1. ANTEPARTUM HAEMORRHAGE

2. Definition:
Bleeding from the genital tract after 22 weeks of pregnancy or during the 1st stage of labor.

3. Classification: Placental Site Bleeding: Extra-Placental Bleeding:
Placenta previa
Accidental haemorrhage.
Extra-Placental Bleeding:
Cervical erosion
Polyp
Carcinoma
Rupture of V. vein in the cervix
Rupture of Vasa Praevia – which is rare.

4. Placenta Praevia AE: DEFINITION: INCIDENCE: 1:200
The placenta is implanted partially or totally on L.U.S.
INCIDENCE: 1:200
AE:
Implantation of fertilized ovum in the isthmus.
Development of chorion in the decidua capsularis.
Abnormal large placenta.

5. DEGREES:
1st degree: The lower edge of placenta reach the upper part of lower uterine segment. Lateralis
2nd degree: The edge of the placenta reaches the int. OS but does not cover the partially dilated cervix. Marginalis
3rd degree: Placenta is covered OS while the cervix partially dilated. Incomplete centralis.
4th degree: Placenta is covered OS while cervix is completely dilated.
Complete centralis.

6. MECHANISM OF BLEEDING:
During labour  sheering of placenta. due to uterine contraction.
CLINICAL PICTURE:
Painless
Causeless
Recurrent bleeding after 28 weeks.
SIGNS
General examination
Depend on severity of bleeding ± anaemia

7. Abdominal examination
Nothing characteristic
Maybe  malpresentation – non engagement head
 Uterus is not tender
 Supra pubic fullness
Vaginal examination
Should not be done except in theatre
Vaginal examination is done when active treatment is indicated
Active Treatment will be done:
Fetal maturity
During labor (patient in labour)
Severe bleeding.

8. INVESTIGATION: Ultrasound – accurate Radiology – this is in the past
Soft tissue placentography
Amniography – radio opaque substance
Detection of fetal head displacement
Public angiography
Cystography – inject sodium iodide 12.5.
IV radio active istope
Thermography

9. At home: In case of emergency
TREATMENT
At home: In case of emergency
Cervix generally – no PV
Sterile vulval pad
Morphine + transfer to hospital
At Hospital:
Antenatal record – all investigation should be done including coagulation profile
Blood transfusion if needed
Abdominal examination
Not in Labour:
Severe bleeding – Cesarean section.
Mild bleeding.
Expect ttt less than 37 weeks do U/S

10. IN LABOUR: ARM & Syntocinon. Cesarean Section 1. Vertex. 1. G
IN LABOUR: ARM & Syntocinon Cesarean Section 1. Vertex G. III, IV 2. Engaged head Post p.p. 3. Degree I – III ant Sever bleeding 4. OS opened Not stop with ARM 5. Mild or moderate bleeding Others as CPD MANAGEMENT OF 3RD STAGE Careful observation due to p.p. haemorrhage.

11. COMPLICATION: Maternal:. During pregnancy. - ant. P. haemorrhage
COMPLICATION: Maternal: During pregnancy ant. P. haemorrhage malpresentation prematurity During labour 1st stage: - haemorrhage slow dilatation of cervix inertia PRM 2nd stage: laceration of cervix 3rd stage: p.p. haemorrhage retain part of placenta

12. DURING PEURPERIUM: FOETAL: Puerperal sepsis Sub involution
Perinatal mortality 10 – 15%
Prematurity
Fetal malformaiton 3-4%
Asphyxia due to:
Anaemia hypoxia
Separation of placenta
Compression of placenta
Prolapse cord

13. ACCIDENTAL HAEMORRHAGE
(Abruptio Placenta)
DEFINITION
Separation of normally situated placenta after 22 weeks gestation.
TYPES:
Ext. (Revealed) Mild
Concealed Severe
Combined Moderate

14. Toxaemia increased in patient with severe type
INCIDENCE
About 1%
Severe form are seen more in primigravida
AE:
Toxaemia: 25 – 60%
Spasm of vessel  degenerage change.
Rupture  Hge
Toxaemia increased in patient with severe type

15. NON-TOXAEMIA: Trauma as  ECV Circumrellate placenta Traction on cord
Sudden increased in IUP as R.M. in case of hydramnios
Vit. C, K, E, deficiency
Folate deficiency
Detachment of placenta after delivery of 1st twin.

16. Utero-placenta apoplexy (couviar’s ut) Coagulation Defect
PATHOLOGY:
All degree of placenta separation can occur from few millions to whole placenta
Degeneration change in the decidual  rupture  haemorrhage in the decidual basalis
1. Decidual than splits 
Leaving then layer adherent to myometrium 
Decidual haematoma  separation  compression
Utero-placenta apoplexy (couviar’s ut)
Coagulation Defect
DIC  low thromboplastin + fibrimolysin high FDP
Fibrinolysis

17. Vaginal bleeding – dark, not severe Tender abdomen History of trauma
INVESTIGATION:
Urine analysis  albumin PET
Fibrinogen 
FDF 
Reveled
Clinical Picture
Symptoms:
Vaginal bleeding – dark, not severe
Tender abdomen
History of trauma

18. Sign:
General examination – hypertensive ± shock  amount of blood.
Sign of hypertensive state of pregnancy
Shock if present
Abdominal examination
Nothing
Uterus is normal in size and consistency
Fetal parts are easily felt
F.H.S positive.

19. CLINICAL PICTURE Concealed antepartum haemorrhage SYMPTOMS Severe abdominal pain = abdominal dist. Shock  N + He

20.  Shock – concealed blood - partly due to over distended uterus
SIGN:
General Examination
 Shock – concealed blood
- partly due to over distended uterus
Pulse rapid, BP subnormal, Temp. subnormal, Oedema
Abdominal examination:
Large uterus
Uterus hard & tender & rigid
F.H.S. are not heart
Vaginal examination:
No bleeding
Cervix is dilated

21. TREATMENT REVEALED Not in labor In labor Before 37 After 37 active
treatment OR CS
in severe bleeding
Expected treatment
- RM uterine distension CS in cases of
Prevent utero-renal reflex severe bleeding
Fetal distress
Oxytocin
CONCEALED
Living Dead – promote early
CS vaginal delivery by:
* RM & Oxytocin
* Clot observation

22. PROGNOSIS Maternal In the past, the maternal mortality was high now 1%
The maternal prognosis depend on:
Extent of placenta separation
Degree of coagulation defect
Degree of utero pl. apoplexy
Revealed or concealed haemorrhage
Adequacy of treatment
B. Fetal
100%  in severe type
30 – 50% in revealed type

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