PLACE : MY CAMPUS

TOPIC : ANTE PARTUM HAEMORRHAGE

TEACHING METHOD : LECTURE

GROUP : 1ST YEAR BSN

NAME OF THE STUDENT : LAIBY JOHN

NAME OF THE FACULTY : DR. NAZIRA SATHARKHAN

DATE : MAY 2008

ANTEPARTUM HAEMORRHAGE

Bleeding from the vagina in the late pregnancy , after the 28th week of gestation and
before the onset of labour is referred to as antepartum haemorrage.

EFFECTS ON THE FETUS

Fetal mortality and morbidity are increased as a result of severe vaginal bleeding in
pregnancy. Still birth or perinatal or neonatal death may occur. Premature placental
separation and consequent hypoxia may result in birth of a child who is physically and
mentally handicapped.

EFFECT ON THE MOTHER

If bleeding is severe it may be accompanied by shock, DIC and renal failure.The mother
may die or live with permanent ill- health.

TYPES OF ANTEPARTUM HAEMORRHAGE

If bleeding from the local lesions of the vaginal tract is excluded , vaginal bleeding in late
pregnancy is confined to placental separation due to placenta praevia or placental
abruption.
A. PLACENTA PRAEVIA

The placenta is partially or wholly implanted in the lower uterine segment on either the
anterior or posterior wall. The anterior location is less serious than the posterior.The
lower uterine segment grows and stretches progressively after the 12th week of
pregnancy. In later weeks this may cause the placenta to separate and severe bleeding can
occur. Bleeding is caused by shearing stress between placental trophoblast and maternal
blood venous sinuses. In some times bleeding may be precipitated by coitus.

DEGREES OF PLACENTA PRAEVIA

Type – 1 placenta praevia
The majority of the placenta is in upper uterine segment. Vaginal delivery is possible.
Blood loss is usually mild and the mother and fetus remain in good condition.

Type – 2 placenta praevia

The placenta is partially located in the lower uterine segment near the internal cervical os.
Vaginal delivery is possible particularly if placenta is anterior. Blood loss is usually
moderate. Fetal hypoxia is more likely to be present than maternal shock.

Type – 3 placenta praevia

The placenta is located over the internal cervical os but not centrally . Bleeding is likely
to be severe particularly when the lower segment stretches and cervix begins to efface
and dilate in late pregnancy . Vaginal delivery is inappropriate because the placenta
precedes the fetus.
Type-4 placenta praevia
The placenta is located centrally over the internal cervical os and torrential haemorrhage
is very likely. Vaginal delivery should not be considered. Caesarean section is essential in
order to save the life of the mother and fetus.

INDICATIONS OF PLACENTA PRAEVIA

Bleeding per vaginum is the only sign and it is painless. The uterus is not tender or
tense.The presence of placenta praevia should be suspected when :
1. The fetal head remains unengaged in a primigravida.
2. There is malpresentation , especially breech.
 3. The lie is oblique or transverse.
4. The lie is unstable, usually in a multigravida.
Localisation of placenta using ultrasonic scanning will confirm the existence of placenta
praevia and establish its degree.

ASSESSING MOTHERS CONDITION

Some mothers may have a history of small repeated bleeding at intervals through out the
pregnancy. Others may have a sudden single episode of vaginal bleeding after the 20th
week , but severe haemorrhage occurs most frequently after the 34th week of pregnancy.
The colour of blood is bright red , denoting fresh bleeding. As retroplacental clot is not
formed. For this reason pain is not a feature of placenta praevia.

GENERAL EXAMINATION
In severe haemorrhage the blood pressure will be low and pulse rate raised due to
shock.Respiratory rate is also rapid and the mother may have air hunger .The mothers
colour will be pale and her skin cold and moist. Temperature will be normal as it is not
associated with infection.
Do only abdominal examination , do not attempt to do a vaginal examination as it will
precipitate a torrential haemorrhage.Try to quantify the amount of blood loss.

ASSESSING THE FETAL CONDITION

Fetal condition should be assessed by using an electronic fetal monitor or fetoscope.Fetal
oxygenation depends upon the proportion of placenta remaining attached. Fetal hypoxia
is an emergency and medical assistance should be called urgently.

MANAGEMENT OF PLACENTA PRAEVIA

It depends on:
1. the amount of bleeding
2. the condition of mother and fetus
3. the location of placenta
4. the stage of pregnancy
CONSERVATIVE management is appropriate if bleeding is slight if the bleeding is
slight and the mother and the fetus are well. The mother should be hospitalized until the
bleeding has stopped. Vaginal delivery is usual with type1 placenta praevia and possible
with type2 unless the placenta is situated immediately above the sacral promontarywhere
it is vulnerable to pressure from an advancing fetal head and may impede descent.The
chance for PPH is more due to the poor living ligature action.

