Antepartum Hemorrhage

It is defined as bleeding from or into the

genital tract after the 28th week of
pregnancy But before the birth of the
baby.
#Causes –
1. Placenta Previa – 35 % cases
2. Abruptio placetae – 35 % cases.
3. Vasa previa – 10 to 15 % cases.
4. Local causes for bleeding.
 1. Placenta Previa –
When the placenta is implanted partially
or completely over the lower uterine
segment it is called placenta previa.

#Etiology –
The following Theories are postulated.
 Dropping down theory.

The fertilized ovum drops down and

is implanted in the lower segment.
 Persistence of chorionic activity – in
the decidua capsularis and its
subsequent development into
capsular placenta which comes in
 contact with decidua vera of the
lower segment.

 Defective decidua – results in

spreading of the chorionic villi over a
wide area in the uterine wall to get
nourishment.

#Risk Factor –
 Previous history of uterine surgery-
Cs, myomectomy, DNC etc.

 Big size placenta –

Twin pregnancy
 Grand Multigravida – m/c risk factor.
  Short Fallopian Tube.

 Advanced age of mother >40 yr of

age.

 Endometritis.

#Types & Degree –

1. Type—I (Low-lying): -
The major part of the placenta is
attached to the upper segment and only
the lower margin encroaches onto the
lower segment but not up to the os.
2. Type—II (Marginal): The placenta
reaches the margin of the internal
 os but does not cover it.
Two type –
A. Anterior marginal.
B. Posterior marginal (most
dangerous) – cord compression,
asphyxia of baby.

3. Type—III (Incomplete or partial

central):-
The placenta covers the internal os
partially (covers the internal os when
closed but does not entirely do so when
fully dilated).

4. Type—IV (Central or total): The

placenta completely covers the
internal os even after it is fully
dilated.
#Degree of PP –
Minor Major
Type 1st Type 2nd (Post.)
Type 2nd Anterior Type 3rd , type 4th

#In minor Degree PP normal delivery

possible, if not then do Cs.

#In major degree delivery possible by

only Cs.
Type II posterior placenta previa. Note
The effective reduction of the
anteroposterior Diameter of the inlet.
#Clinical Features –
 P/V bleeding –
The only symptom of placenta previa
is vaginal bleeding.
sudden onset, painless, apparently
causeless and recurrent.

 FHS – Present. Unless there is major

separation of the placenta with the
Patient in exsanguinated condition.
Slowing of the fetal heart rate on
pressing the head down into The
pelvis which soon recovers promptly
as the pressure is released is
suggestive of the presence Of low
lying placenta especially of posterior
 type (Stallworthy’s sign).

 General condition of the mother

corresponds to the amount of visible
blood loss.

 Malpresentation more common.

 P/V examination is Contra indicated.

Bcz of P/V examination can
aggrevate p/v bleeding.

#Diagnostic Evaluation –
 USG – the best investigation.
  Clinical features.

#Management –

Δ Conservative (expectent) –
Continue the pregnancy if –
 Healthy fetus and no risk for mother.

 Pregnancy <37 wks.

 Hemodynamicaly stable mother (BP,

TPR, HB, HCT )
  No fetal distress.

 No congenital annomalies in fetus.

 No active p/v bleeding.

Δ Radical (Active) –
Terminate pregnancy when –
 Pregnancy >37 wks.

 Hemodynamicaly unstable mother.

 Fetal distress.

 Congenital annomalies
  Active P/V bleeding.

# Types of Radical –
A. Obstetrical (Normal delivery)
 Conduct in type 1st and 2nd
(Ant.) PP.
B. Ceaserian section –
 PP 2nd (Post.), type 3rd and 4th
.

#Steps –
st
1 – Diagnose the Degree of placenta
previa.
A. Minor grade -> ARM + Infusion
Oxytocine + PGE2
 Then if no active bleeding occur –
continue the labour.
If Bleeding start – Perform Cs.

B. Major grade –
Only Cs possible.

#Indications for Cs –
1. All major degree of PP.

2. Minor degree of PP but patient start

bleeding.

3. Severe bleeding (Irrespective of

type of PP).
4. If any obstetrical indications for Cs.

5. CPD (Cephalo pelvic dispreportion).

6. Previous history of Cs.

#Complications of PP –
ΔDuring Pregnancy –
 Antepartum hemorrhage with
varying degrees of shock

 Malpresentation.

 Premature labor.

 Death due to Massive

hemorrhage.

Δ During labour –
 Early rupture of the membranes.
  Cord prolapse.

 Slow dilatation due to attachment of

placenta in lower segment.

 Intrapartum hemorrhage .

 Increased incidence of operative

interference.

 Postpartum hemorrhage.

 Retained Placenta.

ΔPuerperium –
  Sepsis.
 Subinvolution.

#Fetal complication –
 LBW
 IUGR
 Birth injuries.
 IUD
 Asphyxia.

2. Abruptio Placetae

A/k/a Accidental Hemorrhage.

Premature Separation of Placenta.
It is one form of antepartum
hemorrhage where the bleeding occurs
due to premature Separation of normally
situated placenta.

Types –
1. Revealed – Placenta separate from
margin and P/V bleeding visible.
 Most common type.

2. Concealed – placenta separate

from center – blood collect
between placenta and decidua.

3. Mixed – some part of blood collect

and a Part is expelled.
Bleeding is almost always maternal. But
placental tear may cause fetal bleeding.

#Clinical Features –
 P/v bleeding – absent or minimal
with painful.

 Lower abdominal palpation – firm

and tender uterus.

 Fetal body parts easily not palpable.

 FHS – easily not auscultated.

  SFH – Raised

 General condition of the mother does

not depend on the amount of visible
blood loss.

 IUGR, PIH

 Revealed – similer to placenta previa.

P/V examination not
contraindicated.
Mal presentation not present.

#Risk factor –
 Grand mulgipara (m/c)
 Folic acid deficiency. – Decrease
DNA replication which leads to slow
Endometrium growth resulting in
poor attachment of placenta.

 Short UC.

 Advanced age of mother. – Luteal

phase defect.

 Over stretching of uterus. –

polyhydramnios, twin pregnancy.
Macrosomia,

 Abdominal trauma.
  Pre – eclampsia.

#Diagnostic Evaluation –
 C/F
 USG done for PP exclude

#Grades –
1. Grade—0: Clinical features may be
absent. The diagnosis is made after
inspection of placenta Following
delivery.

2. Grade—1 (40%) –
vaginal bleeding is slight, Uterus:
irritable, tenderness may be minimal Or
absent Maternal BP and fibrinogen
levels unaffected FHS is good.

3. Grade—2 (45%) –
vaginal bleeding mild to moderate,
uterine tenderness is always
present , maternal pulse ↑, BP is
maintained , fibrinogen level may be
decrease, shock is absent ,fetal
distress or even fetal death occurs.

4. Grade—3 (15%):
(i) bleeding is moderate to
severe or may be
concealed
(ii) Uterine tenderness Is
marked
(iii) Shock is pronounced
(iv) Fetal death is the rule
(v) Associated coagulation
defect Or anuria may
complicate
#Complications –
1. Revealed –
Maternal risk is proportionate to the
visible blood loss and maternal Death
is rare.

2. Concealed –

 Hemorrhage.

 Shock

 Blood coagulation disorders.

 Oliguria and anuria Due to—(a)
hypovolemia (b) serotonin liberated
from the damaged uterine muscle
producing renal Ischemia.

 Postpartum hemorrhage due to —

(a) atony of the uterus.

 Puerperal sepsis.
इ त स म्