HNS 316 COMBINED PDF Unicorn Printers.
Antepartum
• Obstetrics is "bloody business."
Antepartum
Hemorrhage (APH ) • Death from hemorrhage still remains a leading cause of
HNS 316 maternal mortality.
Causes of bleeding in late pregnancy Antepartum haemorrhage
Causes of 763 Pregnancy-related Deaths Due to Hemorrhage
Causes of Hemorrhage Incidence (%)
• Def: Per vagina blood loss after 24 weeks’ gestation and before
onset of labour.
Placenta praevia 31.0
Abruptio placentae 22.0
‘Unclassified bleeding’ 47.0
• Bleeding from the genital tract in late pregnancy, after the 24th week
Marginal 60.0
of gestation and before the onset of labour.
Show 20.0
Cervicitis 8.0
Trauma 5.0 • Complicates close to 4% of all pregnancies and is a MEDICAL
Vulvovaginal varicosities 2.0
EMERGENCY!
Genital tumours 0.5
Genital infections 0.5 • Is one of the leading causes of antepartum hospitalization, maternal
Haematuria 0.5 morbidity, and operative intervention.
Vasa Praevia 0.5
Other 0.5
Most common causes of Antepartum Hemorrhage Other causes of antepartum haemorrhage include
• Placenta Previa • Rupture of small vessels at the edge of the placenta
• Placental Abruption
• Cervical erosion
• Uterine Rupture
• Cancer of cervix
• Vasa Previa
• Bloody Show
• Severe cervicitis
• Coagulation Disorder • Infected cervical polyp
• Hemorrhoids
• Vaginal Lesion/Injury • NB: the above situations are referred for specific
• Cervical Lesion/Injury management
• Neoplasia
Page 1 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
,HNS 316 COMBINED PDF Unicorn Printers.
Key point to Remember Placenta praevia
• The pregnancy in which such bleeding occurs remains at Definition: Refers to a placenta implanted in the lower
increased risk for a poor outcome even though the bleeding segment of the uterus, and presents ahead of the leading
soon stops and placenta praevia appears to have been pole of the fetus.
excluded by sonography.
Incidence about 1 in 300
Perinatal morbidity and mortality are primarily related to
the complications of prematurity, because the hemorrhage
is maternal.
Types of placenta praevia Types of placenta praevia
Type 1: Low-lying placenta. Type 2: Marginal placenta praevia.
• The majority of the placenta is in the upper uterine segment, with • The placenta is partially located in the lower segment and the edge of
some placenta implanted in the lower uterine segment. the placenta is at the margin of the internal os.
• The placenta edge actually does not reach the internal os but is in • Blood loss is usually moderate, although the conditions of the mother
close proximity to it. and fetus can vary.
• Blood loss is usually mild and the mother and fetus remain in good • Fetal hypoxia is more likely to be present than maternal shock.
condition. • Vaginal birth is possible, particularly if the placenta is anterior.
• Vaginal birth is possible.
Types of placenta praevia
• Type 3: Partial placenta praevia.
• The placenta is located over the internal cervical os but not centrally, thus
the internal os is partially covered by placenta.
• Bleeding is likely to be severe, particularly when the lower segment
stretches and the cervix begins to efface and dilate in late pregnancy.
• Vaginal birth is inappropriate because the placenta precedes the fetus.
Type 4: Total placenta praevia.
• The placenta is located centrally over the internal cervical os, thus
covering it completely.
• Torrential haemorrhage is very likely.
• Caesarean section is essential to save the lives of the woman and fetus.
Page 2 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
,HNS 316 COMBINED PDF Unicorn Printers.
Risk factors
• Advanced maternal age (>40 years)
• Chronic hypertension
• Multiparity
• Multiple gestations
• Previous cesarean delivery
• Tobacco use
• Uterine curettage
• Previous uterine surgery, including
• uterine curettage
• Cocaine use
• History of placenta previa
• Chronic hypertension
• Bleeding results from small disruptions in the placental attachment • In vitro fertilization
during normal development and thinning of the lower uterine segment
Etiology Placenta Previa clinical presentation
The most characteristic event in placenta praevia is painless
• Advancing maternal age hemorrhage.
• Multiparity
• Multifetal gestations This usually occurs near the end of or after the second
• Prior cesarean delivery trimester.
• Smoking
• Prior placenta previa The initial bleeding is rarely so profuse as to prove fatal.
It usually ceases spontaneously, only to recur.
because the placenta occupies the lower uterine segment:
• The foetal head remains high, • Placenta praevia may be associated with placenta accreta,
placenta increta or percreta.
