This document discusses antepartum hemorrhage caused by placenta previa and abruptio placentae. It defines both conditions and describes their causes, risk factors, clinical presentation, diagnosis, and management. Placenta previa is defined as implantation of the placenta in the lower uterine segment and can range from partial to complete coverage of the cervical os. Abruptio placentae is the premature separation of a normally implanted placenta, which can result in both concealed and revealed vaginal bleeding. Diagnosis involves ultrasound and management depends on gestational age and severity of bleeding, ranging from expectant care to cesarean section. Both conditions can threaten the lives of mother and baby if not

1. Haemorrhage during late
pregnancy : Placenta previa,
Abruptio placenta
PRESENTED BY
KRIPA SUSAN KURIEN
2 ND YEAR MSC NURSING

2. Meaning of Antepartum haemorrahge
 Any bleeding that occurs during the late period of
pregnancy is termed as Antepartum hemorrhage

3. Definition
 Haemorrhage from the genital tract in late
pregnancy after the 24 week of gestation and before
the onset of labour is referred to Antepartum
haemorrhage
or
 It is defined as the bleeding from or into the genital
tract after the 28th week of pregnancy but before the
birth of the baby(the first and the second stage of
labour)

4. CONTD DEFINITION...
“bleeding into or from the genital tract after 24
weeks of gestation”
“ Bleeding from the female genital tract anytime
after fetal viability but before delivery”
WHO

5. INCIDENCES
 It affects 4% of all pregnancies.
 It is associated with increased risks of fetal and
maternal morbidity and mortality

6. CAUSES AND CLASSIFICATION
UNEXPLAINED (25% ) EXTRAPLACENTAL
OR (5%)
INDETERMINATE LOCAL CERVICO VAGINAL LESION
trauma, cervical polyp, carcinoma
cervix, genital varicosities, vasa pravia
vulvo vaginal infections , cervicitis
APH
PLACENTAL
BLEEDING (70%)
PLACENTA ABRUPTIO
PRAEVIA PLACENTAE

7.  Causes
 Placenta praevia
 Abruptio placentae
 Distal genital tract / gynaecological bleeding
 Unclassified bleeding
 Abnormal placentation
 Abnormal placental shape
 Vasa praevia
(south australian prenatal pratice
guidelines)

8. Causes and incidence
 Abruptio placenta (1 in 100 pregnancies) 40%
 Placenta previa (1 in 200 pregnancies) 20%
 Unclassified 35%
 Lower genital tract lesion 5%

9. PLACENTA PRAEVIA
 DEFINTION
When the placenta is implanted partially or completely
over the lower uterine segment
or
Occurs when the implantation of the trophoblast takes
place in the lower uterine segment

11. Incidences
 80% in multiparous mothers
 Age greater than 35
 Presence of uterine scar
 Prior placenta praevia
 Multiple pregnancies
 Development of abnormal large placenta (multi fetal
pregnancies)

12. Etiology
Exact cause is not known
Following theories is proposed
DROPPING DOWN THEORY-Fertilized
ovum drops down and implanted in the
lower segment
Poor decidual reaction in upper uterine segment
Failure of zona pellucida to disappear in time
Thoery explains the development of central placenta
praevia

13.  Persistence of choronic activity: in the decidua
capsularis and its subsequent development into the
capsular placenta which comes in contact with
decidua vera of the lower segment – explain
formation of lesser degree of placenta praevia

14.  Defective decidua
Results in spreading of the chorionic villi over a wide
area into the uterine wall to get nourishment
During process , placenta gets membraneous and may
invade the underlying decidua and they also
encroach into the lower uterine segment
Explains the cause for development of placenta accreta
 Big placenta in case of twins

15. Predisposing factors of placenta praevie
 Multi parity
 Increased maternal age
 h/o of previous caesarean section or scars in uterus
 Placental size and abnormality
 Smoking

16. Pathological anatomy
 Placenta- may be large and thin, often tongue shaped
extension from the main placental mass, extensive
areas of degeneration with infarcation and
calcification , placenta may be morbidly adherent(
due to poor decidua formation)

17. Contd.....
 Umbilical cord
 Cord may be attached to margin( battledore) or into
the membranes( velamentous)
 Insertion of cord close to the internal os or fetal
vessel may run across the internal os in velamentous
insertion leads to vasa praevia

