Antepartum haemorrhage

1. ANTEPARTUM
HAEMORRHAGE
(THIRD TRIMESTER
BLEEDING)
MS. MILAN SAWANT

2. • Third-trimester bleeding, ranging from spotting to
massive hemorrhage, occurs in 2% to 6% of all
pregnancies.
• The differential diagnosis includes:
• Bloody show from labor
• Abruptio placentae (AP)
• Placenta previa (PP)
• Vasa previa (VP)
• Cervicitis, postcoital bleeding, trauma, uterine rupture,
and carcinoma.

3. PLACENTA

5. DEFINITION
When the placenta is
implanted partially or
completely over the
lower uterine
segment(over and
adjacent to the internal
os)it is called placenta
previa.

6. INCIDENCE
O.5 – 1% among hospital deliveries
•80% cases found in multiparous women
• Increase incidence beyond 35yrs
•Increase incidence with high birth order and
multiple pregnancy 1 in 300- 400 pregnancy .

7. MECHANISM OF BLEEDING
•Progressive stretching of the lower uterine segment
normally occurs during the 3rd trimester and labour,
but the inelastic placenta cannot stretch with it. This
leads to inevitable separation of a part of the
placenta with unavoidable bleeding.
•The closer to term, the greater is the amount of
bleeding.

8. ETIOLOGY
THEORIES POSTULATED
•Dropping down theory
•Persistence of chorionic activity
•Defective decidua
•Big surface area of the placenta

9. HIGH RISK FACTORS
•Multiparity
•Increased maternal age
•Previous cesarean section or any other scar in the
uterus ( fibroids myomectectomy )
•Placental size and abnormality ( twin)
•Smoking( due to defective decidual vascularisation)
•Prior curettage

10. BROWNE`S CLASSIFICATION
1. TYPE I – Low – lying Major part of the placenta is attached to the
upper segment
•Only the lower margin encroaches to the lower segment But not up
to the os
2. TYPE II – Marginal •Placenta reaches the margin of the internal os
But does not cover it
3. TYPE III – Incomplete or partial central • Placenta covers the
internal os partially
4. TYPE IV – Central or total • Placenta covers the internal os even
after it is fully dilated
Type 1 and type 2 are minor degree. Type 3 and 4 are major degree.

13. CLINICAL FEATURES & SYMPTOMS
•VAGINAL BLEEDING –
•The classical presentation is painless antepartum haemorrhage. Causeless Recurrent
SIGNS
•General condition and anemia are proportionate to the visible blood loss
•ABDOMINAL EXAMINATION
•The size of the uterus proportionate to the period of gestation
•The uterus feels relaxed, soft and elastic without any localised area of tenderness
•Persistence of malpresentation ( breech)
•Head is floating
•Fetal heart sound heard usually
•Stallworthy’s sign
•VAGINAL EXAMINATION SHOULD NOT BE DONE IN SUSPECTED

14. CONFIRMATION OF DIAGNOSIS
• LOCALISATION OF PLACENTA
• SONOGRAPHY
• TAS
• TVS
• Color Doppler flow study
• MAGNETIC RESONANCE IMAGING
CLINICAL
• By internal examination(double set up examination)
• Direct visualization during caesarean section
• Examination of the placenta following vaginal delivery

15. MANAGEMENT
• There are two types of management for placenta previa
based on certain criteria
• They are :
• Expectant management
• Active management
• The most important guiding principle is when the
mothers life is at risk don’t think about saving the baby

16. MANAGEMENT
 IMMEDIATE ATTENTION
• Blood samples are taken
• A large bore IV cannula is sited
• Infusion of NS
• Gentle abdominal palpation
• Inspection of vulva
•EXPECTANT MANAGEMENT - Macaffee and Johnson regime • Bed
rest • Periodic inspection • Supplementary hematinics • A gentle
speculum examination • Rh immunoglobulin • Termination done at 37
weeks • Steroid therapy - Inj betamethasone is given to hasten the
lung maturity of the fetus

17. CONT.
EXPECTANT MANAGEMENT - Macaffee and Johnson
regime
• Bed rest
• Periodic inspection
• Supplementary hematinics
• A gentle speculum examination
• Rh immunoglobulin
• Termination done at 37 weeks
• Steroid therapy – Inj. betamethasone is given to hasten
the lung maturity of the fetus

18. ACTIVE MANAGEMENT INDICATIONS
• Bleeding occurs at or after 37 weeks of pregnancy
• Patient is in labour
• Patient is exsaguinated state on admission
• Bleeding is continuing and of moderate degree
• Baby is dead or known to be congenitally malformed
 DEFINITIVE MANAGEMENT
• CESAREAN DELIVERY
• Placental edge is within 2cm from the internal os
• VAGINAL DELIVERY
• Placental edge is clearly 2-3cm away from the internal os

19. COMPLICATION MATERNAL
DURING PREGNANCY
• APH
• Malpresentation
• Premature labor

20. Complications during labour
MATERNAL
Early rupture of the
membrane
• Cord prolapse
• Slow dilation
• Intrapartum haemorrhage
• Increased incidence of
operative interference
PPH
FETAL
• Asphyxia
• Birth injury
• Low birth weight (m/c)
• IUD
• Congenital malformations

21. Abruptio placenta

22. DEFINITION
DEFINITION
Abruptio placenta is defined as
haemorrhage occurring in pregnancy due
to the separation of a normally situated
placenta. It is also called accidental
haemorrhage or premature separation of
placenta.

23. •INCIDENCE • It is 1 : 200 • It is less than
previa • Accounts for 5 % maternal mortality
and 20% perinatal mortality

24. Types of abruption
1. Revealed
• In this type the blood seeps between the decidua and the
membranes to present at the vagina
2. Concealed
• In this the blood gets collected behind the placenta and forms the
retro placental clot
• Sometimes it may be due to collection between the decidua and
membranes but it can’t present at vagina because the presenting
part is firmly pressed over the cervix
3. Mixed
4. • In this type it is partly revealed and partly retroplacenta