Gynaecology topic

1. ANTEPARTUM HAEMORRHAGE
Prof Dr. Sushila Kharkwal(MD, FICOG,FICMCH)
Head of the Department
Department of Obstetrics and Gynecology
MLBMC Jhansi

2. DEFINITION
• It is defined as bleeding from or into the genital
tract after the 28th week of pregnancy but before
the birth of the baby (the first and second stage of
labor are thus included).
The incidence is about 3% amongst hospital deliveries.

3. CAUSES OF APH

4. PLANCENTA PREVIA
• 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.

5. • The incidence of previa ranges from 0.5% to 1% amongst
hospital deliveries.
• The incidence is increased beyond the age of 35 years,
with high birth order pregnancies and in multiple
pregnancy.
• Increased family planning acceptance with limitation and
spacing of birth lowers the incidence of placenta previa

6. • The high risk factors for placenta previa are—
• (a) Multiparity
• (b) Increased maternal age (> 35 years)
• (c) History of previous cesarean section or any other scar in the
uterus (myomectomy or hysterecotomy)
• (d) Placental size (mentioned before) and abnormality
(succenturiate lobes)
• (e) Smoking — causes placental hypertrophy to compensate
carbon monoxide induced hypoxemia
• (f) Prior curettage.

8. • Lower uterine segment- Due to increased vascularity ,the
lower uterine segment and the cervix becomes soft and
more friable.

9. TYPES OR DEGREES:—There are four types of placenta
previa depending upon the degree of extension of placenta to
the lower segment.

10. TYPES OF PLACENTA PREVIA
• Type—I (Low-lying): The major part of the placenta is
attached to the upper segment and only the lower margin
encroaches onto the lower segment but not up to the os.
• Type—II (Marginal): The placenta reaches the margin of
the internal os but does not cover it.
• Type—III (Incomplete or partial central): The placenta
covers the internal os partially (covers the internal os
when closed but does not entirely do so when fully
dilated).
• Type—IV (Central or total): The placenta completely
covers the internal os even after it is fully dilated.

11. • For clinical purpose, the types are graded into mild
degree (Type-I and II anterior) and major degree (Type-
II posterior, III and IV)
Dangerous placenta previa is the name given to the type II
posterior placenta previa .
(1) Because of the curved birth canal major thickness of the
placenta (about 2.5 cm) overlies the sacral promontory,
thereby diminishing the anteroposterior diameter of the inlet
and prevents engagement of the presenting part. This
hinders effective compression of the separated placenta to
stop bleeding.
(2) Placenta is more likely to be compressed, if vaginal
delivery is allowed.

12. • (3) More chance of cord compression or cord prolapse.
• the last two maye produce fetal anoxia or even death.

13. • CAUSE OF BLEEDING:
• As the placental growth slows down in later months and the lower
segment progressively dilates, the inelastic placenta is sheared off
the wall of the lower segment. This leads to opening up of
uteroplacental vessels and leads to an episode of bleeding.
• As it is a physiological phenomenon which leads to the separation of
the placenta, the bleeding is said to be inevitable. However, the
separation of the placenta may be provoked by trauma including
vaginal examination, coital act, external version or during high
rupture of the membranes. The blood is almost always maternal,
although fetal blood may escape from the torn villi especially when
the placenta is separated during trauma.

14. • CLINICAL FEATURES
• SYMPTOMS:The only symptom of placenta previa is
vaginal bleeding.
• The classical features of bleeding in placenta previa are
sudden onset, painless, apparently causeless and
recurrent
• SIGNS:General condition and anemia are proportionate
to the visible blood loss.

15. • Abdominal examination:
The size of the uterus is proportionate to the period of
gestation.
The uterus feels relaxed, soft and elastic without any
localized area of tenderness.
• Persistence of malpresentation like breech or transverse or
unstable lie is more frequent. There is also increased
frequency of twin pregnancy.
The head is floating in contrast to the period of gestation.
Persistent displacement of the fetal head is very suggestive.
The head cannot be pushed down into the pelvis.
.

