1.
ANTEPARTUM HAEMORRHAGE (APH)
1.1 Definition
Bleeding from the genital tract after fetal viability and before delivery.
Fetal viability
WHO: 22 weeks
RCOG/commonly used: 24 weeks
Importance
Complicates 2–5% pregnancies
Associated with high maternal and fetal morbidity and mortality
1.2 Causes of APH
1. Placenta praevia
2. Abruptio placentae
3. Local causes
Cervical polyp
Carcinoma cervix
Varicose veins
Local trauma
4. Circumvallate placenta
5. Vasa praevia
6. Unclassified/indeterminate haemorrhage
2. PLACENTA PRAEVIA
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2.1 Definition
Presence of placental tissue over or adjacent to the internal os.
Characteristic bleeding
Inevitable haemorrhage
Unavoidable haemorrhage
Reason:
Dilatation of internal os causes placental separation.
2.2 Why Bleeding Occurs
Mechanism
1. Placenta lies over internal os.
2. Lower uterine segment forms.
3. Cervix dilates.
4. Placenta separates.
5. Haemorrhage occurs.
Additional factor
Lower uterine segment contracts poorly.
Bleeding may continue even after placental delivery.
2.3 Traditional Classification
Minor Degree
Type I – Low-Lying Placenta
Placenta near internal os.
Does not reach os.
Type II – Marginal Placenta Praevia
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Placental edge reaches margin of os.
Does not cover os.
Major Degree
Type III – Partial/Incomplete Central
Placenta partially covers internal os.
Type IV – Complete/Central
Placenta completely covers internal os.
Dangerous Placenta Praevia
Type II Posterior Placenta
Why dangerous?
Placenta gets compressed between:
Fetal head
Sacral promontory
Consequences
Cord compression
Fetal distress
Fetal asphyxia
Fetal death
2.4 Current Ultrasound Classification
1. Placenta Praevia
Placenta partially or completely covers internal os.
2. Low-Lying Placenta
Placental edge lies within 2 cm of internal os.
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Does not cover os.
2.5 Incidence
Approximately 1 in 300 deliveries.
2.6 Etiology
Basic mechanism
Damage to:
Endometrium
Myometrium
Leads to:
Low placental implantation
Placenta praevia
Causes of damage
Previous uterine surgery
Infection
2.7 Risk Factors
A. Previous Uterine Procedures
1. Previous caesarean section
2. Previous placenta praevia
3. Prior curettage
4. Prior uterine surgery
5. Myomectomy
6. Dilatation and curettage
B. Maternal Factors
1. Advanced maternal age
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2. Multiparity
C. Pregnancy Factors
1. Multiple pregnancy
2. Male fetus
3. Malpresentation
D. Other Factors
1. Assisted reproductive technology
2. Chorioamnionitis
3. Smoking
4. Cocaine use
2.8 Relation with Previous Caesarean Section
Risk
Increases risk 2–3 fold.
Incidence 4 times higher after previous LSCS.
Important association
Previous LSCS + Anterior Placenta Praevia
Morbidly adherent placenta:
Placenta accreta
Placenta increta
Placenta percreta
2.9 Clinical Features
A. Symptoms
Classical Presentation
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Painless APH
Usually in 2nd or 3rd trimester
Characteristic History
Sudden bleeding
Often wakes patient from sleep
Initial bleeding usually mild
Stops spontaneously
Recurs later
Hallmark
Painless recurrent bleeding
B. Signs
General
Pallor proportional to blood loss
Uterus
Size corresponds to gestational age
Soft
Non-tender
Presentation
Malpresentation common
Presenting part often floating
Fetal Heart Sounds
Usually present
Stallworthy Sign
Definition
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Slowing of fetal heart rate when fetal head is pushed into pelvis with recovery on release.
Suggests
Posterior placenta praevia.
Important Point
❌ Vaginal examination should not be done in suspected placenta praevia.
Reason:
Can cause torrential haemorrhage.
2.10 Diagnosis
Investigation of Choice
Transvaginal Ultrasound (TVS)
Advantages of TVS
1. More accurate than TAS.
2. Better for posterior placenta.
3. Better in obese patients.
4. Measures distance between:
Placental edge
Internal os
Additional Uses
If placenta covers os
Measure:
Extent of placental coverage
Cervical assessment
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Assesses cervical dilatation
Safety
TVS is safe and does not provoke bleeding.
2.11 Placental Migration
Definition
Apparent movement of placenta away from internal os with advancing pregnancy.
