1. Antepartum Haemorrhage (APH)

2. MCQs

3. 1. Placenta Accreta The optimum management is Caesarean hysterectony
Is commonly associated with placenta praevia
Is associated with placenta praevia in over 50% of cases
Methotrexate can be given in selected cases

4. 2. Antepartum haemorrhage (APH)
Is defined as bleeding from the genital tract after 24 weeks’ gestation.
If associated with labour – like pains, a vaginal examination is advisable.
In cases of placental abruption, there is coincident placenta praevia in 1% of patients

5. 3. Placental abruption
Is defined as the premature separation of an abnormally sited placenta
70-80% result in vaginal bleeding
The bleeding is typically bright red and clotting
In 50% of cases the bleeding occurs after 36 weeks’ gestation
Blood loss is invariable of maternal origin
Tends to recur in subsequent pregnancies

6. 4. Placenta Praevia Nulliparity is a risk factor
Complicates approximately 1 in 400 pregnancies.
Is associated with intra-uterine growth restriction
Fetal growth restriction is more commonly encountered in association with placenta praevia than with normally sited placentas
Transvaginal ultrasound is the diagnostic technique of choice.

7. 5. The following statements are true about placenta praevia
Transabdominal ultrasound (TAS) has a false-positive rate of 20% for the diagnosis of placenta praevia
An overdistended maternal bladder makes the diagnosis easier by TAS
TH diagnostic accuracy of transvaginal ultrasound (TVS) is greater than abdominal ultrasound
The diagnostic accuracy of 93-97%
Only 5% of patients diagnosed as having a low-lying placenta in the second trimester continue to have placenta praevia at delivery.

8. 6. Placenta Praevia Complicates approximately 1:400 pregnancies
IS associated with a maternal mortality rate of 0.3% in the UK
Transvaginal ultrasound is the diagnostic technique of choice.
If the placenta edge is less than 3cm from the internal cervical os, a caesarean section should be performed.
There is significant association between placenta praevia and placenta accreta

9. 7. Placental Abruption The risk of recurrence is 8.3-16.7%.
The commonest reason is blunt trauma to the abdomen.
Causes are usually obvious clinically
Many patients with placental abruption are hypertensive at presentation.
Nearly 50% of patients are in established labour.
Approximately 10% of patients are in established labour.

10. Answers Q1 . T, T, T Q2. T, F, F, Q3. F, T, F, T, F, T
Q4. F, F, T, T, T
Q5. F, T, F, T, T
Q6. F, F, T, F, T
Q7. T, F, F, T, T, F

11. Epidemiology Late pregnancy or third trimester bleeding
Complicates 4% of pregnancies

12. APH - Causes Major causes Other Placenta Previa (20%)
Placental Abruption (30%)
Ruptured Vasa Previa - Fetal blood vessels across presenting membranes
Uterine Scar Disruption
Other
Cervicitis or other genital tract infection
Bloody show (may indicate Preterm Labor)
Cervical polyp
Cervical Cancer
Cervical Ectropion
Vaginal trauma

14. History Bleeding characteristics Associated factors Inciting factors
Amount (pads/day), Colour of blood (dark or bright red)
Associated factors
Pelvic, abdominal pain or back pain
Contractions
Inciting factors
Recent examination
Abdominal or pelvic Trauma
Intercourse
Fetal movement
Previous ultrasounds

15. Examination Vital signs Abdominal Exam
Blood Pressure and pulse
Often normal despite significant bleeding
Abdominal Exam
Pain on palpation
Palpable contractions
Hypertonic uterus
Pelvic examination (if no Placenta Previa)
Bimanual exam if placental location known

16. Laboratory Investigations
Haemoglobin
Type and cross 2 to 6 units RCC
Type and cross platelets
Coagulation studies
Prothrombin Time (PT)
Partial Thromboplastin Time (PTT)

17. Investigations Ultrasound Transabdominal Transvaginal Ultrasound
Placental location
Placental Abruption

18. Management Depends upon Conservative
Stage of Pregnancy and fetal viability
Amount of Bleeding
Conservative
Hospitalization
Bed rest
Avoid vaginal examination
Correct anaemia
Blood cross match
Serial scans for fetal growth
Discharge if all well for follow up

19. Management: Emergency
Indications
Brisk Vaginal Bleeding
Unstable vital signs
Fetal Distress
Immediate interventions
Oxygen
Trendelenburg position (raise foot end)
Obtain immediate Intravenous Access
Two large bore IV (16-18 gauge)
Initiate Isotonic crystalloid bolus
Normal saline
Ringer Lactate
Type, cross and transfuse RCC, FFPs, platelets as needed
Record Vital signs, intake output
Call for immediate Obstetric and neonatal support for delivery

20. Complications of Abruption
Coagulation failure
Renal failure
IUD

21. Placenta Previa

22. Definition
Placenta previa is a condition in which the placenta is attached in lower uterine segment close to or covering the cervix

23. Pathophysiology Placenta usually implants at fundus Risk factors
Fundal blood supply is better than lower uterus
Risk factors
Previous C Section, myomectomy
Associated with placenta accreta
High parity
Multiple Gestation – large placenta
Previous uterine instrumentation – D&C, E&C
Past history of placenta previa

24. Pathophysiology Associated Conditions
Abnormal presentation (placenta raises presenting part)
Oblique Lie
Transverse Lie
Placental Abruption
Intrauterine Growth Retardation (IUGR)
Placenta accreta (especially prior C section)
Postpartum Haemorrhage

25. Types Type I: low implantation Type II: marginal placenta
Lower margin dips into lower uterine segment
Does not reach internal os
Type II: marginal placenta
Reaches but does not cover internal os,
Type III: partial previa
Covers internal os when closed
Does not cover os when fully dilated
Type IV: complete previa (central previa)
Covers internal os even when fully dilated

26. Types

27. Clinical presentation
Sudden Painless, profuse uterine bleeding weeks
May be mild (warning haemorrhage)
May be provoked with intercourse, contractions
Abdomen soft and non-tender – less placental separation
Fetal malpresentation
IUGR
Fetal heart present

28. Diagnosis Obstetric Ultrasound
EUA if ultrasound not available, active bleeding, borderline case
MRI

29. Counselling Risk of severe life-threatening hemorrhage
Risk of fetal death
Risk of maternal death
Blood transfusion may be necessary
Hysterectomy may be needed to control bleeding

30. Management Hospitalisation Caesarean section at tertiary care centre
Avoid digital cervical exam mild/No bleedning
Gentle speculum exam is permitted
Delay delivery until lung maturity
Caesarean section at tertiary care centre
Indications
Severe haemorrhage despite fetal immaturity
Major degrees of placenta previa

31. Management Spontaneous Vaginal Delivery: Indications
Spontaneous vaginal delivery in type I & II (anterior) or type I (posterior)
Head engaged: Can tamponade marginal previa
No brisk bleeding on exam
Close fetal and maternal monitoring
EUA in OT with full preparation of emergency Caesarean section
Bleeding management
Syntocinon
Prostaglandin
Hot packs
Internal iliac ligation
Obstetric hysterectomy

32. COMPLICATIONS Maternal Fetal Anaemia Hemorrhage and shock
cesarean hysterectomy
death
Fetal
Prematurity
intrauterine growth retardation
perinatal death

33. Thank you