1. Antepartum Haemorrhage
BATCH - 2007
• ASHISH KUMAWAT
BHMS III YEAR
DR M P K
HOMOEOPATHIC
MEDICAL COLLEGE,
HOSPITAL AND
RESEARCH CENTRE,
JAIPUR

2. Massive Obstetric Haemorrhage
• Second most common cause
• Maternal Death
8.5 / million pregnancies
Also includes post-partum haemorrhage

3. Antepartum Haemorrhage- Definition
Bleeding in pregnancy after 28
weeks gestation

4. Antepartum Haemorrhage - Types
1. Simple
2. Complicated

5. Antepartum Haemorrhage -Simple
1.Local causes
• Vaginal
• Trauma
2.Cervical
• Erosion
• Tumour – Pap Smear
3.Blood Dyscrasia
• Thrombocytopenia
• Anticoagulants

6. Antepartum Haemorrhage - Complicated
Placenta Praevia
• (Inevitable APH)
Abruptio Placentae
• (Accidental APH)

7. Placenta Praevia - Definition
Placenta which has implanted partially or
wholly in the lower uterine segment

8. Placenta Praevia - Types
Old Classification
Grade 1 – Just enters lower segment
Grade 2 – Enters LUS but does not reach os
Grade 3 – Partially covers os but not
completely
Grade 4 – Completely covers os

9. Placenta Praevia – Old Classification

10. Placenta Praevia – Types
Major – Enters LUS but does not cover os
Minor – Covers internal os completely

11. Placenta Praevia – New classification

12. Placenta Praevia- aetiology
• Unclear
• Any damage to endometrium or
myometrium
• Scar tissue impedes migration away from os
• Increased placental mass

13. Placenta Praevia – Increased Mass
• Multiple pregnancy- large surface area
• Cigarette smoking- vasoconstriction
• Cocaine Use – Vasoconstrictionhypertrophy

14. Placenta Praevia –Endo/Myometrial Damage
• Previous C/S
•Spontaneous Abortion
•Uterine abnormalities

15. Placenta Praevia – Other Factors
• Previous Placenta Praevia
• Maternal Age – reduced uterine blood flow
needs greater surface area
• Parity - 3 previous deliveries 2.6 fold
Vessels at site of previous placenta reduced flow-
discourage implantation

16. Placenta Praevia – Associated Complications
• Congenital Abnormality - 6.7% /3.2% ?
• Small for Dates(SGA)
19% - decreased placental perfusion
Reduced nutrient transfer
• Malpresentation – 3 fold increase
Breech
Transverse lie
• Abnormal Placentation – Accreta/Percreta
Unscarred uterus 5% 1 previous C/S 24% 4 C/S 67%
• Pregnancy Induced Hypertension – reduced
½ normal incidence

17. Placenta Praevia - Presentation
• Antepartum Haemorrhage
Late pregnancy
Painless bleeding
• Malpresentation
Breech/High Head/Unstable lie in 3rd
trimester
• Asymptomatic –found at routine U/S scan

18. Placenta Praevia – Diagnosis
Ultrasound
Transabdominal
Transvaginal

19. Placenta Praevia – Abdominal U/S

20. Placenta Praevia – Transvaginal U/S

21. Placenta Praevia - Management
• Antenatal
Inpatient vs Outpatient
Major vs minor
Anaemia
Regular Hb
X-match/Transfuse

22. Placenta Praevia - Management
• Delivery
Timing – Mahady’s equation
Usually 38/52
• Mode of Delivery
Minor praevia – 2cm from os
Examination in theatre/ARM/Vaginal delivery
• Major praevia
Caesarean Section
NB Senior Obstetrician

23. Abruptio Placentae - Types
Revealed APH
Pain + Vaginal bleeding
Concealed
Pain/Shock
No vaginal bleeding

24. Abruptio Placentae - Types
• Placental Site - Upper Uterine Segment

25. Abruptio Placentae – Associated risk factors
• Hypertension/Pre-eclampsia - 44% of all cases
• Maternal Trauma - RTA /Pelvic # - 1.5-9.4%C
• Smoking – 40% increase for each year smoked
• Cocaine – hypertension/catecholamine release
• Thrombophilia
• Cord complications
• Raised alpha feto-protein
• Amniocentesis
• Maternal Age
• Alcohol