16. • Fetal heart sound is usually present, unless there is
major separation of the placenta with the patient in
exsanguinated condition.
Slowing of the fetal heart rate on pressing the head
down into the pelvis which soon recovers promptly as the
pressure is released is suggestive of the presence of low
lying placenta especially of posterior type (Stallworthy’s
sign)

17. • Vulval inspection:
• only inspection is to be done to note whether the bleeding is still
occurring or has inceased, character of the blood—bright red or
dark colored and the amount of blood loss—to be assessed from
the blood-stained clothing. In placenta previa, the blood is bright red
as the bleeding occurs from the separated uteroplacental sinuses
close to the cervical opening and escapes out immediately.
• Vaginal examination must not be done outside the operation theater
in the hospital, as it can provoke further separation of placenta with
torrential hemorrhage and may be fatal. It should only be done prior
to termination of pregnancy in the operation theater under
anesthesia, keeping everything ready for cesarean section.

18. CONFIRMATION Of DIAGNOSIS
• DIAGNOSIS:
• Painless and recurrent
vaginal bleeding in the
second half of pregnancy
should be taken as
placenta previa unless
proved otherwise.
Ultrasonography is the
initial procedure either to
confirm or to rule out the
diagnosis

20. • Sonography: Sonography is the diagnostic technique of choice
(RCOG-2001). It provides the simplest, most precise and safest
method of placental localization
• Transabdominal (TAS): The accuracy after 30th week of
gestation is about 98%.
• Transvaginal (TVS): Transducer is inserted within the vagina
without touching the cervix. The probe is very close to the target
area and higher frequencies could be used to get a superior
resolution.
• It is safe, obviates the discomfort of full bladder and is more
accurate (virtually 100%) than TAS.

21. • Transperineal (TPS): This is well accepted by patients.
Internal os is visualized in 97–100% of cases.
Color Doppler: Diffuse vascular lakes with turbulent flow in the
hypoechoic areas near the cervix is consistent with the
diagnosis of placenta previa. Three-dimensional (3-D) Power
Doppler is the best. Hypervascularity at the uterine serosa –
bladder junction is diagnostic.
• Magnetic Resonance Imaging (MRI): It is a noninvasive
method without any risk of ionizing radiation. Dark
intraplacental bands are seen on T2 weighted images. MRI is
better than ultrasonography to diagnose posterior placenta
previa and placenta previa accreta. Limitations of MRI are
more time consuming, lack of portability and cost

22. • Advantages of Ultrasonography and MRI:
(1) Need of vaginal examination with the risk of hemorrhage
is avoided.
(2) The need of prolonged and unnecessary hospital stay in
patients with clinical diagnosis of APH can be reduced.
(3) Diagnosis of placenta previa can be made even before
the bleeding starts.
(4) Diagnosis of morbid adherent placenta (specially in a
woman with placenta previa and prior cesarean delivery)
can be made.
(5) Plan of delivery can be organized accordingly

23. • Double set-up examination (vaginal examination):It is less
frequently done these days. The indications are:
• (i) Inconclusive USG report (ii) USG revealed type I placenta
or (iii) USG facilities not available. It is done in the operation
theater under anesthesia keeping everything ready for
cesarean section.
• Palpation of the placenta on the lower segment not only
conclusively confirms the clinical diagnosis but also identifies
its degree.
• Visualisation of the placental implantation on the lower
segment can be confirmed during cesarean section.
CLINICAL
CONFIRMATION

25. COMPLICATIONS OF PLACENTA PREVIA
MATERNAL:
—
Antepartum hemorrhage with varying degrees of shock is an
inevitable complication. The first bout of hemorrhage is seldom severe
but torrential hemorrhage can easily be provoked by injudicious
internal examination. Co-existent placental abruption is about 10%.
Malpresentation: There is increased incidence of breech presentation
and transverse lie. The lie often becomes unstable.
Premature labor either spontaneous or induced is common.
Death due to massive hemorrhage during the antepartum,
intrapartum or postpartum period.
Operative hazards, infection or embolism may also cause death.