18. Contd......
 Lower uterine segment
 become soft and and more friable , due to increased
vascularity

19. Types or degrees
 Type- 1( low lying)- major part of the placenta is
attached to the upper segment and only the lower
margin encroaches onto to the lower segment but
not upto the os
 Type 2 ( marginal ) placenta reaches the margin of
the internal os but doesnot cover it
depending on position: type 2 a anterior & type 2b
posterior

22.  Typr 2b posterior or dangerous placenta
 because of the curved birth cannel, major thickness
of placenta overlies the sacral promontory ,thus
reducing antero posterior diameter of inlet , prevent
engagement of presenting part

23.  TYPE 3- ( Incomplete or partial central) – the
placenta covers the internal os partially ( covers the
internal os when closed , but doesnot when fully
dilated )
 Type 4- ( central or total) placenta completely covers
the internal os even after it is fully dilated

25.  Also, classified , clinical purpose
 Mild degree- type 1,and 2
 Major degree- type 2 posterior , 3 and 4

26. Pathophysiology or cause for bleeding
 Placental growth slows down in later months
 Lower segment progressively dilates
 Inelastic placenta sheared off wall of lowersegment
 Opening up of utero placental vessels

27. Clinical features
 SYMPTOMS
 Vaginal bleeding – features sudden onset,painless,
causeless and recurrent
 SIGNS
 Abdominal examination
size of uterus is proportionate to period of gestation
Uterus feel relaxed , soft, elastic without tenderness
Presence of malpresentation is frequent
Head is floating in contrast to period of gestation
FHS is usually present , unless major separation is
seen

28. Contd..
 VULVAL INSPECTION
 To note for bleeding presences, and character of
bleed – bright red or dark cloured , and amount
 Placental praevia bleeding – bright red
 Vaginal examination not to be done outside ot

29. DIAGNOSIS
LOCALISATION OF
PLACENTA
(
PLACENTOGRAPHY)
SONOGRAPHY
TRANS ABDOMINAL
TRANS VAGINAL
TRANS PERINEAL
COLOUR DOPPLER
MAGNATIC
RESONANCE
IMAGING
CLINICAL
INTERNAL
EXAMINATION
DIRECT
VISUALISATION
EXAMINATION OF
PLACENTA

30. Differential diagnosis
 Confused with other causes of bleeding in later
months
 Vasa praevia- unsupported umbilical vessels in
vilamentous placenta , lie below the presenting part
and run across the cervical os
 Vessels are torn either spontaneous OR during
rupture of membranes
 Colour flow doppler helps in the diagnosis

32. Contd...
 Local cervical lesions -Differentiated using speculum
examination
 Circumvallate placenta : bleeding is slight and
diagnosis made after
examination the placen
ta after delivery

33. Complications
 Maternal
 Fetal
MATERNAL
1. during pregnancy : antepartum haemorrhage with
varying degree of shock, malpresentation ,
premature labour
2. During labour : early rupture of membranes, cord
prolapse, slow dilation of cervix, intrapartum
haemorrhage, increased incidence of operative
interference, postpartum haemorrhage , retained
placenta

34. Contd.....
 3. during puerperium: SEPSIS( operative interfernce
, placenta site near to vagina , subinvolution,
embolism
FETAL
low birth weight babies , asphyxia , intrauterine death
birth injuries , congenital malformations

35. MANAGEMENT
 PREVENTION
 To minimize risk , following guidelines are followed
 Adequate antenatal care
 Antenatal diagnosis – using USG .and periodic
examinations
 Warning haemorrhage – not to be ignored
 Family planning and limitation of births

36. Contd...
 1.AT HOME
 Immediately put to bed, assess the blood loss , gentle
abdominal examination to note the height of the
uterus ,to ausculate FHS , VAGINAL
EXAMINATION NOT DONE
 2. TRANSFER TO HOSPITAL
 Arrangement to be made to shift to the nearest
hospital as quick as possible( equipped with facility
for emergency cs)

37.  3. TREATMENT ON ADMISSION
 IMMEDIATE ATTENTION FORMULATION OF LINE OF
 Amount of blood loss treatment
 Blood samples to be taken
 Infusion of normal saline, crossed matched blood
 Gentle abdominal palpation &auscultation(note FHS)
 Inspection of vulva ( to note presence of bleeding)
EXPECTANT ACTIVE

38.  Expectant treatment
1.Policy advocated – macafee nd johnson 1945
2.Vital prequites- availability of blood transfusion,
facilities for c section to be avaliable for 24 hours
3.Selection of cases – mother in good health status ,
duration of pregnancy less than 37 weeks , active
vaginal bleeding is absent , fetal well being is
assured

