, smaller than expected

23. SpontaneousAbortion
MissedMiscarriage
 Also known as delayed or silent abortion
 Usually follows threatened abortion
 Bleeding occurs between uterine wall and
gestational sac and embryo dies
 Layers of blood clots form and later become
organised
 Retainment of fetus inhibits menses
 Other signs of pregnancy diminish
 Confirmed by ultrasound
 Surgical evacuation or expectant management
possible

24. SpontaneousAbortion
MissedMiscarriage–GestationalTrophoblasticDisease
 GTD general term that covers
 Hydatidiform mole (benign)
 Choriocarcinoma (malignant)

25. SpontaneousAbortion
MissedMiscarriage–GestationalTrophoblasticDisease
 Clinical presentation of Hydatidiform Mole
 Exaggerated signs of pregnancy, appearing by 6-8
weeks due to high levels of HCG
 Bleeding or a blood stained vaginal discharge after
period of amenorrhoea
 Ruptured vesicles, resulting in light pink or brown
vaginal discharge, or detached vesicles, which may be
passed vaginally
 Anaemia as a result of the gradual loss of blood
 Early-onset pre-eclampsia
 On examination, uterine size exceeding that expected
for gestation
 On palpation, a uterus that feels ‘doughy’ or elastic

26. SpontaneousAbortion
MissedMiscarriage–GestationalTrophoblasticDisease
 Hydatidiform Mole
 Gross malformation of trophoblast
 Chorionic villi proliferate and become avascular
 Found in cavity of uterus and rarely within uterine
tube
 Can lead to development of cancer, therefore
accurate and rapid diagnosis, treatment and follow-
up paramount
 Two forms of mole
 Complete hydatidiform mole (risk of choriocarcinoma)
 Partial mole

27. SpontaneousAbortion
MissedMiscarriage–GestationalTrophoblasticDisease
 Treatment of Hydatidiform Mole
 Treatment is to remove all trophoblastic tissue
 In some cases, mole will abort spontaneously
 If this does not occur, vacuum aspiration or D and C
necessary
 Spontaneous abortion carries less risk of malignant
change
 Pregnancy to be avoided in follow up period
 IUCDs contraindicated and hormonal methods of
contraception to be avoided until HCG levels normal

28. SpontaneousAbortion
MissedMiscarriage–GestationalTrophoblasticDisease
 Choriocarcinoma
 Malignant disease of trophoblastic tissue
 HCG levels will rise and test will become strongly
positive again
 May occur in next pregnancy following evacuation
of mole
 Condition rapidly fatal unless treated
 Disease spreads by local invasion and via
bloodstream
 Metastases my occur in lungs, liver or brain

29. SpontaneousAbortion
MissedMiscarriage–GestationalTrophoblasticDisease
 Treatment of Choriocarcinoma
 Responds extremely well to chemotherapy
 Cytotoxic drugs are used singly or in combination
with other therapy
 Nearly always completely successful
 Pregnancy should be avoided for at least one year
on completion of treatment
 Subsequent pregnancy will require close HCG
monitoring as there is a risk of recurrance

30. SpontaneousAbortion
SepticMiscarriage
 Signs and Symptoms
 Pain: Severe or variable
 Bleeding: Variable, may be offensive
 Cervical Os: Open
 Uterus: Bulky, tender and painful on
examination

31. SpontaneousAbortion
SepticMiscarriage
 May occur after spontaneous or induced abortion,
more likely after incomplete miscarriage
 Causitive organisms include Staphyloccus aureus,
Clostridium welchii, Escherichia coli, Klebsiella,
Serratia and Bacteroides species, and group B
haemolytic streptococci
 Woman will feel acutely ill with fever, tachycardia,
headache, nausea and general malaise
 High vaginal swab and blood cultures should be
taken
 Antibiotics before any surgical intervention
 Risks include septicaemia, endotoxic shock, DIC,
liver and renal damage, salpingitis and infertility

32. SpontaneousAbortion
MidwiferyAssessments
 Blood loss
 Amount?
 Nature?
 When did it start?
 What were you doing
at the time?
 Pain
 Menstrual History
 Confirm LMP
 Symptoms of Pregnancy
 Still present?
 Have they changed?
 Obstetric History
 Gynaecological History
 Cervical infections
 Cervical operations
 Contraceptive History
 Blood Group and Rhesus
Status

