2. 06/29/13
DEFINITION
Bleeding per vaginam after the period of
viability(28 weeks) of pregnancy and before
labour (delivery of the baby).
The incidence of APH in KBTH is 1.2-1.8% of
total births and it accounts for about 8% of all
caesarian sections in KBTH
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AETIOLOGY
Bleeding from placenta site
Placenta praevia
Placenta abruption
Bleeding from local causes in the genital tract
Cervical polyps
Friable condyloma acuminata
Cervicitis
Cervical carcinoma
Florid vaginal candidiasis
Vulva varicosities
Vasa praevia
Uterine rupture
Unknown causes.
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A zygote that implants low in the uterus is
likely to form a placenta that lies with close
proximity to the cervix
The placenta so located may
Be aborted
Migrate upward to the upper segment
(placental migration)
May fail to migrate upward. With failure of the
placenta to migrate, the placenta remains in
the lower uterine segment and over the
internal os
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The etiology of PP is unknown.
Bleeding is thought to occur in association
with the development of the lower uterine
segment in the third trimester.
Placental attachment is disrupted as this
area gradually thins in preparation for
labour.
Bleeding then ensues as the thinned lower
uterine segment is unable to contract
adequately to prevent blood flow from the
open vessels.
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Grading
Type 1: placenta is partially located in the lower
segment and the lower edge of the placenta does not
reach the internal os (lateral placenta praevia)
Type 2: placenta is partially located in the lower
segment and the lower edge of the placenta reaches
the internal os but not cross it.(marginal placenta
praevia)
Type 3: placenta covers the internal os completely
when the cervix is closed, but covers the internal os
partially when the cervix is fully dilated (partial
placenta praevia)
Type 4: placenta completely covers the closed
internal os and even at full dilatation covers it
completely (central placenta praevia)
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Clinical presentation
Usually presents in the 3rd
Trimester
Symptoms:
painless spontaneous recurrent vaginal
bleeding.
First episode is usually not heavy (warning
hemorrhage).
The blood is fresh and clots readily.
Symptoms of anaemia depending on the
amount of blood loss
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Examination
- Soft abdomen
- Abnormal lie
- Malpresentation
- High presenting part at term
- Fetal heart usually unaffected
SPECULUM EXAM
- If local lesion suspected
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Diagnosis
A good history
Examination: a VE is absolutely contraindicated
as it could lead to torrential bleeding
Investigations for placenta localisation
1. Ultrasound
2. MRI
3. CT scan
4. Placenta arteriorgraphy
5. Reduced placentography
6. Radioisotope Tc 99
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Management of Placenta Praevia
This depends on the severity of the bleeding
and the gestational age of the pregnancy.
However in all cases of praevia you admit the
patient .
Clinically assess the patient
Resuscitate depending on the severity
VAGINAL EXAMINATION IS CONTRAINDICATED
Do a sterile speculum examination
Ultrasound examination when the patient is
stable.
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Expectant Management
The main aim is to achieve maximum foetal maturity if
possible
- Patient is admitted
- Clean white pad that does not form gel is inspected
every morning
- At least 2 units of blood should be cross matched and
kept on the ward.
- When patient is to visit the lavatory, she should inform
the medical staff or colleague patient
- At 37 completed weeks, repeat Ultra Sound to assess
foetal wellbeing in preparation for delivery
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Put mother on fetal kick count
Palpate for fetal parts
Check the FH twice daily
Ultrasound for placental localization at 34wks
If there is severe bleeding, that will jeopardize
the health of the mother, then immediate
delivery, irrespective of GA must be carried
out
Also, if the patient is at 34wks and comes in
with severe bleeding, delivery should be
carried out
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Delivery
Stage 1 & 2a – vaginal delivery if no
contraindications.
Stages 2b, 3 and 4 – Caesarian section is
indicated
C/S is also in the ff
- Any patient with repeated bleeding
- Severe bleeding
- Presentation other than vertex
- Other obstetric indications such as contracted
pelvis.