• which results in malpresentation
• Coagulopathy is rare with placenta previa.
• and unstable lie.
• If bleeding is severe, the blood pressure is low, the pulse and
respirations are high,
• and there is shock corresponding with the amount of
bleeding.
Page 3 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
,HNS 316 COMBINED PDF Unicorn Printers.
Diagnosis
• Placenta praevia or abruption should always be suspected in
women with uterine bleeding during the latter half of
pregnancy.
• The possibility of placenta praevia should not be dismissed
until appropriate evaluation, including sonography, has clearly
proved its absence.
• The diagnosis of placenta praevia can seldom be established
firmly by clinical examination. Such examination of the cervix
is never permissible unless the woman is in an operating
room with all the preparations for immediate cesarean
delivery, because even the gentlest examination of this sort
can cause torrential hemorrhage.
Factors to aid in Differential diagnosis
Pain: Characteristics- Did the pain precede the bleeding and is it
continuous or intermittent?
TVS: Transvaginal ultrasonography has substantively Onset of bleeding: Was it associated with events eg coitus
improved diagnostic accuracy of placenta praevia.
Amount of visible blood: Is there any reason to suspect that
some blood has been retained in utero?
MRI Colour of blood: dark or bright: Is it bright red or darker in
colour?
At 18 weeks, 5-10% of placentas are low lying. Most Tenderness of the abdomen: Does the mother resent
‘migrate’ with development of the lower uterine segment. abdominal palpation?
Factors to aid in Differential diagnosis Management of placenta praevia
Consistency of the abdomen: Is it soft, tense, board-like?
Management depends on
Degree of shock: Is this commiserate with the amount of visible
• The amount of bleeding
blood or more severe?
• The condition of mother and foetus
Lie, presentation, and engagement: Are any of these abnormal
when taking account of parity and gestation? • The location of the placenta
Audibility of foetal heart rate: Is the fetal heart heard? • The stage of pregnancy
Ultrasound scan: Does a scan suggest that the placenta is in the
lower segment?
Page 4 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
,HNS 316 COMBINED PDF Unicorn Printers.
Aims of Management Management
IV access If in a health centre or dispensary, refer all pregnant women with
vaginal bleeding to hospital:
Admit to hospital
• Run IV running intravenous drip of saline or dextrose before
transfer
Control Bleeding
• A nurse should always accompany the Pt to the hospital.
NO VAGINAL EXAMINATION
• Hospital management will depend on the amount of blood loss,
Placental localization the condition of the mother and foetus, the location of the
placenta and the gestation period.
Conserve the pregnancy up to 38 weeks gestation
Management Measures to be Taken in the Case of Placenta
Praevia,
• The aim of management is to control haemorrhage and to try to
conserve the pregnancy up to 38 weeks gestation when the Blood is taken for HB grouping and cross matching
foetus is mature. She is put on mild sedation -phenobarbitone
• Assess foetal condition No abdominal palpation is done as it may trigger severe bleeding
Save all pads to assess blood loss
• Where there is slight vaginal bleeding, conservative treatment is Give high protein diet
started if the pregnancy has not reached 38 weeks of gestation. Take two hourly vital signs
• The patient is admitted for complete bed rest and total care. On the third day speculum examination is done to exclude
incidental haemorrhage
Management Management
• At 34 weeks scanning is carried out to assess progress and to • In placenta praevia type two with placenta posteriorly situated
confirm diagnosis and in type three and four, caesarean section is performed
• The patient should be retained in hospital until the 37th week
when Examination Under Anaesthesia (EUA) is done in theatre • In the case of moderate to severe vaginal bleeding, set up
ready for caesarean section in case of intravenous infusion and prepare for immediate caesarean
severe bleeding section.
• In placenta praevia type one and two and if placenta is anterior,
• Blood for HB grouping and cross matching should be taken
the membranes are ruptured and spontaneous delivery
awaited. Labour is induced with oxytocin • Physical and psychological preparation of the mother is done.
Page 5 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
,HNS 316 COMBINED PDF Unicorn Printers.
Placenta Previa Management-pathway
Severe
Resuscitate Caesarean section
Cont. Management
bleeding
• Delivery by Caesarean section as needed
>34/52
Moderate Gestation
bleeding >34/52 • Occasionally Caesarean hysterectomy necessary.