26. Abruptio Placentae - Symptoms
• Vaginal Bleeding ( Revealed) 80%
• Abdominal /Back Pain (Severe) 70%
• Fetal Distress 60%
• Contractions (Hypertonic) 35%
• Preterm Labour 25%
• Fetal Death in utero 15%

27. Abruptio Placentae - Complications
Maternal
• Haemorrhagic /Hypovolaemic SHOCK
• Coagulopathy DIC/Hypofibrinogenaemia
• Couvelaire Uterus / Uterine rupture
• Renal Failure
• Ischaemic Necrosis distal organs
(Liver,Adrenals,Pituitary)

28. Abruptio Placentae - Complications
Fetal
• Hypoxia - Fetal distress - CTG
• Anaemia
• Growth Retardation - if treated conservatively and
survives
• CNS Abnormalities
• Intra Uterine Death

29. Abruptio Placentae - Investigations
• Blood Group - X match
Rh – anti D
• Haemoglobin/FBC – Platelets
• Clotting Time / Fibrinogen /FDP /PTT
• Urea /Creatinine
• Ultrasound - exclude Praevia
• CTG - Non Stress Test
• Biophysical Profile - NB <6

30. Abruptio Placentae - Management
• Correct SHOCK
I V access – 2 large bore cannulae
• Crystalloids IV – emergency
BLOOD as soon as possible
• Correct DIC - ? Heparin
• Catheterise - hourly urine output chart
• Assess for delivery
FH absent - induce – IV oxytocin
FH present- ? C/S ?Induce

31. Treatment

32. IPECACUANHA
Uterine hæmorrhage, profuse, bright, gushing,
with nausea. Vomiting during
pregnancy. Pain from navel to uterus.
Menses too early and too profuse.

33. MILLEFOLIUM
Menses early, profuse, protracted.
Hæmorrhage from uterus; bright red,
fluid. Painful varices during pregnancy.

34. TRILLIUM PENDULUM
Uterine hæmorrhages, with sensation as though
hips and back were falling to pieces; better tight
bandages. Gushing of bright blood on least
movement. Hæmorrhage from fibroids (Calc; Nitr
ac; Phos; Sulph ac). Prolapse, with great bearing-
down. Leucorrhœa copious, yellow, stringy
(Hydras; Kali b; Sabin). Metrorrhagia at
climacteric. Lochia suddenly becomes sanguinous.
Dribbling of urine after labor.

35. CHINA OFFICINALIS
Menses too early. Dark clots and
abdominal distention. Profuse menses with
pain. Desire too strong. Bloody leucorrhœa.
Seems to take the place of the usual
menstrual discharge. Painful heaviness in
pelvis

36. BELLADONNA
Sensitive forcing downwards, as if all the viscera
would protrude at genitals. Dryness and heat of
vagina. Dragging around loins. Pain in sacrum.
Menses increased; bright red, too early, too
profuse. Hæmorrhage hot. Cutting pain from hip
to hip. Menses and lochia very offensive and hot.
Labor-pains come and go suddenly. Mastitis pain,
throbbing, redness, streaks radiate from nipple.
Breasts feel heavy; are hard and red. Tumors of
breast, pain worse lying down. Badly smelling
hæmorrhages, hot gushes of blood. Diminished
lochia.

37. HYOSCYAMUS NIGER
Before menses, hysterical spasms. Excited
sexual desire. During menses, convulsive
movements, urinary flux and sweat. Lochia
suppressed. Spasms of pregnant women.
Puerperal mania.

38. I Would like to give the thanks to
Resp. mam Mrs. PUNIT Who gave me good
suggestion & motivation to prepare this
project & thanks to all my friends who
helped me.