26. During labor
Early rupture of the membranes
Cord prolapse due to abnormal attachment of the cord.
Slow dilatation of the cervix due to the attachment of placenta on
the lower segment.
Intrapartum hemorrhage due to further separation of placenta
with dilatation of the cervix.
Increased incidence of operative interference.

27. Postpartum hemorrhage is due to:
1. Imperfect retraction of the lower uterine segment
2. Large surface area of placenta with atonic uterus due to preexisting
anemia.
Occasional association (15%) of morbidly adherent placenta (placenta
accreta, increta, percreta) on the lower segment.
3.Trauma to the cervix and lower segment because of extreme softness
and vascularity.
Retained placenta and increased incidence of manual removal add further
hazard to the postpartum shock.
Increased incidence of retained placenta is due to : (1) Increased surface
area
(2) Morbid adhesion.
The risk of placenta previa being accreta in a woman with previous one
cesarean section is 10–20% and it rises to about 50% with two or more prior cesarean
section

28. Puerperium: Sepsis is increased due to: (a) increased operative
interference (b) placental site near to the vagina and (c) anemia and
devitalized state of the patient. (2) Subinvolution (3) Embolism
FETAL COMPLICATIONS IN PLACENTA PREVIA
Low birth weight
Repeated small bouts of hemorrhage while carrying on the expectant treatment can
cause chronic placental insufficiency and fetal growth restriction.
Labor in a woman with placenta previa complicated with prolapse of umbilical cord and
footling.
Asphyxia is common and it may be the effect of — (a) early separation of placenta (b)
compression of the placenta or (c) compression of the cord.
Intrauterine death is more related to severe degree of separation of placenta, with
maternal hypovolemia and shock.
Birth injuries are more common due to increased operative interference.
Congenital malformation

29. PREVENTION: Placenta previa is one of the inherent obstetric hazards and to minimize
the risks, the following guidelines are useful.
— Adequate antenatal care to improve the health status of women and correction of
anemia.
— Antenatal diagnosis of low lying placenta at 20 weeks with routine ultrasound needs
repeat
ultrasound examination at 34 weeks to confirm the diagnosis.
— Significance of “warning hemorrhage” should not be ignored.
— Color flow Doppler USG in placenta previa is indicated to detect any placenta
accreta. Where
this is not possible, such women with an increased risk of placenta accreta, should be
managed
as if they have placenta accreta until proved otherwise.
MANAGEMENT

30. AT HOME: (1) The patient is immediately put to bed.
(2) To assess the blood loss—(a) inspection of the clothing
soaked with blood
(b) to note the pulse, blood pressure and degree of anemia
(3) Quick but gentle abdominal examination to mark the
height of the uterus, to auscultate the fetal heart sound
and to note any tenderness on the uterus
(4) Vaginal examination must not be done. Only inspection
is done to see whether the bleeding is present or absent and
to put a sterile vulval pad

31. TRANSFER TO HOSPITAL: Arrangement is made to shift the patient to an
equipped hospital having facilities of blood transfusion, emergency
cesarean section and neonatal intensive care unit (NICU).
‘Flying Squad’ service is ideal for transfer of such type of patients. An
intravenous Ringer’s solution drip should be started and is kept running
during transport. Patient should be accompanied by two or three persons fit
for donation of blood, if necessary.
ADMISSION TO HOSPITAL: All cases of APH, even if the bleeding is
slight or absent by the time the patient reaches the hospital, should be
admitted.
The reasons are: (1) All the cases of APH should be regarded as due to
placenta previa unless proved otherwise.
(2) The bleeding may recur sooner or later and none can predict when it
recurs and how much she will bleed.