Resuscitate
steroids Unstable
Stable
36/52
Mild
Gestation Conservative care
bleeding
36/52
Complications of Placenta Praevia
PLACENTAL ABRUPTION
The following are some complications of placenta praevia:
• Post partum haemorrhage
• Placenta accrete
• Puerperal sepsis
• Anaemia
• Maternal death
• Foetal death
• Fetal hypoxia
• Maternal shock
• Air embolism
Placental Abruption Types of Placental Abruption
Def: Normally implanted placenta occuring after the 22nd
week of pregnancy • Revealed or external haemorrhage- There is free (visible) vaginal
haemorrhage.
The Latin abruptio placentae, means "rending asunder of the
placenta • Concealed haemorrhage- The blood is trapped between the
placenta, membranes and the uterine wall. There is no visible
Occurs in 1-2% of all pregnancies bleeding.
Perinatal mortality rate associated with placental abruption • Mixed or combined haemorrhage- Bleeding is partly revealed
was 119 per 1000 births compared with 8.2 per 1000 for all and partly concealed.
others.
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•What are the risk factors for
placental abruption?
Causes of Placental Abruption
The primary cause of placental abruption is unknown, but there are several /Risk
• Chronic hypertension associated conditions.
• Multiparity
• Increased age and parity • Cigarette smoking
• Preeclampsia
• Previous abruption • Preeclampsia • Thrombophilias
• Short umbilical cord
• Chronic hypertension • Cocaine use
• Sudden decompression of an over distended uterus
• Thrombophilias • Preterm ruptured • Prior abruption
• Tobacco, cocaine, or methamphetamine use membranes
• Trauma: blunt abdominal or sudden deceleration • Uterine leiomyoma
• • Multifetal gestation
Unexplained elevated maternal alpha fetoprotein level • External trauma
• Uterine fibroids • Hydramnios
• Pathophysiology
Bleeding with placental abruption is almost always maternal.
• Placental abruption is initiated by hemorrhage into the
decidua basalis. Significant fetal bleeding is more likely to be seen with traumatic
abruption.
• The decidua then splits, leaving a thin layer adherent to the
myometrium.
In this circumstance, fetal bleeding results from a tear or
• Development of a decidual hematoma that leads to fracture in the placenta rather than from the placental
separation, compression, and the ultimate destruction of the separation itself.
placenta adjacent to it.
Page 7 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
Antepartum
• Obstetrics is "bloody business."
Antepartum
Hemorrhage (APH ) • Death from hemorrhage still remains a leading cause of
HNS 316 maternal mortality.
Causes of bleeding in late pregnancy Antepartum haemorrhage
Causes of 763 Pregnancy-related Deaths Due to Hemorrhage
Causes of Hemorrhage Incidence (%)
• Def: Per vagina blood loss after 24 weeks’ gestation and before
onset of labour.
Placenta praevia 31.0
Abruptio placentae 22.0
‘Unclassified bleeding’ 47.0
• Bleeding from the genital tract in late pregnancy, after the 24th week
Marginal 60.0
of gestation and before the onset of labour.
Show 20.0
Cervicitis 8.0
Trauma 5.0 • Complicates close to 4% of all pregnancies and is a MEDICAL
Vulvovaginal varicosities 2.0
EMERGENCY!
Genital tumours 0.5
Genital infections 0.5 • Is one of the leading causes of antepartum hospitalization, maternal
Haematuria 0.5 morbidity, and operative intervention.
Vasa Praevia 0.5
Other 0.5
Most common causes of Antepartum Hemorrhage Other causes of antepartum haemorrhage include
• Placenta Previa • Rupture of small vessels at the edge of the placenta
• Placental Abruption
• Cervical erosion
• Uterine Rupture
• Cancer of cervix
• Vasa Previa
• Bloody Show
• Severe cervicitis
• Coagulation Disorder • Infected cervical polyp
• Hemorrhoids
• Vaginal Lesion/Injury • NB: the above situations are referred for specific
• Cervical Lesion/Injury management
• Neoplasia
Page 1 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
,HNS 316 COMBINED PDF Unicorn Printers.
Key point to Remember Placenta praevia
• The pregnancy in which such bleeding occurs remains at Definition: Refers to a placenta implanted in the lower
increased risk for a poor outcome even though the bleeding segment of the uterus, and presents ahead of the leading
soon stops and placenta praevia appears to have been pole of the fetus.
excluded by sonography.
Incidence about 1 in 300
Perinatal morbidity and mortality are primarily related to
the complications of prematurity, because the hemorrhage
is maternal.
Types of placenta praevia Types of placenta praevia
Type 1: Low-lying placenta. Type 2: Marginal placenta praevia.