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Vaginal Delivery
The Double Set-up Approach
Preparation
-Two units of cross-matched blood in theatre
-Patient starved over night
-Two trolleys set, on for EUA and the other for CS
Procedure
-Two obstetricians, one to do EUA the other scrubbed
for a CS if need be.
-If EUA provokes heavy bleeding a CS is performed.
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Predisposing Factors
Maternal hypertension
Chronic hypertension
PIH
Trauma to the abdomen
Polyhydramnios
PROM
Anticoagulant therapy
Advanced parity
Low socio-economic status
Smoking
Obstetric procedures e.g.. External cephalic version,
amniocentesis, amniotomy in polyhydramnios
Increasing Maternal age
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Mechanism
Follows spontaneous rupture of blood vessels
at placenta bed with haematoma formation.
Couvelaire uterus- blood dissect into the
myometrium
Deranged metabolic exchange- foetal hypoxia
and probable death
Release of tissue thromboplastin-DIC-
consumptive coagulopathy- bleeding disorder
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Grading
1. Not recognised before delivery
2. Classical signs, Foetus alive
3. A. Foetus dead
No Coagulopathy
B. Foetus dead
Coagulopathy present
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Differentials
This must considered in terms of causes of vaginal
bleeding and causes of abdominal pain.
1. Abdominal pains
Acute appendicitis
Pyelonephritis
Twisted ovarian cyst
Red degenerating uterine fibroid
Retroperitoneal haemorrhage
Rectus sheath haematoma
Chorioamnionitis
Lumbar or sacral strain
Ruptured uterus
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Complications
Maternal
Life threatening maternal haemorrhage and shock
DIC
Increased risk of PPH
Acute tubular necrosis of kidneys
Uraemia
Maternal death
Foetal
Hypoxia (asphyxia)
Anaemia
IUGR associated with expectant management
Foetal death
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General Management
Admit the patient
Set up an IV line with a wide bore cannula
Take blood for:
FBC and sickling
GXM (about 2-4 units of blood;2-4 units FFP)
Coagulation profile (including platelet count)
Clot observation test
BUE and Cr
LFT
Rh status
Apt test on vaginal bleed (if possible)
IVF (crystalloids and colloids) while waiting for blood
Pass catheter to measure urine output
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Expectant management
This may be done for mild cases in which the foetus is
immature. Such cases may develop mild localised
tenderness over the uterus. USG identifies a small retro
placental clot.
Admit patient
Pain relief
Continuous electronic FHR monitoring (if available)
Repeat USG for first few hours to monitor the rate of
progression of retro placental clot.
Mature foetal lung with corticosteroids
Monitor foetus subsequently by
daily foetal kick count
2x weekly CTG
2x weekly USG
If abruption progresses deliver as soon as possible
If abruption does not progress continue expectant
management till 37 completed weeks and deliver.
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Immediate Delivery
IUFD
Resuscitate mother
Induce labour (if no contraindications present)
Aim at vaginal delivery
CS may be necessary when there is
uncontrollable maternal bleeding
Live foetus
Immediate delivery by CS( foetal distress)
Vaginal delivery may be acceptable when
patient presents in labour and rapid delivery
is anticipated
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Prognosis
Foetal outcome is very poor
-hypoxia
-prematurity
Maternal death is very high but
depends on availability of blood ;hard
working house officers and residents;
time of presentation.
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VASA PRAEVIA
This is bleeding from foetal vessels. It often results from
velamentamous insertion of the umbilical cord.
The cord inserts at a distance from the placenta and it is not
protected by Wharton’s jelly.
The umbilical cord vessels traverse between the chorion and
amnion without protection and might cross the os.
Bleeding from foetal vessels is usually associated with abnormal
foetal heart pattern and delivery should be rapid by emergency
CS.
Incidence is approx 1 per 5000 singleton delivery
Foetal mortality is very high ;about 75 – 100% of cases of
rupture these vessels.
The apt test is used in diagnosis of vasa praevia by mixing
suspected bloody vaginal fluid with water and centrifuging. The
supernatant is mixed with 1.0% NaOH. A pink colour after
another centrifuge indicates the presence of foetal blood