32. TREATMENT ON ADMISSION
IMMEDIATE ATTENTION: Overall assessment of the case is quickly made as
regards:
(1) Amount of the blood loss — by noting the general condition, pallor, pulse rate
and blood pressure.
(2) Blood samples are taken for group, cross matching and estimation of
hemoglobin.
(3) A large-bore IV cannula is sited and an infusion of normal saline is started and
compatible cross matched blood transfusion should be arranged.
(4) Gentle abdominal palpation to ascertain any uterine tenderness and
auscultation to note the fetal heart rate.
(5) Inspection of the vulva to note the presence of any active bleeding.
Confirmation of diagnosis is made from the history, physical examination and with
sonographic examination.

33. FORMULATION OF THE LINE OF TREATMENT
Expectant treatment
The policy had been advocated by Macafee and Johnson (1945), in an attempt to
improve the fetal salvage without increasing undue maternal hazards. The aim is to
continue pregnancy for fetal maturity without compromising the maternal health.
Vital prerequisites:
(1) Availability of blood for transfusion whenever required.
(2) Facilities for cesarean section should be available throughout 24 hours, should it
prove necessary.
Selection of cases:
Suitable cases for expectant management are:
(1) Mother is in good health status
(hemoglobin > 10 g%; hematocrit > 30%).
(2) Duration of pregnancy is less than 37 weeks.
(3) Active vaginal bleeding is absent.
(4) Fetal well-being is assured (CTG and USG)

34. Conduct of expectant treatment:
(1) Bed rest with bathroom and toilet privileges.
(2)Investigations—like hemoglobin estimation, blood grouping and urine for protein
are done.
(3) Periodic inspection of the vulval pads and fetal surveillance with USG at interval
of 2–3 weeks
(4) Supplementary hematinics should be given and the blood loss is replaced by
adequate cross matched blood transfusion, if the patient is anemic.
(5) When the patient is allowed out of the bed (2-3 days after the bleeding stops),
a gentle speculum (Cusco’s) examination is made to exclude local cervical and
vaginal lesions for bleeding
(6) Use of tocolysis (magnesium sulfate) can be done if vaginal bleeding is
associated with uterine contractions.
(7) Use of cervical cerclage to reduce bleeding and to prolong pregnancy is not
helpful (RCOG 2005).
(8) Rh immunoglobin should be given to all Rh negative (unsensitized) women

35. Termination of the expectant treatment:
The expectant treatment is carried up to 37 weeks of pregnancy. By this
time, the baby becomes sufficiently mature.
Preterm delivery may have to be done in conditions, such as:
(1) Recurrence of brisk hemorrhage and which is continuing.
(2) The fetus is dead.
(3) The fetus is found congenitally malformed on investigation.
Repeated small bouts of hemorrhage is not an indication for termination
of expectant
treatment.
Replacement of the blood loss can be made by blood transfusion.
Steroid therapy is indicated when the duration of pregnancy is less than
34 weeks. Betamethasone reduces the risk of respiratory distress of the
newborn when preterm delivery is considered

36. Active (Definite) Management (Delivery):
The indications of definitive management (delivery) are :
(1) Bleeding occurs at or after 37 weeks of pregnancy.
(2) Patient is in labor.
(3) Patient is in exsanguinated state on admission.
(4) Bleeding is continuing and of moderate degree.
(5) Baby with nonreassuring cardiac status or dead or known to be
congenitally deformed.
A. Cesarean delivery is done for all women with sonographic evidence of
placenta previa where
placental edge is within 2 cm from the internal os.
. Vaginal delivery may be considered where placenta edge is clearly 2–3
cm away from the internal
cervical os (based on sonography).