Cause
Differential growth of:
Upper uterine segment
Lower uterine segment
When to Repeat Scan
If low-lying placenta diagnosed at 18–20 weeks
Repeat at:
32 weeks
Factors Favouring Migration
1. Earlier gestational age at diagnosis
2. Marginal placenta praevia
Factors Making Migration Unlikely
1. Placenta covering internal os
2. Early gestational age at diagnosis
3. Previous caesarean section
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2.12 Adherent Placenta
When to Suspect
Previous LSCS + Anterior placenta praevia
Types
1. Placenta accreta
2. Placenta increta
3. Placenta percreta
Ultrasound Finding
Absence of normal subplacental sonolucent zone
Additional Investigations
1. Doppler ultrasound
2. MRI
Risk
Risk increases with increasing number of previous caesarean sections.
2.13 Differential Diagnosis
Most Important
Abruptio placentae
Others
Other causes of APH
2.14 Complications
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A. Maternal
1. Shock
2. Preterm labour
3. Increased caesarean section rate
4. Postpartum haemorrhage (PPH)
5. Morbidly adherent placenta
Accreta
Increta
Percreta
B. Fetal (Perinatal)
1. Prematurity
2. Hypoxia due to placental separation
3. MANAGEMENT OF PLACENTA PRAEVIA
3.1 Initial Management in APH
1. Resuscitation
Two large-bore IV cannulas (14–16G)
Start crystalloids/colloids
2. Blood Tests
Hb
Hematocrit
PCV
Blood grouping
Cross-matching
3. Blood Transfusion
If required
4. Urine Monitoring
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Catheterization
Hourly urine output
5. Ultrasound
Placental localisation
Fetal wellbeing
6. Vaginal Examination
❌ Not done routinely
7. Speculum Examination
✔ To exclude cervical/vaginal causes
8. Suspected Vasa Praevia
Apt test (Singer alkali denaturation test)
3.2 Expectant Management
Principle
Bleeding usually:
Stops spontaneously
Recurs later
Pregnancy can be prolonged if mother and fetus remain stable.
Measures
General
Reassurance
Complete bed rest
Hospital admission
Correct Anaemia
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Blood transfusion if needed
Supplements
Iron
Calcium
Vitamins
Steroids
Betamethasone:
12 mg IM
2 doses
24 hours apart
Between 24–35 weeks
Purpose:
Fetal lung maturity
Rh-Negative Mother
Anti-D immunoglobulin
Always Keep Ready
Cross-matched blood
Not Recommended
❌ Tocolytics
❌ Cervical cerclage
3.3 Prerequisites for Expectant Management
1. Maternal condition good
2. Fetal condition good
3. Gestation <36 weeks
4. Not in labour
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5. Hospital with:
Blood bank
Emergency LSCS facility
3.4 When to Terminate Expectant Management
1. 36–37 weeks reached
2. Active labour
3. Fetal death
4. Profuse bleeding
5. Maternal jeopardy
6. Fetal jeopardy
3.5 Caesarean Section
Indications
All placenta praevia
Most low-lying placentae
Timing
Usually 36–37 weeks
Requirements
Blood bank available
Experienced obstetrician
Experienced anaesthetist
3.6 Problems During Caesarean Section
A. Delivery of Baby
Problem
Anterior placenta may obstruct delivery.
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Management
Hand passed beneath placental edge.
Occasionally placenta must be cut through.
B. Postpartum Haemorrhage
Causes
1. Poor lower segment contractility
2. Engorged vessels
Management
1. Figure-of-eight sutures
2. Purse-string sutures
3. Uterine artery ligation
4. Ovarian artery ligation
5. Internal iliac artery ligation
6. Uterine packing
Failure of Conservative Measures
➡ Hysterectomy
3.7 Adherent Placenta
Risk Factors
Previous LSCS
Anterior placenta
Complications
1. Massive haemorrhage
2. Urinary tract injury
3. Blood transfusion requirement
4. Hysterectomy
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Preferred Treatment
Caesarean hysterectomy with placenta left in situ
Important
❌ Do not attempt placental removal.
Reason:
Torrential haemorrhage
3.8 Vaginal Examination and Vaginal Delivery
Vaginal Examination
Generally avoided.
May be attempted if:
1. Placental edge >2 cm from os
2. Head fixed
3. Diagnosis uncertain
Precaution
Double set-up examination in OT
Vaginal Delivery Allowed When
1. Placenta not felt
2. Cervix dilated
3. Membranes ruptured
4. No active bleeding
Otherwise: ➡ Caesarean section preferred.
4. ASYMPTOMATIC PLACENTA PRAEVIA
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4.1 Follow-up
If diagnosed at 18–20 weeks
Repeat scan at:
1. 28 weeks
2. 32 weeks
Major Placenta Praevia
Consider admission from 32 weeks.
