dr.

Udin Sabarudin, SpOG, MM

Depart. of Obstetrics - Gynecology
Padjadjaran University / Hasan Sadikin
Hospital

OBSTETRICAL HEMORRHAGE

Bleeding before 20 weeks of pregnancy

Antepartum hemorrhage

Post partum hemorrhage

Cause of vaginal bleeding at

the third trimester
Rupture of vaginal varicose
Laceration of vagina or cervix
Placenta previa
Abruptio placentae

ANTEPARTUM HEMORRHAGE
Placenta Previa
Abruptio placentae

Normal implantation of the placenta

Fundal

Corpus

Implantation at the lower segment

Front

Behind

PLACENTA PREVIA :
DEFINITION :
Placenta is located over or very near the
internal os
Prae : Front
Vias : Route

FOUR DEGREES OF THIS

ABNORMALITY
1. Total placenta

previa

The internal cervical os

is covered completely
2. Partial placenta previa
The internal cervical os
is partially covered

FOUR DEGREES OF THIS

ABNORMALITY
3. Marginal placenta previa
The edge of placenta is at
the margin of the
internal os
2. Low lying placenta
The placenta is implanted
in the lower uterine
segment such that the
placental edge actually
does not reach the

VASA PREVIA :

The fetal vessels course through

membranes and present at the cervical
os

Uncommon cause of antepartum

hemorrhage, associated with a high
rate or fetal death

THE DEGREE OF PLACENTA PREVIA

Depend on large measure on the cervical

dilatation at the time of examination

Eg. Low lying placenta at 2 cm dilatation

may become a partial placenta previa at
8 cm dilatation because the dilating
cervix has uncovered placenta

Total placenta previa

BLEEDING >>> !!!

Marginal placenta previa

Placenta
cervix

CHANGING THE DEGREE OF P.P

Marginal

Amnion (+)
Lateral
Dilatation >

Dilatation

Bleeding
Retracted
Amnion

Lower segmen

Lower
segmen

Cervix
Bleeding

Partial placenta previa

> 1/2 O

BLEEDING >>>

< 1/2 O

BLEEDING >

PREDISPOSING FACTOR :

Multipara, with interval <

Fibroids

Habitual abortion

CLINICAL FINDINGS :

Hemorrhage :

Frequent
Usually does not appear until
near the end of the second
trimester or after

Painless

Spontaneously

Initial bleeding is rarely

profuse as to prove fatal

Lacunae

Maternal vessels

HAFT ZOTE

Fetal vessels

CLINICAL FINDINGS :

Oblique or lie position

Presenting part - high

DIAGNOSIS :

Speculum

Fornix palpation

Double set up examination at

the operating room

USG

WARNING :

Digital palpation to try to ascertain

changing relations between the edge of the
placenta and the internal os as the cervix
dilates can incite severe hemorrhage

Examination of the cervix is never

permissible unless the woman is in an
operating room with all the preparations for
immediate cesarean section

MANAGEMENT :

Active :
Termination
Vaginally
CS
Expectative :
Depend on maturity
(< 37 weeks ; < 2500 gr)
Bleeding
Maternal condition

VAGINAL DELIVERY :

Amniotomy tamponade

Braxton Hicks version

Cunam Willet

TAMPONADE BY PRESENTING PART

Placenta
Cervix

Amnion
In tact

Head press
the placenta

Amnion (+)

Head Breech

CUNAM-WILLETT

PLACENTAL ABRUPTION :
DEFINITION :
The separation of the placenta from its
site of normal implantation before the
delivery of the fetus after 22 weeks of
pregnancy

SINONYM :

Accidental hemorrhage

Abruptio placentae

Solutio placentae

Ablatio placentae

Premature separation of the normally

implanted placenta

PATHOLOGY
Hemorrhage into the decidua basalis
Decidua then splits, leaving a thin layer
adherent to the myometrium
Decidual hematoma
Separation, compression and the ultimate
destruction of the placenta adjacent to it

TYPE :

Concealed hemorrhage
separated completelly
freq 20%
fatal
External hemorrhage
incomplete
freq 80%

CONCEALED HEMORRHAGE

EXTERNAL HEMORRHAGE

COMBINED

ETIOLOGY :

Hipertension

Trauma

Multiparity

Folic acid deficiency

Hidramnion ; gemelly

Umbilical cord - short

CLINICAL DIAGNOSIS :

Hemorrhage with pain

Fetal - Not palpable

Heart beat - not detected

Uterine hypertonus

Anemi shock

Amnion bulging

COMPLICATION :

Early : - Hemorrhage
- Shock

Late : - Consumtive coagulopathy

- Hypofibronogenemia
- Utero placental apoplexy
(couvelaire uterus)
- Renal failure

MANAGEMENT :
Depend on status of the mother & fetus:

Transfusion

Electrolyte solution

Corticosteroids

Fibrinogen

OBSTETRIC MANAGEMENT :

Amniotomi
Oxytocin infusion
Cesarean section :
Fetus alive
Cervix not dilated
2 hours after oxytocin infusion
uterine contraction (-)