37. VAGINAL EXAMINATION should be done with a double set up
arrangement in the operation theater keeping everything ready for
cesarean section .
Contraindications of vaginal examination are:
(1) Patient in exsanguinated state.
(2) Diagnosed cases of major degree of placenta previa confirmed by
ultrasonography .
(3) Associated complicating factors such as malpresentation, elderly
primigravidae, pregnancy with history of previous cesarean section,
contracted pelvis etc. which themselves are indications for cesarean
section

40. ABRUPTIO PLACENTAE
DEFINITION:
It is one form of antepartum hemorrhage where the
bleeding occurs due to premature separation of normally
situated placenta.

41. VARIETIES :
(1) Revealed : Following separation of the placenta, the blood insinuates
downwards between the membranes and the decidua. Ultimately, the
blood comes out of the cervical canal to be visible externally. This is the
most common type.
(2) Concealed : The blood collects behind the separated placenta or
collected in between the membranes and decidua. The collected blood
is prevented from coming out of the cervix by the presenting part which
presses on the lower segment. At times, the blood may percolate into
the amniotic sac after rupturing the membranes. In any of the
circumstances blood is not visible outside. This type is rare.
(3) Mixed : In this type, some part of the blood collects inside
(concealed) and a part is expelled out (revealed).
Bleeding is almost always maternal.

43. Risk factors are :
(a) high birth order pregnancies with gravida 5 and above — three times more
common than
in first birth
(b) advancing age of the mother
(c) poor socio-economic condition (d) malnutrition (e) smoking (vasospasm).
Hypertension in pregnancy is the most important predisposing factor.
Preeclampsia, gestational hypertension and essential hypertension, all
are associated with placental abruption.
Trauma: Traumatic separation of the placenta usually leads to its marginal separation with
escape of blood outside
other factors are:
-Sudden uterine decompression
-Short cord
-Placental anomaly
-Folic acid defeciency
-Thrombophilias
-Prior abruption

44. PATHOGENESIS:
Depending upon the etiological factors , premature placental
separation is initiated by hemorrhage into the decidua basalis.
The collected blood (decidual hematoma) at the early phase, hardly
produces any morbid pathological changes in the uterine wall or on the
placenta.
Rupture of the basal plate may also occur, thus communicating the
hematoma with the intervillous space. The decidual hematoma may be
small and self
limited; the entity is evident only after the expulsion of
the placenta (retroplacental hematoma).

45. The features of retroplacental hematoma are:
(a) Depression found on the maternal surface of the placenta
with a clot which may be found firmly attached to the area
(b) Areas of infarction with varying degree of organization
If, however, a major spiral artery ruptures, a big hematoma is
formed.

48. CHANGES IN OTHER ORGANS:
liver - apart from the changes found in preeclampsia, presence of fibrin
knots in the hepatic sinusoids is an important finding. Kidneys may show
acute cortical necrosis or acute tubular necrosis.
Shock proteinuria is probably due to renal anoxia which usually
disappears 2 days after delivery, whereas proteinuria due to
preeclampsia tends to last longer.
BLOOD COAGULOPATHY: Blood coagulopathy is due to excess
consumption of plasma fibrinogen due
to disseminated intravascular coagulation and retroplacental bleeding.
There is overt hypofibrinogenemia
(< 150 mg/dL) and elevated levels of fibrin degradation products and D-
dimer

49. CLINICAL CLASSIFICATION:Depending upon the degree of placental
abruption and its clinical effects, the cases are graded as follows:
Grade—0: Clinical features may be absent. The diagnosis is made after
inspection of placenta following delivery.
Grade—1 (40%):(i) vaginal bleeding is slight (ii) uterus: irritable,
tenderness may be minimal or absent (iii) maternal BP and fibrinogen
levels unaffected (iv) FHS is good.
Grade—2 (45%):(i) vaginal bleedingmild to moderate (ii) uterine
tenderness is always present(iii) maternal pulse ↑, BP is maintained (iv)
fibrinogen level may be decreased (v) shock is absent(vi) fetal distress or
even fetal death occurs.
Grade—3 (15%): (i) bleeding is moderate to severe or may be
concealed (ii)uterine tenderness is marked (iii) shock is pronounced (iv)
fetal death is the rule (v) associated coagulation defect or anuria may
complicate.