33. SpontaneousAbortion
MidwiferyResponsibilities
 Referral
 Support groups
 Recurrent miscarriage clinic
 GP/gynaecologist-obstetrician
 Advice
 Expect a grief reaction
 Dependent on gestation, lactation may occur
 Understand it takes weeks – months to recover from a miscarriage
physically and even longer emotionally
 Menstruation may return four to six weeks later
 Await the next normal period before trying to conceive
 Expect bleeding for up to two weeks
 No intercourse, swimming, tampons for two weeks or duration of
bleeding
 Support
 Remember the partner too

34.  Implantation Bleeding
EARLYPREGNANCYBLEEDING

35. ImplantationBleeding
 As the trophoblast erodes the endometrial
endothelium and the blastocyst implants, a
small vaginal loss may be apparent
 Occurs at approximately 10-12 days post
conception, around the same time as
expected menses and may be mistaken for a
woman’s period, although abnormal (usually
bright red and lighter)
 It is significant when calculating LMP for
estimation of due date

36.  Decidual Bleeding
EARLYPREGNANCYBLEEDING

37. Decidual Bleeding
 Occasionally there is bleeding from the decidua
during the first 10 weeks, usually at around the
time menses is expected
 Caused by menstrual hormones
 Especially common in the early stages of
pregnancy, before the lining has completely
attached to the placenta
 Not thought to be a health threat to mother
or fetus
 May affect calculation of EDD

38.  Ectopic Pregnancy
EARLYPREGNANCYBLEEDING

39. EctopicPregnancy
 Occurs when a fertilised ovum implants itself
outside the uterine cavity
 Sites can include the uterine tube, an ovary,
the cervix or the abdomen
 95% implant in the uterine tube (tubal
pregnancy), of which 64% are implanted in
the ampulla of the fallopian tube (where
fertilisation takes place)


40. EctopicPregnancy
RiskFactors
 Any alterations of the normal function of the uterine
tube in transporting gametes contributes to the risk of
ectopic pregnancy:
 Previous ectopic pregnancy
 Previous surgery on the uterine tube, pelvic or abdominal
surgery which may cause adhesions
 Exposure to diethylstillboestrol in utero (postcoital
contraception)
 Congenital abnormalities of the tube
 Endometriosis
 Previous infection including chlamydia, gonorrhoea and pelvic
inflammatory disease
 Use of intrauterine contraceptive devices
 Assisted reproductive technology
 Delayed childbearing (>35 years)

41. EctopicPregnancy
SignsofEctopicPregnancy
 Tubal pregnancy very rarely remains
asymptomatic beyond 8 weeks gestation
 Typical Signs:
 Localised/abdominal pain
 Amenorrhoea
 Vaginal bleeding or spotting
 Atypical Signs:
 Shoulder pain
 Abdominal distension
 Nausea, vomiting
 Dizziness, fainting

42. EctopicPregnancy
ClinicalPresentation
 Pelvic pain can be very severe
 Acute symptoms are the result of tubal rupture (more
likely to occur between 5-7 weeks gestation) and relate
to the degree of haemorrhage there has been
 Ultrasound enables an accurate diagnosis of tubal
pregnancy, making management more proactive
 Vaginal ultrasound, combined with the use of sensitive
blood and urine tests which detect the presence of
HCG, helps to ensure diagnosis is made earlier
 If the tube ruptures, shock may ensue; therefore
resuscitation, followed by laparotomy, is needed
 The mother should be offered follow-up support and
information regarding subsequent pregnancies

43. EctopicPregnancy
Diagnosis
 The woman will give a history of early pregnancy signs
 The uterus will have enlarged and feel soft
 Abdominal pain may occur as the tube distends and
uterine bleeding may be present
 Abdomen may be tender and distended
 Shoulder tip pain due to referred pain
 Woman may appear pale, complain of nausea and
collapse
 Severe pain felt during pelvic exam
 A mass may be felt on one side of the uterus
 Hormonal assay will find progesterone levels low and
hCG levels falling
 USS may show fluid or and mass in pelvic cavity and
absence of intrauterine pregnancy

