Antepartum haemorrhage is defined as bleeding from or into the genital tract after fetal viability Causes
• Placenta praevia
and before delivery. • Abruptio placenta
In the past viability was considered to be from 28 weeks onwards, but due to the improvements in • Rupture uterus
neonatal survival, this has been changed. The cut off point for fetal viability is now considered as • Rupture vasa previa
• Local causes like cervical polyp, cancer cervix, varicose veins and local trauma
22 weeks by the WHO. • Unclassified or indeterminate
PLACENTA PRAEVIA:
is defined as a placenta located partly or completely in the lower uterine segment,in a location
overlying or in close proximity.
Risk Factors
• Previous history of placenta previa (12 times more risk)-most important risk factor.
• Multiparity and increased maternal age(> 35 years)
• H/O any previous uterine surgery—like cesarean (risk increases as number of cesareanincreases)
• Previous uterine curettage
• Increased placental size as in multifetal pregnancy
• Succenturiate lobe
• Smoking
PLACENTA PRAEVIA CLASSIFICATION
Older classification
Browne’s classification for placenta previa
-Type 1 Lateral Placenta dipping into the lower segment but not reaching upto theos.
-Type 2 Marginal Placental edge reaches the internal os.
-Type 3 Incomplete central Placenta covers the internal os when closed, but not when fully
dilated.
-Type 4 Central Placenta covers the internal os even when fully dilated.
Recent classificationIn
a recent Fetal Imaging Workshop sponsored by the National Institutes of Health the
followingclassification was recommended:
Placenta Previa: The internal os is covered partially or completely by placenta.
Low-lying placenta: Implantation in the lower uterine segment is such that the placental
edgedoes not reach the internal os and remains outside a 2 cm wide perimeter around the os.If
Pathophysiology Placenta previa: placenta diagnosed as placenta previa or low lying placenta at 20 weeks, further imaging
is more commonly seen in early gestation and in many such cases, with advancing gestation and growth of the shouldoccur. When?
uterus, the placenta is lifted into the upper uterine segment. (placental migration). -1. Women who bleed should be managed individually according to their needs.
-2. In asymptomatic suspected major placenta previa, imaging should be performed at 32 weeks
This mechanism of placental migration is poorly understood but may be related to a preferential growth of the toconfirm the diagnosis and allow planning for 3rd trimester management and delivery.
placenta towards a better vascularized upper endometrium (trophotropism). Because low lying placenta or placenta previa detected in the mid second trimester that
Abnormal implantation of the placenta may occur when there is disruption or scarring of the uterine cavity, laterresolves in pregnancy is associated with vasa previa, transvaginal ultrasound with color /
pulsedDoppler in the third trimester around 32 weeks is recommended to rule out vasa previa.
most commonly as aresult of a previous cesarean delivery. Placental migration from lower segment during 2nd
and 3rd trimesters is less likely to occur if:
1.The placenta is posterior. Clinical Features:
SymptomsVaginal bleeding.
2. The placenta covering the internal os.
The classical features of bleeding in placenta previa are sudden onset, painless,apparently
3. There is a previous caesarean section causeless and recurrent. The blood is almost always maternal.
Signs
• Pallor, if present, will be proportionate to the amount of bleeding.
• Size of the uterus corresponds to the period of amenorrhoea.
• Uterus is soft and non-tender.
• Malpresentations are common and if it is a cephalic presentation, the head is usually floating.
• Fetal heart sounds will usually be heard (c.f. abruption). Slowing of the fetal heart rate on
pressingthe head down into the pelvis and prompt recovery on release of the pressure is
termedStallworthy’s sign and is suggestive of posterior placenta previa.
Confirmation of diagnosis
Ultrasonography is the initial procedure either to confirm or to rule out the diagnosis.
―Transvaginal (TVS): Transducer is inserted within the vagina without touching the cervix.
The probe is very close to the target area and higher frequencies could be used to get a superiorresolution.
Transvaginal ultrasonography allows precise assessment of the distance between theinternal os and the
placental edge.
Differential diagnosis
Routine ultrasound scanning at 20 weeks should include placental localization as screening for lowlying Placenta previa is at times confused with other causes of bleedingoccurring in later months of
placenta. pregnancy.