50. CLINICAL FEATURES OF ABRUPTIO PLACENTAE
The clinical features depend on:
(i) degree of separation of placenta,
(ii) speed at which separation occurs and
(iii) amount of blood concealed inside the uterine cavity. But they may be very
deceptive
in posteriorly implanted placenta.
DIAGNOSIS: Mainly clinical. Ultrasonography or MRI may be helpful.
The essential points to arrive at the diagnosis of the concealed variety are:
(i) shock out of proportion to external bleeding
(ii) unexplained extreme pallor
(iii) presence of preeclamptic features
(iv) uterus is tense, tender
and woody hard
(v) FHS is absent
(vi) diminished urinary output
(vii) presence of blood coagulation disorders

51. COMPLICATIONS OF ABRUPTIO PLACENTAE
MATERNAL:
In revealed type—maternal risk is proportionate to the visible blood loss and
maternal
death is rare.
In concealed variety—The following complications may occur either singly or in
combination.
(1) Hemorrhage which is either totally concealed inside the uterus or more commonly,
part is revealed outside. There may be intraperitoneal or broad ligament hematoma.
(2) Shock may be out of proportion to the blood loss. Release of thromboplastin into
the maternal circulation results in DIC or there may be amniotic fluid embolism.
(3) Blood coagulation disorders .
(4) Oliguria and anuria due to—(a) hypovolemia (b) serotonin liberated from the
damaged uterine muscle producing renal ischemia and (c) acute tubular necrosis

52. (5) Postpartum hemorrhage due to — (a) atony of the uterus and (b)
increase in serum FDP
(6) Puerperal sepsis

53. FETAL:
In revealed type, the fetal death is to the extent of 25–30%.
In concealed type, however, the fetal death is appreciably high, ranging
from 50% to 100%.
The deaths are due to prematurity and anoxia due to placental
separation. With same degree of placental separation, the fetus is put to
more risk in
abruptio placentae than in placenta previa.
This is due to the presence of preexisting placental pathology with poor
functional reserve in the former, in contrast to an almost normal
placental functions in the latter.
Risk of recurrence in subsequent pregnancy is about 5–20% with high
perinatal mortality

54. MANAGEMENT OF ABRUPTIO PLACENTAE
Prevention:
The prevention aims at—
(1) Elimination of the known factors likely to produce
placental
separation.
(2) Correction of anemia during antenatal period so that the
patient can withstand blood loss.
(3) Prompt detection and institution of the therapy to
minimize the grave complications namely shock, blood
coagulation disorders and renal failure

55. TREATMENT
AT HOME: The patient is to be treated as outlined in
placenta previa and arrangement should be made to shift the
patient to an equipped maternity unit as early as possible.
IN THE HOSPITAL: Assessment of the case is to be done as
regards: (a) amount of blood loss
(b) maturity of the fetus and
(c) whether the patient is in labor or not
(d) presence of
any complication and
(e) type and grade of placental abruption

56. Emergency measures:
(i) blood is sent for hemoglobin and hematocrit estimation,
coagulation profile (fibrinogen level, FDP, prothrombin time,
activated partial thromboplastin time and platelets),
ABO and Rh grouping and urine for detection of protein
(ii) Ringer’s solution drip is started with a wide bore cannula
and arrangement for blood transfusion is made for
resuscitation.
Close monitoring of maternal and fetal condition is done

57. Management options are:
(a) immediate delivery
(b) management of complications if there is any
(c) expectant management (rare).
Definitive treatment (immediate delivery):
The patient is in labor: Most patients are in labor following a
term pregnancy: The labor is accelerated by low rupture of the
membranes.
Rupture of the membranes with escape of liquor amnii
accelerates labor and it increases the uterine tone also.
Oxytocin drip may be started to accelerate labor when needed

