Download MBBS OBS and Gynec Antepartum Haemorrhage Lecture PPT

? CASE 1
? A 32-year-old multigravida at 31 weeks gestation is admitted to the
obs dept after a motor-vehicle acci-dent. She complains of sudden
onset of moderate vaginal bleeding for the past hour. She has
intense,constant uterine pain and frequent contractions. Fetal heart

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tones are regular at 145 beats/min. On in-spection her perineum is
grossly bloody
? Diagnosis, investigations & management.?

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? CASE 2
? A 34-year-old multigravida at 31 weeks gestation comes to the obs

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dept stating she woke up in themiddle of the night in a pool of
blood. She denies pain or uterine contractions. Examination of the
uterusshows the fetus to be in transverse lie. Fetal heart tones are
regular at 145 beats/min. On inspection herperineum is grossly
bloody.

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? Diagnosis. ?
? Investigation & management?

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ANTEPARTUM
HAEMORRHAGE

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?Antepartum haemorrhage is defined as bleeding from genital tract after foetal

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viability and before delivery
?Viability ---28 weeks onwards
?Due to improvements in foetal survival
qWHO ? 22 weeks
qUK ? 24 weeks

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?It complicates 2-5% of all pregnancies , and lead to a high foetal and maternal
mortality and morbidity

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CAUSES
vPlacenta previa
vAbruptio placenta

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vCircumvallate placenta
vVasa praevia
vUnclassified or intermediate haemorrhage
vLocal causes: polyp , ca cervix, varicose veins
local trauma

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PLACENTA
PREVIA
C J A B D U L K A L A M

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qPlacenta praevia is defined as a
placenta located partly or
completely in the lower uterine

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segment
qThe bleeding is called inevitable or
unavoidable haemorrhage as dilation
of internal os inevitable results in
haemorrhage

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? Incidence 1 in 300

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AETIOLOGY
? it has been suggested that damage to endometrium or myometrium can
predispose to a low implantation & subsequent implantation of placenta
praevia

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? Prior surgery on uterus
? CS , myomectomy ,D & C
? Infection or chorioamnionitis
? Previous placenta praevia
? Advanced maternal age

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? Multiparity ,multiple pregnancy , malpresentations , smoking

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PATHOGENESIS
Risk factor
Defective placental migration\large placenta
Low lying placenta

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Separation of placenta during formation of lower uterine segment &
dilation of internal os
Inability of the lower uterine segment to contract
bleeding

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CLASSIFICATION

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? Low lying placenta or lateral placenta praevia ,the
placenta edge does not reach internal os but is in close
Type 1
proximity
? Marginal placenta praevia, placental edge reaches the

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margin of internal os ,but does not cover it
Type 2
? Partial or incomplete central placenta praevia
? Placenta covers internal os when closed ,but only
partial y when the os is dilated

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Type 3
? Total ,central or complete placenta praevia
Type 4
? Placenta covers internal os even on dilation

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? Type 1 & 2 minor
? Type 3 & 4 major
? Placenta can be anterior or
posterior

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? Type 2 posterior placenta is called
dangerous type as it is likely to be
compressed between foetal head
& sacral promontory

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CLINICAL FEATURES

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? SYMPTOMS
? Painless and recurrent bouts of antepartum haemorrhage
? SIGNS
? Pallor [proportionate to bleeding]
? Size of uterus corresponds to period of amenorrhoea

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? Uterus soft & non tender
? Malpresentation common `if cephalic head is usually floating
? Foetal parts can be felt in anterior placenta & difficult in posterior placenta
? foetal heart sound usually heard
? Stallworthy`s sign : slowing of heart rate on pressing the head down into the

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pelvis & prompt recovery on release
? Vaginal examination should not be done

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DIFFERENTIAL DIAGNOSIS
? Al causes of antepartum haemorrhage

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COMPLICATIONS
? MATERNAL
? FOETAL
? Shock due to haemorrhage
? prematurity

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? Increased chance of cs
? Hypoxia due to placental
? Postpartum haemorrhage
separation
? Morbidity adherent placenta

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? Placenta accreta
? Placenta increta
? Placenta percreta

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MORBIDITY ADHERENT PLACENTA
? The placenta is adherent to the uterine wal due to partial or total
absence of decidua basalis and fibrinoid layer ( Nitabuch layer )

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? Thank you

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