39.  4. conduct of expectant treatment
a) Bed rest with bathroom privilages
b) Investigation like hb, blood grouping , urine for
proteinurea ,
c) Periodic examination of vulval pads and fetal
surveillance with usg at intervals of 2-3 weeks
d) Supplementary heamatintics – blood loss to be
replaced by cross matched blood
e) Gentle speculum( cusco’s) examination made –
rule out local cervical and vaginal lesions

40.  TERMINATION OF EXPECTANT TREATMENT
 Treatment carried upto 37 weeks followed by
termination
 Premature termination done: recurrence for brisk
haemorrhage , fetus is dead, fetus congentially
malformed
 Steriod therapy – indicated if pregn is less than 34
weeks

41. ACTIVE INTERFERENCE
 Indications :
 1. bleeding occurs at or after 37 wk of gestation
 2. pt is in labour
 3. pt is in exsanguished state
 4.Bedding is continuous
 5. baby is dead
Also the contraindication for putting pt to expectant
treatment

42.  DEFINITVE TREATMENT
 Instituted soon following hospitalisation or following
expectant management
 Involves
 1. vaginal examination : followed by low rupture of
membranes or caesarean section
 2. caesarean section without internal examination

43. 1.VAGINAL EXAMINATION
 Double set up examination done in ot, following
everything ready in ot
 Contraindications:
 Pt in exsanguished state
 Diagnosed of major degree of placenta praevia (usg)
 Associated complication factors and previous history
of caesarean section

44.  A.low rupture of membranes :
 Aim – induce labour by low rupture membranes
using kochers forceps ( in lesser degree type 1 and
typr 2 anterior)
 Finger inserted to exclude cord prolapse
 Oxytocin drip may be started , if not
contraindications
 Aminiotomy – if fails to stop bleeding or initiate
labour, then caesarean section to be done

45.  Percautions during vaginal birth:
 Active step be to be taken to restore blood volume
 Methergin 0.2mg given following delivery ant
shoulder
 Proper examination of the cervix following delivery
 Baby’s blood hb to be checked

46.  B.CAESAREAN SECTION
 Indication
 Severe degree of placenta praevia
 Lesser degree of placenta praevia
 Complication of factors are associated with lesser
degree of placenta praevia where vaginal delivery is
unsafe

47.  2. Caseraen section without internal
examination

48.  SCHEME OF MANAGEMENT OF PLACENTA PRAEVIA IN
HOSPITAL
All APH patients are to be admitted
Expectant Treatment Active Interference
 No active bleeding bleeding continues
 Pregnancy <37 wks Ultra sonography pregnancy >37wks
Placental edge is clearly 2-3 cm placental edge within 2cm of
Away from the internal os. the internal os or placenta
praevia.
 Vaginal delivery
 Caesarean delivery Caesarean delivery
APH

49. PROGNOSIS
 MATERNAL: reduction of maternal deaths in
placenta preavia due to 1. early diagnosis
 2. omission of internal examination
 3.free availability of blood transfusion
 Potent antibiotics
 Wider use of caesarean section
FETAL: Reduction in death due to judicious extention
of expectant treatment

50. ABRUPTIO PLACENTA
 DEFINITION
 Form of antepartum haemorrhage where bleeding
occurs due to premature separation of normally
situated placenta

51. Types
 1.Revealed : following seperation of placenta , the
blood insinuates downwards between the
membranes and the decidua, blood seen out of the
cervical cannal
 Common type

52.  2. concealed : blood collected behind the separated
placenta or between the membranes and decidua
 Collected blood prevented from coming out of cervix
by presenting part which presses on lower segment
 Blood percolates
into amniotic sac
after rupturing the
membrane
Blood not visible

53.  3. MIXED : part of blood collected inside (concealed)
and a part is expelled out ( revealed)

55. INCIDENCES AND SIGNIFICANCES
 1 in 200 deliveries
 Significant cause of perinatal mortality( 15- 20%)
and maternal mortality( 2- 5%)

56. RISK FACTORS
 Increased age & parity.
 Hypertensive disorders.
 Preterm ruptured membranes.
 Multiple gestation.
 Polyhydramnios.
 Smoking.
 Cocaine use.
 Prior abruption.
 Uterine fibroid.
 Trauma

57. ETIOLOGY
A. Hypertension in pregnancy
B. Trauma – attempted external cephalic version,
road traffic accident or blow on abdomen, needle
puncture of aminocentesis
C. Sudden uterine decompression – lead to decreased
SA of uterus hence in placental seperation
D. Short cord
E. Supine hypotension syndrome
F. Placental anomaly
G. Folic acid deficiency