ACTIVE MANAGEMENT
Severe vaginal bleeding will necessitate immediate delivery by caesarean section. Special
care of the new born should be arranged especially if the new born is preterm. Arrange
for cross matched blood .
COMPLICATIONS
1. PPH is the most probable complication, oxytocic drugs should be given as the
baby is delivered. If uncontrolled haemorrhage occurs hysterectomy may be
required.
2. Maternal shock may result from blood loss and hypovolaemia.
3. Maternal death occasionally ensues.
4. Fetal hypoxia due to placental separation.
5. Fetal death – 5-15%

B. PLACENTAL ABRUPTION

Premature separation of a normally situated placenta occurring after 20th week of

pregnancy is known as placental abruption. It is often associated with PIH or sudden
reduction in uterine size ,rarely direct trauma to the abdomen also .

TYPES
1.If blood escapes from the placental site it separates the membranes from the uterine
wall and drains through the vagina.
2.The blood which is retained behind the placenta may be forced into the myometrium
and it infiltrates between the muscle fibres of the uterus and this concealed haemorrhage
can make the uterus bruised and edematous , this is termed Couvelaire uterus.There is no
vaginal bleeding .The mother will have all the signs and symptoms of hypovolaemic
shock.
3.A combination of these two situation where some of the blood drains via the vagina and
some is retained behind the placenta is known as a mixed haemorrhage.
The classification based on the degree of separation and therefore related to the condition
of the mother and baby is of mild, moderate and severe haemorrhage.

GENERAL EXAMINATION
The mother is likely to be anxious, experiencing abdominal pain, skin will be pale and
moist if she is shocked, edema of the face , fingers and pretibial area of the lower limbs.
Low BP and raised PR are the signs of shock. Reduced may lead to air hunger.

ABDOMINAL EXAMINATION
Concealed haemorrhage may lead to uterine enlargement in excess of gestation.The
uterus had a hard consistency and palpation may be difficult and should not be attempted
if uterus is rigid and excessively painful. Fetal parts may not be palpable.FHR should be
checked with a sonicaid as it is not possible to hear with a fetoscope.

ASSESSING FETAL CONDITION

Retroplacental haemorrhage is a major threat to the fetal survival. CTG recording or
ultrasound will give the information about fetal condition.

MANAGEMENT
Needs immediate medical care.
Pain exacerbates shock and must be alleviated with inj.morphin or pethedine.
Shock may be due to hypovolemia, to extravasation, consequent pain or DIC.Whole
blood should be infused to restore the blood volume , frozen plasma infusion to replenish
the clotting factors, plasma expander if blood is not available.Haemaccel is a plasma
expander as it will not interfere with platelet function and not needed grouping and cross
matching and improve renal function.
Mother should rest on her side. The legs may be elevated body must remain horizontal.
Check urinary output by insertion of indwelling catheter..Check urine for the presence of
protein which may also be related to PIH.
Fluid intake should be measured .
Fundal height and abdominal girth are measured hourly to detect continued bleeding
behind the placenta.

INVESTIGATIONS
In concealed haemorrhage clotting studies to be carried out.

MANAGEMENT
1. Mild separation of placenta - The placental separation and haemorrhage are slight the
mother and fetus are in a stable condition. Ultrasonic scan should be done to determine
the degree of concealed bleeding. CTG to be done twice daily to asses the fetal condition.
If the mother is not in labour and the gestation is less than 37weeks she may be cared in
an antenatal area for few days and can go home if no more bleeding. If above 37 weeks
will have an amniotomy to induce labour.
2. Moderate separation of placenta- One quarter of the placenta may be separated , blood
loss will be 1000ml.The mother will be shocked , fetus may be alive, IUD is a
probability. Immediate care to reduce shock. Assess the fetal condition , if alive
immediate CS to be done, if in good condition , or has already died can try for vaginal
delivery.
3. Severe separation of placenta- This is an obstetric emergency, at least two thirds of the
placenta has become detached and 2000ml blood or more are lost from the circulation.
The mother will be severly shocked and the fetus is almost certainly dead.Treatment is to
manage shock Labour may begin spontaneously .

CARE OF THE BABY

Paediatrician should be present at birth to resuscitate the infant , the baby may need
neonatal intensive care. If in good condition will require minimal resuscitation and can be
transferred to the postnatal area.

COMPLICATIONS
1. DIC
2. PPH
3.Renal failure as a result of hypovolemia.
4.Pitutary necrosis is a possible concequence of prolonged and severe hypotension.

BIBLIOGRAPHY
1. D.C.Dutta, Text book of obstetrics, New central book agency, 6th edition, Calcutta,
2004,pg no.- 243-261.
2. V. Ruth Bennet & Linda K. Braun, Myles Text Book of Midwives, ELBS, 12th edition,
Edinburgh, UK ,1993,PG no.-321-329.