44. EctopicPregnancy
Diagnosis
Nowadays occurrence of an extra-uterine
pregnancy is diagnosed with a combination of
serum hCG levels and ultrasound scan

45. EctopicPregnancy
Treatment
 Common perception is that everyone with an
ectopic needs an operation to deal with it
 However, a number of treatment options are
available including expectant management if
no bleeding, pain or shock
 If there is evidence of pain and bleeding
producing shock, immediate treatment is
essential, as it is a life-threatening condition
 This is a surgical emergency and in most
cases a laparotomy is performed

46. EctopicPregnancy
SurgicalTreatment
 Salpingectomy
 Salpingectomy (tubal removal) is the principle
treatment especially where there is tubal rupture
 Salpingotomy
 Conservative surgical management may be
employed when the ectopic has not ruptured and
where the tube appears normal
 This is called salpingotomy, where the ectopic is
removed and the tube allowed to heal

47. EctopicPregnancy
ExpectantTreatment
 Used when pain is less and indicators are that the
ectopic is a small one or it is not bleeding too much
 Expectant approach involves close follow up with hCG
tests every 2-7 days until levels have returned to
normal
 Is successful in 90% of selected patients
 Methotrexate – a drug that destroys actively growing
tissues such as the placental tissues that support the
pregnancy is used as an injection in selected cases to
avoid surgery (in non ruptured ectopic)
 Side effects include abdominal pain for 3 – 7 days in
50% of cases and mild symptoms of nausea, mouth
dryness and soreness and diarrhoea

48.  Placental Abruption
 Placenta Praevia
ANTEPARTUMHAEMORRHAGE

49. AntepartumHaemorrhage
 Defined as bleeding from the genital tract
after the 24th week of gestation and before
the onset of labour
 Bleeding during labour is referred to as
Intrapartum Haemorrhage
 Bleeding usually due to placental separation,
but can also be due to incidental causes from
extraplacental sites in the birth canal, such as
cervical polyps or some other local lesion

50. AntepartumHaemorrhage
EffectsontheFetus
 Mortality and Morbidity increased as a result
of severe vaginal bleeding in pregnancy
 Stillbirth or neonatal death may occur
 Premature separation of the placenta and
subsequent hypoxia may result in severe
neurological damage in the baby

51. AntepartumHaemorrhage
EffectsontheMother
 If bleeding is severe, it may be accompanied by
shock and disseminated intravascular
coagulation (DIC)
 The mother may die or be left with permanent
ill health
 APH is unpredictable and the woman’s
condition can deteriorate rapidly at any time
 Rapid decisions about the urgency of need for
medical or paramedic presence, or both, must
be made often at the same time as observing
and talking to the woman and her partner

52. AntepartumHaemorrhage
CausesofBleedinginLatePregnancy
Placenta Praevia Incidence = 31.0%
Placental Abruption Incidence = 22.0%
‘Unclassified Bleeding”, e.g. Incidence = 47.0% (Total)
Marginal
Show
Cervicitis
Trauma
Vulvovaginal varosities
Genital tumours
Genital infections
Haematuria
Vasa praevia
Other

53. AntepartumHaemorrhage
InitialAssessmentofPhysicalCondition
 Take a detailed history from the woman
 Take observations: Temperature, Pulse,
Respiratory Rate, Blood Pressure
 Observe for any pallor or breathlessness
 Assess the amount of blood loss
 Perform a gentle abdominal examination,
observing signs that the woman is going into
labour

54. AntepartumHaemorrhage
InitialAssessmentofPhysicalCondition
 Ask the mother is the baby has been moving as
much as normal
 Attempt to auscaltate the fetal heart
 Insert large bore canula, take bloods for FBC,
Cross match, LFTs, Clotting times, Kleihaur if
necessary
 Obstetric referral
 Anti-D administration if applicable
 Steroids if <34 weeks gestation

55. AntepartumHaemorrhage
InitialAssessmentofPhysicalCondition
On no account must any vaginal or rectal
examination be done; nor may an enema or
suppository be given to a woman suffering
from an Antepartum Haemorrhage

56. DifferentialDiagnosis
 Pain
 Did the pain precede bleeding and is it continuous or
intermittent?
 Onset of bleeding
 Was this associate with any event such as coitus?
 Amount of blood loss visible
 Is there any reason to suspect that some blood has been
retained in utero?
 Colour of the blood
 Is it bright red or darker in colour?
 Degree of shock
 Is this commensurate with the amount of blood visible or
more severe?