Clinical confirmation 1. Abruptio placentae.
2. The local cervical lesions (polyps, carcinoma) can easily bedifferentiated by a speculum
Double set-up examination (vaginal examination): It is less frequently done these days. examination.
The indications are:
(i) Inconclusive USG report
Bleeding in Late (ii) USG revealed type I placenta or
Pregnancy (iii) USG facilities not available. It is done in the operation theater under anesthesia keepingeverything ready for
cesarean section. Palpation of the placenta on the lower segment not onlyconclusively confirms the clinical
diagnosis but also identifies its degree.
by fatema okoff
Complications of placenta previa
A. Maternal
Antepartum, intrapartum, or postpartum orrhage, with varying degrees of shock.
•Malpresentation.
• Increased incidence of operative interference.
• Cord prolapse
• Retained placenta: Placenta previa accreta is a serious complication. The risk of placenta previa
being accreta in a womanwith previous one cesarean section is 10–20% and it rises to about 50%
with two or more prior cesarean section
• Preterm labour Premature rupture of membranes.
• Puerperal sepsis, subinvolution, embolism.
Death due to massive hemorrhage during the antepartum, intrapartum or postpartum period.
Operative hazards, infectionor embolism may also cause death.
B. Fetal
• Asphyxia
• Birth injuries
• Low birth weight
• Congenital malformation
• Intrauterine death
A) Immediate attention:
2. Amount of the blood loss The amount of blood lost is often underestimated and part of
bloodmay be concealed, so it is important when estimating the blood loss, to assess for signs
ofclinical shock and the presence of fetal compromise or fetal demise. The following
definitionshave been used: Spotting – staining, streaking or blood spotting noted on underwear
Minorhaemorrhage – blood loss less than 50 ml Major haemorrhage – blood loss of 50–1000 ml,
withno signs of clinical shock Massive haemorrhage – blood loss more than 1000 ml and/or signs
ofclinical shock.
3. Blood samples are taken for group, cross matching and estimation of hematocrit.
4. A large-bore IV cannula is sited and an infusion of normal saline is started and compatible
MANAGEMENT crossmatched blood transfusion should be arranged.(in case of severe bleeding, 4 units of
Admission to hospital: All cases of APH, even if the bleeding is slight or absent by the time bloodmust be crossed matched and made readily available).
thepatient reaches the hospital, should be admitted. The reasons are: 5. Confirmation of diagnosis is made from sonographic examination
(1) All the cases of APH should beregarded as due to placenta previa unless proved otherwise.
(2) The bleeding may recur sooner orlater and none can predict when it recurs and how much she B) Formulation of the line of treatment:
The definitive treatment depends upon the duration of pregnancy, fetal and maternal status
will bleed.
🔹
andextent of the hemorrhage.
🔹
Treatment on admission
🔹 Immediate attention.
Formulation of the line of treatment
🔹 Expectant management.
Active (Definite) management.
Expectant management
– (Called as Macaffee and Johnson regime)
Aim: goal is to carry pregnancy till term without putting mother's life at risk with an aim to
achievefetal lung maturity.
Prerequisites:
• Availability of blood for transfusion whenever required
• Facilities for caesarean section should be available throughout 24 hours.
Candidates:
• Mother in good health status- Hemoglobin > 10 gm%
• Hematocrit > 30% and sheshould be hemodynamically stable.
• Duration of pregnancy less than 37 weeks
• Active vaginalbleeding is absent
• Fetal well-being is assured by USG and cardiotocography and no fetalmalformation
Active (Definite) Management (Delivery):
The indications of definitive management (delivery) are:
(1) Bleeding occurs at or after 37 weeks of pregnancy.
(2) Patient is in labor.
(3) Patient is in exsanguinated state on admission.
(4) Bleeding is continuing and of moderate degree.
(5) Fetus with nonreassuring cardiac status or dead or known to be congenitally deformed
A. Cesarean delivery is done for all women with sonographic evidence of placenta previa
whereplacental edge is within 2 cm from the internal os. It is especially indicated if it is posterior
orthick.
“Patients with placenta previa and severe bleeding should be delivered bycesarean section
irrespective of the type of placenta previa.”
B. Vaginal delivery may be considered where placenta edge is clearly 2–3 cm away from the
internalcervical os unless heavy bleeding ensues.