58. Contd...
 Torsion of uterus
 Cocaine abuse
 Thrombophilias
 Prior abruption

59.  Types of Abruptio Placentae:
Clinical manifestation of
haemorrhage
Ultrasonographic localization of
haemorrhage
•The bleeding remains confined
inside the uterus without any
evidence of external bleeding. It is a
severe form.—Concealed type.
• Retro placental—Between
placenta and myometrium.
• The bleeding appears as vaginal
bleeding. It is a mild form.—
Revealed type .
• Sub chorionic—Between the
placenta and the membranes.
•Both concealed and revealed type—
Mixed type.
• Pre placental—Between placenta
and the amniotic fluid.
•Blood may percolate through the
layers of myometrium upto serous
coat– Couvelaire uterus.
APH

60.  CONVELAIRE UTERUS
 described by convelaire
 Severe form of concealed haemorrahge
 Massive intravasation of blood into the uterine
musculature upto the serous coat

61.  Depending upon the degree of placental
abruption..
 Grade 0- clinical features absent.
 Grade 1- a) Vaginal bleeding is slight, b) Uterus is irritable
tenderness may be minimal or absent, c) Maternal BP and
fibrinogen levels unaffected, d) FHS is good
 Grade 2- a) Vaginal bleeding mild to moderate, b) Uterine
tenderness is always present, c) Maternal pulse ,BP is
maintained, d) Fibrinogen , e) Shock absen, f) Fetal
distress or fetal death occurs
 Grade 3- a) Bleeding is moderate to severe or may be
concealed, b) Uterine tenderness is marked, c) Shock is
pronounced, d) Fetal death is the rule, e) Associated
coagulation defect or anuria may complicate.
APH

62.  Clinical Features:
Symptoms Revealed type Concealed type
• Character of
bleeding
Abdominal discomfort
and vaginal bleeding (
dark ).
Continuous abdominal
pain and slight bleeding.
• General condition Proportionate to visible
blood loss, shock is
absent.
Shock may be
pronounced which is out
of proportion to visible
blood loss.
• Pallor Related to blood loss. Severe pallor.
• Features of pre-eclampsia
May be absent. Frequent association.
• Uterine height Proportionate to period of
gestation.
Disproportionately
enlarged and globular.
• Fetal parts & FHS Present . Absent .
• Urine output Normal . Usually diminished.
APH

63.  Laboratory Investigation:
Investigation Revealed type Concealed type
• Blood: Hb% Low value proportionate
to the blood loss.
Markedly lower, out of
proportion to the visible
blood loss.
• Coagulation Profile Usually unchanged. Clotting time increased
Fibrinogen level low
Platelet count low.
• Urine for protein May be absent. Usually present.
• Confusion in
Diagnosis
With placenta praevia. With acute obstetrical
gynecological surgical
complication.
APH

64. DIFFERENTIAL DIAGNOSIS
 A. REVEALED TYPE : confused with placenta
praveia
 B. MIXED OR CONCEALED:
 rupture uterus
 rectus sheath hematoma
 appendicular or instentinal perforation
 twisted ovarian tumor
 volvulus
 acute hydraminous
 tonic uterine contraction

65.  Complications of Abruptio Placentae:
Maternal: 1. Revealed type: Maternal death is rare.
2. Concealed type: Haemorrhage
Blood coagulation disorder
Shock
Oliguria and anuria
Puerperal sepsis
Postpartum haemorrhage due to
atony of the uterus.
Fetal: 1. Revealed type: Fetal death is to extent of 25-30%
2. Concealed type: Fetal death is high( 50-100%) due
to prematurity and anoxia due to placental separation.
APH

66. Management
 1. PREVENTION
 2. TREATMENT
 1. PREVENTION – aims at eliminating known
factors that cause risks, correction of anaemia,
prompt detection and institution of treatment

67.  2. TREATMENT
 1. AT HOME : Arrangement to be made for shift the
patient to the hospital
 2. IN HOSPITAL: A. REVEALED TYPE
a) Assessment of case : amt of blood loss, maturity of
fetus
b) Preliminaries:1. Blood for hb
estimation,haemotocrit estimation, coagulation
profile , ABO and rh grouping , urine for detection
of protein, 2. ringer solution drip is started

