Antepartum haemorrhage -1

1. ANTEPARTUM
HAEMORRHAGE-I
DR. RUPAL

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.
• Incidence -3% amongst hospital deliveries.

3. CAUSES

4. PLACENTA 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.
INCIDENCE:
-About one-third cases of antepartum hemorrhage.
-The incidence of placenta previa ranges from 0.5–1%.
-In 80% cases, it is found to multiparous women.
-Incidence increases beyond the age of 35, with high
birth order pregnancies and in multiple pregnancy.

5. ETIOLOGY
• Dropping down theory
• Persistence of chorionic activity in the decidua capsularis
and its development into capsular placenta
• Defective decidua
• Big surface area of placenta

6. Predisposing factors
• Multiparity
• Increased maternal age(>35yrs)
• History of previous cesarean section or any other scar in the
uterus (myomectomy or hysterotomy)
• Placental size and abnormality (succenturiate lobes)
• Smoking
• Prior curettage

7. TYPES/DEGREES OF
PLACENTA PREVIA
*For clinical purpose, the types are graded into
Mild degree (Type-I and II anterior) and
Major degree (Type-IIposterior, III and IV).

8. CLINICAL FEATURES
SYMPTOMS
ONLY SYMPTOM- VAGINAL BLEEDING
Classical features of bleeeding
suddenonset,painless,apparently causeless and
recurrent.
• 5% cases occurs for the first time during labor, especially
in primigravidae.
• one-third of cases, there is a history of “warning
hemorrhage” usually slight.
• bleeding is unrelated to activity and often occurs during
sleep and the patient becomes frightened on awakening
to find herself in a pool of blood

9. • SIGNS
General condition and anemia are proportionate to the
visible blood loss.
ABDOMINAL EXAMINATION
The size of the uterus is proportionate to the period of
gestation.
The uterus feels relaxed, soft and elastic
Persistence of malpresentation like breech or transverse
or unstable lie is more frequent.
The head - floating
Fetal heart sound is usually present, unless there is major
separation of the placenta with the patient

10. • VULVAL INSPECTION -blood is bright red
• 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
• CONFIRMATION OF DIAGNOSIS- USG

12. MANAGEMENT
IMMEDIATE
(1) Amount of the blood Loss assessed — 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.
(6)Confirmation of diagnosis is made from the history, physical
examination and with USG.

13. EXPECTANT MANAGEMENT
Macafee and Johnson (1945)
• 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.
• Selection of cases:
(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 (USG).

14. (1) Bed rest with bathroom 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 (see p. 244)
(4) Supplementary hematinics
(5) When the patient is allowed out of the
bed (2-3 days after the bleeding stops), a
gentle speculum 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) Rh immunoglobin should be given to all
Rh negative (unsensitized) women.

15. • Expectant management at Hospital or at Home? Hospital
setting is ideal. home care may be allowed in some. Selected
cases are — (a) patient lives close to hospital (b) 24-hour
transportation is available (c) Bed rest assured and (d) patient
is well motivated to understand the risks.
• Termination of the expectant treatment:37 weeks of
pregnancy.
• Steroid therapy is indicated when the duration of pregnancy is
less than 34 weeks

16. ACTIVE
MANAGEMENT(DELIVERY)
 Bleeding occurs at or after 37 weeks of pregnancy
Patient is in labor
Patient is in exsanguinated state on admission
Bleeding is continuing and of moderate degree
Baby is dead or known to be congenitally deformed
DEFINITIVE MANAGEMENT
• Cesarean delivery –placental edge is within 2 cm from the
internal os.
• Vaginal delivery -placenta edge is clearly 2–3 cm away from
the internal cervical os