57. DifferentialDiagnosis
 Consistency of the abdomen
 Is it soft or tense and board-like?
 Tenderness of the abdomen
 Does the mother resent abdominal palpation?
 Lie, presentation and engagement
 Are any of these abnormal when account is taken of parity and
gestation?
 Audibility of the fetal heart
 Is the fetal heart heard?
 Ultrasound scan
 Does a scan suggest that the placenta is in the lower uterine
segment?

58. AntenatalHaemorrhage
SupportiveTreatment
 Provide woman and partner with emotional
reassurance
 Give rapid fluid replacement (warmed) with a
plasma expander, and later with whole blood if
necessary
 Give analgesia
 If at home, arrange transfer to hospital
 Subsequent management depends on the
definite diagnosis

59. Section88 MaternityNotice
ReferralGuidelines
Previous Obstetric History
 LEVEL 2 (Code 3001)
- Previous Placental Abruption
Current Pregnancy
 LEVEL 2 (Code 4004)
- Antepartum Haemorrhage
 LEVEL 3 (Code 4020)
- Placenta Praevia (At or >32 weeks)

60.  Placental Abruption
ANTEPARTUMHAEMORRHAGE

61. PlacentalAbruption
 Premature separation of a normally situated
placenta, occurring after the 24th week of
pregnancy
 Aetiology is not always clear, some predisposing
factors are:
 Pregnancy-induced hypertension or pre-eclampsia
 A sudden reduction in uterine size, e.g. SRM with
polyhydramnios or after the birth of a first twin
 Short umbilical cord
 Direct trauma to the abdomen (risk remains for 2 days
following trauma)
 High parity
 Previous caesarean section
 Cigarette smoking or illicit drug use (esp. Cocaine)

62. PlacentalAbruption
 Blood loss may be:
 Revealed
 Concealed
 Mixed
 Separation may be:
 Mild
 Moderate
 Severe
 Complications of Placental Abruption:
 Disseminated Intravascular Coagulation
 Postpartum Haemorrhage
 Renal Failure
 Pituitary Necrosis

63. PlacentalAbruption
MildSeparationofthePlacenta
 Separation and the haemorrhage are minimal
 Mother and fetus are in a stable condition
 No indication of maternal shock
 Fetus is alive, with normal heart sounds
 Consistency of uterus is normal
 No tenderness on abdominal palpation

64. PlacentalAbruption
ManagementofMildSeparationofthePlacenta
 Ultrasound scan
 Determine placental location
 Identify any degree of concealed bleeding
 Monitoring of fetal heart rate
 Frequently to assess fetal condition whilst bleeding
persists
 CTG should be carried out once or twice daily
 Admission to hospital
 Women who are not yet 37 weeks gestation may be
cared for in an antenatal ward for a few days
 May be discharged if there is no further bleeding and
placenta has been found to be in the upper uterine
segment

65. PlacentalAbruption
ManagementofMildSeparationofthePlacenta
 Induction of Labour
 May be offered for woman who have passed the 37th
week of pregnancy
 Especially if there has been more than one episode of
mild bleeding
 Further management
 Heavy bleeding or evidence of fetal distress may
indicate that a caesarean section is necessary

66. PlacentalAbruption
ModerateSeparationofthePlacenta
 Separation of about one-quarter
 Considerable amount of blood may be lost, some
of which will escape from the vagina and some
will be retained as a retroplacental clot or an
extravasation into the uterine muscle
 Mother will be shocked, with tachycardia and
hypotension
 Degree of uterine tenderness with abdominal
guarding
 Fetus may be alive, although hypoxic and
intrauterine death is also a possibility