68.  C. DEFINITIVE TREATMENT :
I. Pt in labour :labour accelerated by low rupture of
membranes , oxytocin drips to be started to
accelerate labour
II. Pt not in labour:
a. preg 37 weeks or more then induction of labour is
done by low ruptue of membranes
b.Indication for caesarean section: fetal distress ,
amniotomy could not be done or failed, associated
complicating factors, confusion in diagnosis
Preg less than37 weeks : bleeding moderate to severe(
low rupture of mebrane , oxytocin drip is started),
bleeding slight or stopped( put on conservative mx)

69.  B. MIXED OR CONCEALED TYPE
 Defentive treatment:
i. Blood samples are taken
ii. To correct hypovolemia
iii. Artificial rupture of membranes
iv. Vaginal delivery
v. Caesarean section – indicated in two extreme cases
1. early – unfavourable cervix, whr speedy delivery
is not possible
vi. 2.late – progress of labour delayed in spite of
amniotony and oxytocin

70. Abruptio Placentae
Resuscitation
Revealed Concealed
Pt. in labour Pt. not in labour Delivery
APH
ARM+Oxytocin Delivery ARM+Oxytocin Caesarean Sec.
Vaginal delivery ARM+ Caesarean Vaginal delivery
Oxytocin delivery
Vaginal delivery
Oxytocics is continued to improve uterine tone along blood transfusion.

71. Difference between placenta praevia & Abruptio
placentae:
APH
Points of discussion Placenta praevia Abruptio placentae
Nature of bleeding &
Painless, causeless and
Painful, continuous and
character of blood
recurrent & bright red.
dark coloured
General condition
and anemia
Proportionate to visible
blood loss.
Out of proportion to the
visible blood loss.
Features of pre-eclampsia
Not relevant. Present in 1/3rd of cases.
Height of uterus Proportionate to the
gestational age.
Enlarged and
disproportionate.
Feel of uterus Soft and relaxed. Tense, tender, rigid.
Malpresentation It is common. Head is
high.
Unrelated as head is
engaged.
FHS Present. Absent.

72. Points of discussion Placenta praevia Abruptio placentae
Placentography (USG) Placenta in lower segment. Placenta in upper
segment.
Vaginal examination Placenta is felt on the
lower segment.
Placenta is not felt in
lower segment.
APH
A, Partial abruption with concealed hemorrhage. B, Partial abruption with
apparent hemorrhage. C, Complete abruption with apparent hemorrhage.

73. Unexplained or indetreminate bleeding
 Collective group of entities where a confident
diagnosis of placenta praevia or abruptio placenta
cannot be made , nor is there any local lesions to
account for the cause of bleeding
 Marginal sinus haemorrahge
 Circumvallate placenta or excessive show

74. APH
 An extra placental cause of APH is suspected when placental
praevia and abruptio placentae are excluded from history,
clinical examination and USG.
 A gentle speculum examination of the cervix and vagina
helps to settle the diagnosis of local causes of bleeding in
such cases. Benign conditions like cervical ectropion, cervical
polyp are not treated during the pregnancy. A cervical polyp
can however be removed, if recurrent bleeding persists.

75.  Broadly divided into LOCAL CAUSES OF
BLEEDING
 And OTHER CAUSES
 LOCAL CAUSES – includes vulvar vein varicosities,
cervical erosions, cervical polyps , cervical
carcinomas , cervical lesions
 OTHER CAUSES – Execess show, coagulopathies,
uterine ruptures

76.  A. Local causes
 Vulvar vein varicosities Condition of varicose
vein occuring in vulva during pregnancy
 Cervical erosions- raw looking granular
appearance of cervix, occurs when the inner linning
of the cervical cannal comes out onto the part whr
cervix can be visualised
 Cervical cancers- cancers arising from the cervix ,
also cause vaginal bleeding

77.  Cervicitis : Inflammtion of the cervix , caused due
to infection of the endo cervix

78.  B. OTHER CAUSES
 1. clotting problems : DIC OR disseminated
intravascular coagulation
 Is pathological form of clotting factors that consumes
large amount of clotting factors that is diffuse
causing widepread external bleeding , internal
bleeding or both
 Is a over activation of clotting cascade and
fibrinolytic sytem , resulting in depletion of plaletes
and clotting factors

79.  Management : correcting the underlying cause and
replacement of essential factors and fluid volume
 2. CORD INSERTIONS AND PLACENTAL
VARIATION:
 Velamentous insertion of cord :traction on the cord
may tear , one or more of fetal vessels, as a result
fetus bleed to death
 Battledore insertion of the cord- increases the risk for
fetal haemorrhage

81. Thank you