1. Antepartum Haemorrhage
Dr. Abdalla H. Elsadig MD

2. Definition
Bleeding from the genital tract in pregnancy between 20 to 24 week’s gestation and the onset of labour.
It affects 4% of all pregnancies.
It is associated with increased risks of fetal and maternal morbidity and mortality.

3. causes Placenta praevia. Placental abruption. Local causes:
- cervical ectropion/cervical trauma.
- local infection of the cervix/vagina.
- cervical polyps/cervical cancer.
Undetermined origin.
Rare cause: torn from vasa paevia (fetal origin).

4. Placenta praevia Definition:
a placenta that partially or wholly situated in the lower uterine segment. Its incidence is 0.4 to 0.8% of pregnancies.
Lower uterine segment:
it forms after 28 week’s gestation and it has 3 definitions
Is that part of the uterus which measures about 5 cm from the internal os (metric definition used in U/S).
Is that part of the uterus which stretches and dilates in labour (physiological definition occurs in labour).
Is that part of the uterus which lies below the level at which the visceral peritoneum is reflected on the dome of the bladder from being ultimately adherent to the upper uterine segment (anatomical definition used in caesarean section).

5. Placenta praevia Grades:
Grade 1: the placental edge is in the lower uterine segment but does not reach the internal os (low implantation).
Grade 2: the placental edge reaches the internal os but does not cover it.
Grade 3: the placenta covers the internal os when it is close and is asymmetrically situated (partial).
Grade 4: the placenta covers the internal os and is centrally situated (complete)
Grade 2: the placenta could be situated anteriorly or posteriorly.

6. Implantation of the placenta at or near the cervix.

7. Placenta praevia Predisposing factors:
Older multiparous women. Women > 40 years have 9-fold greater risks than women < 20 years of age.
Multiple pregnancy.
Previous caesarean section. The risk increases with increasing numbers of C/S
Smoking.
Associations:
Fetal abnormality (double in placenta praevia).
IUGR (multiple bleeds).
Placental abruption (co-exist in 10% of placenta praevia).

8. Placenta praevia Clinical presentation
Bleeding: usually mild but it could be severe; recurrent, painless and causeless.
Soft uterus.
Normal fetal heart rate (unless there is severe bleeding or associated abruption).
High presenting part.
Fetal malpresentation (breech/transverse/oblique).
Vaginal examination is contraindicated.

9. Placenta praevia Diagnosis: Clinical presentation.
U/S: Transvaginal is better than transabdominal; the woman does not need full bladder and can determine the placental edge in posterior PP.
- 5% of low lying placenta can be diagnosed at weeks but only 0.5% have PP at delivery.
- in the second trimester, if the placenta covers the internal os with an overlap > 2.5 cm and the placental edge is thick; placenta praevia will persist.
MRI: expensive.
Examination in the theatre: if no facilities or in doubt.

10. Complications of Placenta praevia
Preterm delivery and its complications.
Preterm premature rupture of membranes.
IUGR (repeated bleeding).
Malpresentation; breech, oblique, transverse.
Fetal abnormalities (double in PP).
↑ number of C/S.
Morbid placentae: placenta acreta(80%), increta and percreta.
Postpartum haemorrhage: lower segment not contract and retract, morbid placenta, C/S.

11. Management of Placenta Praevia
Asymptomatic and minor bleeding:
Admission (minor). Asymptomatic PP admitted at 36 weeks.
CBC, cross matching and preparation of blood.
Coagulation profile.
Maternal and fetal monitoring.
Correction of anaemia.
Anti-D if the mother is rhesus negative.
Tocolytic: safe, gain 13 days, other than B-agonist to be used.
Corticosteroids 48 hours before delivery ( at 38 week’s).
Vaginal delivery: placenta 4.5 cm from the internal os, low head, no bleeding. Consider examination in theatre if in doubt .
C/S (of choice): grade 4, 3, placenta within 2 cm of the internal os, high head, bleeding, presence of added factors.

12. Placenta Abruption Definition:
bleeding following premature separation of a normally situated
Incidence: 5% of pregnancies.
Grades:
Asymptomatic: retroplacental clot seen after placental delivery.
Mild: vaginal bleeding (revealed) + uterine tenderness; visible retroplacental clot after placental delivery.
± revealed bleeding; enough placental separation producing fetal compromise and visible retroplacental clot after placental delivery.
± revealed bleeding with maternal signs (uterine tetany, hypovolaemia, abdominal pain) and late stage fetal compromise or fetal death. 30% of these women will develop DIC.

13. Extensive retroplacental clot removed from maternal placental surface in a case of abruption

14. Predisposing factors of Placenta Abruption
Hypertension: PET (24%), chronic hypertension ( 9-fold).
Fetal abnormality: ↑ maternal serum α-fetoprotein, ↑ recurrence of abruption. ?? poor placentation (↓ adhesiveness).
Thrombophilias: factor V leiden, prothrombin gene, protein C & S deficiency, antiphospholipid syndrome & homocysteinaemia.
Trauma: ECV, cordocentesis, road traffic accidents.
Rupture membranes: rapid decompression in polyhydramnios.
Folic acid deficiency.
Chorioamnionitis.
Previous abruption: 6 times to recur.
Multiple pregnancy.
Smoking.

15. Diagnosis of Placenta Abruption
Clinical presentation:
Bleeding: revealed/concealed, so clinical picture is important.
Pain on the uterus and this increases in severity.
Signs of shock (hypovolaemia): fainting and collapse.
Hard tender uterus ( uterine tetany).
Difficult to palpate the fetal parts and to hear the fetal heart.
The diagnosis is clinical.
U/S: is to
Confirm fetal viability, assess fetal growth & normality, measure liquor, do umbilical artery Doppler velocities.
Exclude placenta praevia.

16. Complications of Antepartum haemorrhage
Premature delivery.
Fetal distress and death
Haemorrhagic shock.
Acute renal failure: acute tubular or cortical necrosis.
DIC (release of tissue thromboplastin)
Uterine atony (Couvelaire uterus).
PPH.

17. Management of Placenta Abruption
Principle of management:
Early delivery (50% of abruption present in labour).
Adequate blood transfusion.
Adequate analgesia.
Detailed maternal and fetal monitoring.
Coagulation profile (30% develop DIC).
C/S: distressed baby, severe bleeding, alive baby & not in advanced labour. Perinatal mortality rate is 15-20%.
Vaginal delivery: very low gestation, dead baby, cervix is fully dilated (Ventouse delivery).
Conservative: small abruption, well mother and fetus, if the gestational age < 34, give steroids.

18. Management of Placenta Abruption
Conservative: Time taken to achieve delivery depends on:
rate of the bleeding.
The rate of change in the clotting studies.
The clinical condition of the mother and fetus.
CTG: twice/day.
Serial U/S and umbilical artery Doppler waveform.
No conservative after 38 week’s gestation.
Anti-D if the mother is rhesus positive.
Anticipate PPH.
In cases of previous CS, discuss hysterectomy.

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