58. Vaginal delivery is favored in cases with:
(i) limited placental abruption (ii) FHR tracing is reassuring (iii) facilities for
continuous (electronic) fetal monitoring is available (iv) prospect of
vaginal delivery is soon or (v) placental abruption with a dead fetus.
The advantages of amniotomy are: (a) initiates myometrial contraction and
labor process (b) expedites delivery (c) better compression of spiral artery
to arrest hemorrhage
(d) reduces entry of
thromboplastin into maternal circulation and thereby (e) reduces the risk
of renal cortical necrosis and
DIC

59. The patient is not in labor:
(i) Bleeding continues (ii) > Grade I abruption :
Deliveryeither by
(A) induction of labor or (B) cesarean section.
(A) Induction of labor
is done by low rupture of membranes.
Oxytocin may be added to expedite delivery.
Labor usually starts soon in majority of cases and delivery is completed
quickly (4–6 hours).
Placenta with varying amount of retroplacental clot is expelled most often
simultaneously with the delivery of the baby.
Inj. oxytocin 10.IU IV (slow) or IM or Inj. methergine 0.2 mg IV is given
with the
delivery of the baby to minimize postpartum blood loss. Oxytocics should
be used to improve the uterine tone along with blood transfusion

60. (B) Cesarean section:
Indications are :
(a) severe abruption with live fetus
(b) amniotomy could not be done (unfavorable cervix)
(c) prospect of immediate vaginal delivery despite amniotomy is remote
(d) amniotomy failed to control bleeding
(e) amniotomy failed to arrest the process of abruption (rising fundal
height)
(f) appearance of adverse features (fetal distress, falling fibrinogen level,
oliguria)

61. Management of complications:
The major complications of placental abruption are:
(a) hemorrhagic shock.
(b) DIC.
(c) renal failure and
(d) uterine atony and postpartum hemorrhage.
Hypovolemia should be corrected early.
Blood pressure may not be a correct guide to assess shock, as it may
be high due to severe degree of vasospasm.
Irrespective of the patient’s general condition, at least one liter of blood
transfusion should be the minimum when the diagnosis of concealed
accidental hemorrhage is made. The best guide to monitor the patient is
the use of central venous pressure (CVP).
Hematocrit should be at least 30% and urinary output ≥ 30 mL/h.

62. INDETERMINATE BLEEDING
The diagnosis of unclassified bleeding should be made after
exclusion of placenta previa, placental abruption and
local causes
. Rupture of vasa previa, marginal sinus hemorrhage,
circumvallate placenta, marked decidual reaction on
endocervix or excessive show may be a possible cause of
such bleeding

63. Vasa Previa:
The unsupported umbilical vessels in velamentous placenta, lie below
the presenting part and run across the cervical os.
These vessels are torn either spontaneously or during rupture of
membranes.
Color-flow Doppler (TVS) is helpful for antenatal diagnosis.
Fetal mortality is high (50%) due to fetal exsanguination.
Detection of nucleated red blood cells (Singer’s alkali denaturation test)
or fetal
hemoglobin (Apt test) is diagnostic.
Vaginal bleeding is often associated with fetal distress (tachycardia,
sinusoidal FHR tracing).

64. MANAGEMENT:
Management depends on fetal gestational age, severity of
bleeding, persistence or recurrence of bleeding.
Center must be equipped with appropriate neonatal care
facilities in view of preterm delivery.
A Considering the risks of bleeding, patient with confirmed vasa
previa, needs antenatal admission at 28–32 weeks of gestation.
Expectant management can be done in selected cases for fetal
lung maturity similar to placenta previa.
Antenatal corticosteroids should be given

65. B Any case with bleeding vasa previa, delivery should be done
by category-1 emergency cesarean section.
Intrapartum diagnosis of vasa previa, needs expeditious delivery.
C A case of confirmed vasa previa at term (≥37 weeks) should
be delivered by elective cesarean section prior to onset of labor.
D Neonatal blood transfusion may be needed.

66. THANK YOU