• Placenta praevia
and before delivery. • Abruptio placenta
In the past viability was considered to be from 28 weeks onwards, but due to the improvements in • Rupture uterus
neonatal survival, this has been changed. The cut off point for fetal viability is now considered as • Rupture vasa previa
• Local causes like cervical polyp, cancer cervix, varicose veins and local trauma
22 weeks by the WHO. • Unclassified or indeterminate
PLACENTA PRAEVIA:
is defined as a placenta located partly or completely in the lower uterine segment,in a location
overlying or in close proximity.
Risk Factors
• Previous history of placenta previa (12 times more risk)-most important risk factor.
• Multiparity and increased maternal age(> 35 years)
• H/O any previous uterine surgery—like cesarean (risk increases as number of cesareanincreases)
• Previous uterine curettage
• Increased placental size as in multifetal pregnancy
• Succenturiate lobe
• Smoking
PLACENTA PRAEVIA CLASSIFICATION
Older classification
Browne’s classification for placenta previa
-Type 1 Lateral Placenta dipping into the lower segment but not reaching upto theos.
-Type 2 Marginal Placental edge reaches the internal os.
-Type 3 Incomplete central Placenta covers the internal os when closed, but not when fully
dilated.
-Type 4 Central Placenta covers the internal os even when fully dilated.
Recent classificationIn
a recent Fetal Imaging Workshop sponsored by the National Institutes of Health the
followingclassification was recommended:
Placenta Previa: The internal os is covered partially or completely by placenta.
Low-lying placenta: Implantation in the lower uterine segment is such that the placental
edgedoes not reach the internal os and remains outside a 2 cm wide perimeter around the os.If
Pathophysiology Placenta previa: placenta diagnosed as placenta previa or low lying placenta at 20 weeks, further imaging
is more commonly seen in early gestation and in many such cases, with advancing gestation and growth of the shouldoccur. When?
uterus, the placenta is lifted into the upper uterine segment. (placental migration). -1. Women who bleed should be managed individually according to their needs.
-2. In asymptomatic suspected major placenta previa, imaging should be performed at 32 weeks
This mechanism of placental migration is poorly understood but may be related to a preferential growth of the toconfirm the diagnosis and allow planning for 3rd trimester management and delivery.
placenta towards a better vascularized upper endometrium (trophotropism). Because low lying placenta or placenta previa detected in the mid second trimester that
Abnormal implantation of the placenta may occur when there is disruption or scarring of the uterine cavity, laterresolves in pregnancy is associated with vasa previa, transvaginal ultrasound with color /
pulsedDoppler in the third trimester around 32 weeks is recommended to rule out vasa previa.
most commonly as aresult of a previous cesarean delivery. Placental migration from lower segment during 2nd
and 3rd trimesters is less likely to occur if:
1.The placenta is posterior. Clinical Features:
SymptomsVaginal bleeding.
2. The placenta covering the internal os.
The classical features of bleeding in placenta previa are sudden onset, painless,apparently
3. There is a previous caesarean section causeless and recurrent. The blood is almost always maternal.
Signs
• Pallor, if present, will be proportionate to the amount of bleeding.
• Size of the uterus corresponds to the period of amenorrhoea.
• Uterus is soft and non-tender.
• Malpresentations are common and if it is a cephalic presentation, the head is usually floating.
• Fetal heart sounds will usually be heard (c.f. abruption). Slowing of the fetal heart rate on
pressingthe head down into the pelvis and prompt recovery on release of the pressure is
termedStallworthy’s sign and is suggestive of posterior placenta previa.
Confirmation of diagnosis
Ultrasonography is the initial procedure either to confirm or to rule out the diagnosis.
―Transvaginal (TVS): Transducer is inserted within the vagina without touching the cervix.
The probe is very close to the target area and higher frequencies could be used to get a superiorresolution.
Transvaginal ultrasonography allows precise assessment of the distance between theinternal os and the
placental edge.
Differential diagnosis
Routine ultrasound scanning at 20 weeks should include placental localization as screening for lowlying Placenta previa is at times confused with other causes of bleedingoccurring in later months of
placenta. pregnancy.
Clinical confirmation 1. Abruptio placentae.