• The majority of the placenta is in the upper uterine segment, with • The placenta is partially located in the lower segment and the edge of
some placenta implanted in the lower uterine segment. the placenta is at the margin of the internal os.
• The placenta edge actually does not reach the internal os but is in • Blood loss is usually moderate, although the conditions of the mother
close proximity to it. and fetus can vary.
• Blood loss is usually mild and the mother and fetus remain in good • Fetal hypoxia is more likely to be present than maternal shock.
condition. • Vaginal birth is possible, particularly if the placenta is anterior.
• Vaginal birth is possible.
Types of placenta praevia
• Type 3: Partial placenta praevia.
• The placenta is located over the internal cervical os but not centrally, thus
the internal os is partially covered by placenta.
• Bleeding is likely to be severe, particularly when the lower segment
stretches and the cervix begins to efface and dilate in late pregnancy.
• Vaginal birth is inappropriate because the placenta precedes the fetus.
Type 4: Total placenta praevia.
• The placenta is located centrally over the internal cervical os, thus
covering it completely.
• Torrential haemorrhage is very likely.
• Caesarean section is essential to save the lives of the woman and fetus.
Page 2 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
,HNS 316 COMBINED PDF Unicorn Printers.
Risk factors
• Advanced maternal age (>40 years)
• Chronic hypertension
• Multiparity
• Multiple gestations
• Previous cesarean delivery
• Tobacco use
• Uterine curettage
• Previous uterine surgery, including
• uterine curettage
• Cocaine use
• History of placenta previa
• Chronic hypertension
• Bleeding results from small disruptions in the placental attachment • In vitro fertilization
during normal development and thinning of the lower uterine segment
Etiology Placenta Previa clinical presentation
The most characteristic event in placenta praevia is painless
• Advancing maternal age hemorrhage.
• Multiparity
• Multifetal gestations This usually occurs near the end of or after the second
• Prior cesarean delivery trimester.
• Smoking
• Prior placenta previa The initial bleeding is rarely so profuse as to prove fatal.
It usually ceases spontaneously, only to recur.
because the placenta occupies the lower uterine segment:
• The foetal head remains high, • Placenta praevia may be associated with placenta accreta,
placenta increta or percreta.
• which results in malpresentation
• Coagulopathy is rare with placenta previa.
• and unstable lie.
• If bleeding is severe, the blood pressure is low, the pulse and
respirations are high,
• and there is shock corresponding with the amount of
bleeding.
Page 3 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
,HNS 316 COMBINED PDF Unicorn Printers.
Diagnosis
• Placenta praevia or abruption should always be suspected in
women with uterine bleeding during the latter half of
pregnancy.
• The possibility of placenta praevia should not be dismissed
until appropriate evaluation, including sonography, has clearly
proved its absence.
• The diagnosis of placenta praevia can seldom be established
firmly by clinical examination. Such examination of the cervix
is never permissible unless the woman is in an operating
room with all the preparations for immediate cesarean
delivery, because even the gentlest examination of this sort
can cause torrential hemorrhage.
Factors to aid in Differential diagnosis
Pain: Characteristics- Did the pain precede the bleeding and is it
continuous or intermittent?
TVS: Transvaginal ultrasonography has substantively Onset of bleeding: Was it associated with events eg coitus
improved diagnostic accuracy of placenta praevia.
Amount of visible blood: Is there any reason to suspect that
some blood has been retained in utero?
MRI Colour of blood: dark or bright: Is it bright red or darker in
colour?
At 18 weeks, 5-10% of placentas are low lying. Most Tenderness of the abdomen: Does the mother resent
‘migrate’ with development of the lower uterine segment. abdominal palpation?
Factors to aid in Differential diagnosis Management of placenta praevia
Consistency of the abdomen: Is it soft, tense, board-like?
Management depends on
Degree of shock: Is this commiserate with the amount of visible
• The amount of bleeding
blood or more severe?
• The condition of mother and foetus
Lie, presentation, and engagement: Are any of these abnormal
when taking account of parity and gestation? • The location of the placenta
Audibility of foetal heart rate: Is the fetal heart heard? • The stage of pregnancy
Ultrasound scan: Does a scan suggest that the placenta is in the
lower segment?
Page 4 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
,HNS 316 COMBINED PDF Unicorn Printers.
Aims of Management Management
IV access If in a health centre or dispensary, refer all pregnant women with
vaginal bleeding to hospital:
Admit to hospital
• Run IV running intravenous drip of saline or dextrose before
transfer
Control Bleeding
• A nurse should always accompany the Pt to the hospital.