67. PlacentalAbruption
ManagementofModerateSeparationofthePlacenta
 Fluid replacement
 Should be monitored with the aid of a central
venous pressure line
 Monitoring of fetal condition
 Should be assessed with continuous CTG if the fetus
is alive
 Immediate caesarean section may be indicated
once the woman’s condition is stablised

68. PlacentalAbruption
ManagementofModerateSeparationofthePlacenta
 If fetus is alive or has already died, vaginal birth
may be contemplated
 Such a birth is advantageous because it enables
the uterus to contract and control the bleeding
 Spontaneous labour frequently accompanies
moderately severe abruption, but if it does not,
then amniotomy is usually sufficient to induce
labour
 Syntocinon may be used with great care, if
necessary
 Delivery is often quite sudden, after a short labour
 Drugs to attempt to cease labour is usually
inappropriate

69. PlacentalAbruption
SevereSeparationofthePlacenta
 Acute obstetric emergency
 Two-thirds of the placenta has become
detached
 2000 mls of blood or more are lost from the
maternal circulation
 Most or all of the blood can be concealed
behind the placenta
 Woman will be severely shocked, perhaps to a
degree far beyond what might be expected
from the amount of blood loss visible

70. PlacentalAbruption
SevereSeparationofthePlacenta
 Woman will have severe abdominal pain with
excruciating tenderness; the uterus has a
board like consistency
 Hypotensive, however woman may be
normotensive owing to preceding
hypertension
 The fetus will almost certainly be dead
 Features associated with severe haemorrhage:
 Coagulation defects (e.g. DIC)
 Renal failure
 Pituitary failure

71. PlacentalAbruption
ManagementofSevereSeparationofthePlacenta
 Treatment is same as for moderate separation
 Whole bloods transfused rapidly and subsequent amounts
calculated in accordance with the woman’s central venous
pressure
 Labour may begin spontaneously in advance of amniotomy
and the midwife should be alert for signs of uterine
contraction causing periodic intensifying of abdominal pain
 However, if bleeding continues of a compromised fetal heart
rate is present, caesarean section may be required as soon as
the woman is adequately stable
 The woman requires constant explanation and psychological
support, despite the fact that her shocked condition may
mean she is not fully conscious
 Pain relief must be considered
 Don’t forget the partner!

72.  Placenta Praevia
ANTEPARTUMHAEMORRHAGE

73. PlacentaPraevia
 Placenta partially or wholly implanted in the
lower uterine segment on either the anterior
or posterior wall
 Lower segment of uterus grows and stretches
progressively after the 12th week of
pregnancy
 In later weeks, this may cause the placenta to
separate and severe bleeding can occur

74. PlacentaPraevia
DegreeofPlacentaPraevia
 Type 1 Placenta Praevia
 Majority of placenta is in the upper uterine segment
 Blood loss is usually mild
 Mother and fetus remain in good condition
 Vaginal birth is possible
 Type 2 Placenta Praevia
 Placenta is partially located in the lower segment near
the internal cervical os
 Blood loss is usually moderate
 Condition of mother and fetus can vary
 Vaginal birth is possible, particularly if placenta is
anterior

75. PlacentaPraevia
DegreeofPlacentaPraevia
 Type 3 Placenta Praevia
 Placenta is located over the internal cervical os but not
centrally
 Bleeding is likely to be severe
 Vaginal birth is inappropriate
 Type 4 Placenta Praevia
 The placenta is located centrally over the internal
cervical os
 Torrential haemorrhage is very likely
 Caesarean section is essential

76. Indicationsof PlacentaPraevia
 Bleeding from vagina is the only sign, and it is
painless
 Uterus is not tender or tense
 Presence of placenta preavia should be
considered when:
 Fetal head is not engaged in a primigravida (after 36
weeks gestation)
 There is a malpresentation, especially breech
 The lie is oblique or transverse
 The lie is unstable, usually in a multigravida
 Location of the placenta under USS will confirm
the existence and extent of placenta praevia

77. Managementof PlacentaPraevia
 Management of placenta praevia depends
on:
 The amount of bleeding
 The condition of mother and fetus
 The location of the placenta
 The stage of pregnancy