2. The local cervical lesions (polyps, carcinoma) can easily bedifferentiated by a speculum
Double set-up examination (vaginal examination): It is less frequently done these days. examination.
The indications are:
(i) Inconclusive USG report
Bleeding in Late (ii) USG revealed type I placenta or
Pregnancy (iii) USG facilities not available. It is done in the operation theater under anesthesia keepingeverything ready for
cesarean section. Palpation of the placenta on the lower segment not onlyconclusively confirms the clinical
diagnosis but also identifies its degree.
by fatema okoff
Complications of placenta previa
A. Maternal
Antepartum, intrapartum, or postpartum orrhage, with varying degrees of shock.
•Malpresentation.
• Increased incidence of operative interference.
• Cord prolapse
• Retained placenta: Placenta previa accreta is a serious complication. The risk of placenta previa
being accreta in a womanwith previous one cesarean section is 10–20% and it rises to about 50%
with two or more prior cesarean section
• Preterm labour Premature rupture of membranes.
• Puerperal sepsis, subinvolution, embolism.
Death due to massive hemorrhage during the antepartum, intrapartum or postpartum period.
Operative hazards, infectionor embolism may also cause death.
B. Fetal
• Asphyxia
• Birth injuries
• Low birth weight
• Congenital malformation
• Intrauterine death
A) Immediate attention:
2. Amount of the blood loss The amount of blood lost is often underestimated and part of
bloodmay be concealed, so it is important when estimating the blood loss, to assess for signs
ofclinical shock and the presence of fetal compromise or fetal demise. The following
definitionshave been used: Spotting – staining, streaking or blood spotting noted on underwear
Minorhaemorrhage – blood loss less than 50 ml Major haemorrhage – blood loss of 50–1000 ml,
withno signs of clinical shock Massive haemorrhage – blood loss more than 1000 ml and/or signs
ofclinical shock.
3. Blood samples are taken for group, cross matching and estimation of hematocrit.
4. A large-bore IV cannula is sited and an infusion of normal saline is started and compatible
MANAGEMENT crossmatched blood transfusion should be arranged.(in case of severe bleeding, 4 units of
Admission to hospital: All cases of APH, even if the bleeding is slight or absent by the time bloodmust be crossed matched and made readily available).
thepatient reaches the hospital, should be admitted. The reasons are: 5. Confirmation of diagnosis is made from sonographic examination
(1) All the cases of APH should beregarded as due to placenta previa unless proved otherwise.
(2) The bleeding may recur sooner orlater and none can predict when it recurs and how much she B) Formulation of the line of treatment:
The definitive treatment depends upon the duration of pregnancy, fetal and maternal status
will bleed.
🔹
andextent of the hemorrhage.
🔹
Treatment on admission
🔹 Immediate attention.
Formulation of the line of treatment
🔹 Expectant management.
Active (Definite) management.
Expectant management
– (Called as Macaffee and Johnson regime)
Aim: goal is to carry pregnancy till term without putting mother's life at risk with an aim to
achievefetal lung maturity.
Prerequisites:
• Availability of blood for transfusion whenever required
• Facilities for caesarean section should be available throughout 24 hours.
Candidates:
• Mother in good health status- Hemoglobin > 10 gm%
• Hematocrit > 30% and sheshould be hemodynamically stable.
• Duration of pregnancy less than 37 weeks
• Active vaginalbleeding is absent
• Fetal well-being is assured by USG and cardiotocography and no fetalmalformation
Active (Definite) Management (Delivery):
The indications of definitive management (delivery) are:
(1) Bleeding occurs at or after 37 weeks of pregnancy.
(2) Patient is in labor.
(3) Patient is in exsanguinated state on admission.
(4) Bleeding is continuing and of moderate degree.
(5) Fetus with nonreassuring cardiac status or dead or known to be congenitally deformed
A. Cesarean delivery is done for all women with sonographic evidence of placenta previa
whereplacental edge is within 2 cm from the internal os. It is especially indicated if it is posterior
orthick.
“Patients with placenta previa and severe bleeding should be delivered bycesarean section
irrespective of the type of placenta previa.”
B. Vaginal delivery may be considered where placenta edge is clearly 2–3 cm away from the
internalcervical os unless heavy bleeding ensues.