NO VAGINAL EXAMINATION
• Hospital management will depend on the amount of blood loss,
Placental localization the condition of the mother and foetus, the location of the
placenta and the gestation period.
Conserve the pregnancy up to 38 weeks gestation
Management Measures to be Taken in the Case of Placenta
Praevia,
• The aim of management is to control haemorrhage and to try to
conserve the pregnancy up to 38 weeks gestation when the Blood is taken for HB grouping and cross matching
foetus is mature. She is put on mild sedation -phenobarbitone
• Assess foetal condition No abdominal palpation is done as it may trigger severe bleeding
Save all pads to assess blood loss
• Where there is slight vaginal bleeding, conservative treatment is Give high protein diet
started if the pregnancy has not reached 38 weeks of gestation. Take two hourly vital signs
• The patient is admitted for complete bed rest and total care. On the third day speculum examination is done to exclude
incidental haemorrhage
Management Management
• At 34 weeks scanning is carried out to assess progress and to • In placenta praevia type two with placenta posteriorly situated
confirm diagnosis and in type three and four, caesarean section is performed
• The patient should be retained in hospital until the 37th week
when Examination Under Anaesthesia (EUA) is done in theatre • In the case of moderate to severe vaginal bleeding, set up
ready for caesarean section in case of intravenous infusion and prepare for immediate caesarean
severe bleeding section.
• In placenta praevia type one and two and if placenta is anterior,
• Blood for HB grouping and cross matching should be taken
the membranes are ruptured and spontaneous delivery
awaited. Labour is induced with oxytocin • Physical and psychological preparation of the mother is done.
Page 5 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
,HNS 316 COMBINED PDF Unicorn Printers.
Placenta Previa Management-pathway
Severe
Resuscitate Caesarean section
Cont. Management
bleeding
• Delivery by Caesarean section as needed
>34/52
Moderate Gestation
bleeding >34/52 • Occasionally Caesarean hysterectomy necessary.
Resuscitate
steroids Unstable
Stable
36/52
Mild
Gestation Conservative care
bleeding
36/52
Complications of Placenta Praevia
PLACENTAL ABRUPTION
The following are some complications of placenta praevia:
• Post partum haemorrhage
• Placenta accrete
• Puerperal sepsis
• Anaemia
• Maternal death
• Foetal death
• Fetal hypoxia
• Maternal shock
• Air embolism
Placental Abruption Types of Placental Abruption
Def: Normally implanted placenta occuring after the 22nd
week of pregnancy • Revealed or external haemorrhage- There is free (visible) vaginal
haemorrhage.
The Latin abruptio placentae, means "rending asunder of the
placenta • Concealed haemorrhage- The blood is trapped between the
placenta, membranes and the uterine wall. There is no visible
Occurs in 1-2% of all pregnancies bleeding.
Perinatal mortality rate associated with placental abruption • Mixed or combined haemorrhage- Bleeding is partly revealed
was 119 per 1000 births compared with 8.2 per 1000 for all and partly concealed.
others.
Page 6 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
, HNS 316 COMBINED PDF Unicorn Printers.
•What are the risk factors for
placental abruption?
Causes of Placental Abruption
The primary cause of placental abruption is unknown, but there are several /Risk
• Chronic hypertension associated conditions.
• Multiparity
• Increased age and parity • Cigarette smoking
• Preeclampsia
• Previous abruption • Preeclampsia • Thrombophilias
• Short umbilical cord
• Chronic hypertension • Cocaine use
• Sudden decompression of an over distended uterus
• Thrombophilias • Preterm ruptured • Prior abruption
• Tobacco, cocaine, or methamphetamine use membranes
• Trauma: blunt abdominal or sudden deceleration • Uterine leiomyoma
• • Multifetal gestation
Unexplained elevated maternal alpha fetoprotein level • External trauma
• Uterine fibroids • Hydramnios
• Pathophysiology
Bleeding with placental abruption is almost always maternal.
• Placental abruption is initiated by hemorrhage into the
decidua basalis. Significant fetal bleeding is more likely to be seen with traumatic
abruption.
• The decidua then splits, leaving a thin layer adherent to the
myometrium.
In this circumstance, fetal bleeding results from a tear or
• Development of a decidual hematoma that leads to fracture in the placenta rather than from the placental
separation, compression, and the ultimate destruction of the separation itself.
placenta adjacent to it.
Page 7 of 84 A Subsidiary of Unicorn Ralex Ventures. 0725 311 114/0799 135 515
