APH

By: Huzaifa Hamid

Definition

 is defined as vaginal bleeding from 24 weeks to

delivery of the baby.
 Or any bleeding occurring in the antenatal
period after 20 weeks gestation.
 It complicates 2–5% of pregnancies.
 It is associated with increased risks of fetal and
maternal morbidity and mortality
Causes

• Erosion • Varicosities • Abraptio p.

• Lacerations • Placenta p.
• Polyps • Vasa previa
• Cancer
Initial steps in management of late
pregnancy bleeding:
initial management:
 patient’s vitals further steps in management:
 FHM  Give blood transfusion for

 IV fluids
large volume loss.
 Place Foley catheter and
measure urine output.
Order lab tests:
 Perform vaginal exam to rule
 CBC
out lacerations.
 DIC workup (platelets, PT,
 Schedule delivery if fetus is
PTT, fibrinogen, and D- in jeopardy or gestational
dimer) age is ≥ 36 weeks.
 Type and cross-match

 Ultrasound “The most

Apt, Kleihauer-Betke,
accurate”
Never perform and
a digital or speculum Wright’s
examination in astain
patienttests
with late
vaginal bleeding untilif ablood
determine vaginal is
ultrasound first rules out placenta
fetal, maternal, or both. previa.
ABRUPTIO
PLACENTA
Introduction
 Definition:
It is the separation of the placenta from its site
of implantation before delivery of the fetus.
 Varieties:
- Total or partial
- Revealed or Concealed
 Incidence:
1 in 200 deliveries
Placental Abruption
Pathophysiology
Initiated by bleeding into the decidua basalis, the
bleeding splits the decidua, and a decidual
hematoma forms. The hematoma leads to
separation, compression, and destruction of the
placenta adjacent to it.
a. The process may be self-limited, with no further
complication to the pregnancy or may continue to
become catastrophic.
b. Bleeding insinuates between the fetal
membranes and uterus which may extravasate or
may remain concealed. Concealed abruptions can
often be more compromising to maternal
hemodynamic status since they are generally
underappreciated.
Risk Factors

 Increased age & parity.  Smoking.

 Hypertension.  Cocaine use.
 Preterm ruptured  Prior abruption.
membranes.  Uterine fibroid.
 Multiple gestation.  Trauma
 Polyhydramnios.
Clinical presentation

 Vaginal bleeding.
 Constant and severe abdominal pain.

 Irritable, tender, and typically hypertonic

uterus.
 Evidence of fetal distress (if severe).

 Maternal shock.

 Disseminated intravascular coagulation.

Up to 20% of placental abruptions can present
without vaginal bleeding because bleeding is
concealed.
U|S for Abruptio placenta
Abratio Placenta

Diagnosis:
Clinically:
 Late trimester painful bleeding
 Normal placental implantation

 Disseminated intravascular coagulopathy

(DIC)

Ultrasonography:
Management

Conservative

Vaginal
Delivery

Emergency
CS
Management
 Emergency cesarean delivery: if maternal or fetal jeopardy is
present as soon as the mother is stabilized.

 Vaginal delivery: if bleeding is heavy but controlled or

pregnancy is >36 weeks. Perform amniotomy and induce
labor. Place external monitors to assess fetal heart rate
pattern and contractions. Avoid cesarean delivery if the fetus
is dead.

 Conservative in-hospital observation: if mother and fetus are

stable and remote from term, bleeding is minimal or
decreasing, and contractions are subsiding. Confirm normal
placental implantation with sonogram and replace blood loss
with crystalloid and blood products as needed.
Complications

Maternal : Fetal :
 Hypovolemia.  Hypoxia.

 DIC.  IUGR.

 Renal failure.  IUFD.

 Death.  Anemia

 Uterine rupture
PLACENTA
PREVIA
Introduction
Definition:
the placenta is implanted in the lower uterine segment.
Classification:
 Complete placenta previa: The placenta covers the
entire internal cervical os.
 Partial placenta previa: The placenta partially covers
the internal cervical os.
 Marginal placenta previa: One edge of the placenta
extends to the edge of the internal cervical os.
 Low-lying placenta: Within 2 cm of the internal
cervical os.
Incidence:
Complicates approximately 1 in 300 pregnancies.
 Placenta Previa

Ultrasound performed in the second trimester may show a placenta previa in

5% to 15% of cases. However, as the lower uterine segment develops, over
90% of these previas will resolve. A repeat ultrasound should be performed at
28 weeks to confi rm the presence of a placenta previa.
Placental migration

 At 16 weeks 20%
 At 40 weeks 0.5%

 Why the difference?

 TrophoTropism
Placental migration
Mechanism of migration
Pathophysiology of bleeding

Avulsion of villi, stretching of

lower uterine segment
Risk Factors
 Multiparty
 Increased maternal
age
ART!!!
 Previous placenta
previa
 Multiple gestation

 Previous C/S

 Uterine anomalies

 Maternal smoking
Presentation & Diagnosis

 Late trimester bleeding

 Lower segment placental implantation
 No pain
 MRI or Double set-up

Transabdominal US
(95% accurate)
U|S Placenta Previa
Management

Emergency cesarean delivery

Conservative in-hospital observation

Vaginal delivery

Scheduled cesarean delivery

Management
 Emergency cesarean delivery: if maternal or fetal jeopardy
is present after stabilization of the mother.
 Conservative in-hospital observation: Conservative
management of bed rest is performed in preterm gestations if
mother and fetus are stable and remote from term. The initial
bleed is rarely severe. Confirm abnormal placental
implantation with sonogram and replace blood loss with
crystalloid and blood products as needed.
 Vaginal delivery: This may be attempted if the lower
placental edge is >2 cm from the internal cervical os.
 Scheduled cesarean delivery: if the mother has been
stable after fetal lung maturity has been confirmed by
amniocentesis, usually at 36 weeks’ gestation.
Complications of Placenta
praevia
 Preterm delivery.
 PPROM.
 IUGR
 Malpresentation
 Fetal abnormalities
 ↑ number of C/S.
 morbidly adherent placenta
 Postpartum haemorrhage
 morbidly adherent placenta

If placenta previa occurs over a previous uterine scar the villi

may invade beyond Nitabuch layer resulting in PLACETNA
ACRETA

Placenta accreta: The placenta is abnormally attached directly to the

myometrium.
Placenta increta: The placenta invades the myometrium.
 Summary

Abruptio Placenta Placenta Previa

Pain Yes No

Risk factors Previous Previous previa

abruption Multiparity
Hypertension Structural
Trauma abnormalities
Cocaine abuse (e.g., fibroids)
Advanced maternal
age

Diagnosis: Placenta in Placenta implanted

normal over the lower
Sonogram position ± uterine segment
retroplacental
hematoma
 Summary
Abruptio Placenta Placenta Previa
1. Emergent c-section: Best choice for placenta previa
Management or if patient/fetus is deteriorating.
2. Vaginal delivery if ≥ 36 weeks or continued bleeding.
May be attempted in placenta previa if placenta is > 2
cm
from internal os.
3. Admit and observe if bleeding has stopped, vitals and
fetal heart rate (FHR) stable, or < 34 weeks.
Disseminated Placenta accreta/
Complication intravascular increta/percreta
coagulation → hysterectomy
Any question?