4.2 Advice
Avoid
1. Sexual intercourse
2. Travel
General
Stay near hospital.
Seek immediate care if bleeding occurs.
4.3 Delivery
Recommended Timing
37 completed weeks.
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5. ABRUPTIO PLACENTAE
5.1 Definition
Abruptio placentae = Premature separation of a normally situated placenta before delivery.
Other names
1. Accidental haemorrhage
2. Premature placental separation
5.2 Incidence
Occurs in about 1% of pregnancies.
Major cause of perinatal mortality.
Incidence increases towards term.
5.3 Etiology and Risk Factors
5.3.1 Maternal Diseases
Hypertension (Most Important Risk Factor)
5-fold increased risk.
Associated with:
Preeclampsia
Hypothyroidism
Asthma
5.3.2 Thrombophilias
Acquired
Antiphospholipid syndrome
Associated with:
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Thrombosis
Recurrent miscarriage
Early-onset preeclampsia
FGR
Congenital
Factor V Leiden mutation
Prothrombin gene mutation
Protein C deficiency
Protein S deficiency
5.3.3 Hyperhomocysteinaemia
Associated with folate deficiency.
5.3.4 PPROM
(Preterm Premature Rupture of Membranes)
Release of thrombin may precipitate abruption.
5.3.5 Direct Trauma
Blunt abdominal trauma
Amniocentesis
External cephalic version
5.3.6 Rapid Uterine Decompression
Delivery of first twin
Hydramnios
5.3.7 Uterine Factors
Uterine anomalies
Submucous fibroids
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5.3.8 Other Associations
Previous abruption (10% recurrence)
Smoking
Cocaine abuse
Raised maternal serum α-fetoprotein
Decreased PAPP-A
Multiparity
Advanced maternal age
5.4 Pathogenesis
Sequence
1. Vasospasm
2. Myometrial relaxation
3. Venous congestion
4. Arteriolar rupture
5. Decidual hematoma formation
6. Placental separation
7. Fetal hypoxia
5.5 Grading (Sher and Statland)
Grade I (Mild)
Not diagnosed clinically before delivery.
Diagnosed by retroplacental clot after delivery.
Fetus alive.
Grade II (Moderate)
Classical features present.
No maternal distress.
Fetus alive.
Grade III (Severe)
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Grade IIIA
Fetus dead
No coagulopathy
Grade IIIB
Fetus dead
Coagulopathy present
5.6 Classification According to Bleeding
5.6.1 Revealed Abruption (60%)
Mechanism
Blood escapes between:
Membranes
Uterine wall
Then exits through:
Cervix
Vagina
Features
Visible vaginal bleeding
Less severe than concealed type
5.6.2 Concealed Abruption (35%)
Mechanism
Blood remains trapped inside uterus.
Features
Little or no vaginal bleeding
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Uterus distended with blood
More severe fetal hypoxia
Higher maternal complications
More likely to cause
Couvelaire uterus
Fetal demise
DIC
5.6.3 Mixed Abruption (5%)
Partly revealed
Partly concealed
5.7 Couvelaire Uterus
Definition
Extravasation of blood into uterine musculature beneath serosa.
Other Name
Uteroplacental apoplexy
Features
Bluish uterus
Multiple ecchymoses
Blood may extend to:
Tubes
Ovaries
Peritoneal cavity
Importance
❌ Not an indication for hysterectomy by itself.
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Consequences
1. Tetanic uterine contractions
2. Increased intrauterine pressure
3. Reduced placental perfusion
4. Severe fetal hypoxia
5. Sudden fetal death
5.8 Chronic Placental Abruption
Cause
Chronic placental ischemia
Features
Recurrent mild bleeding
Oligohydramnios
Fetal growth restriction
Coagulation failure
Usually absent
6. DIAGNOSIS OF ABRUPTIO PLACENTAE
6.1 Symptoms
1. Abdominal Pain
Severe
Constant
More severe in concealed type
2. Bleeding
Present in
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Revealed abruption
Mixed abruption
May be absent in
Concealed abruption
6.2 Signs
General
Pallor
Often disproportionate to visible blood loss
Blood Pressure
Hypertension may be present
Associated preeclampsia common
Uterus
Fundal Height
May be larger than gestational age
Consistency
Tense
Tender
Rigid ("Woody hard uterus")
Fetal Findings
Fetal Parts
Difficult to palpate
Fetal Heart Sounds
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Fetal distress
Absent FHS in severe cases
CTG Findings
1. Variable decelerations
2. Late decelerations
3. Reduced variability
4. Prolonged bradycardia
5. Sinusoidal pattern
6.3 Vaginal Examination
Performed Only After
Placenta praevia has been excluded.
Findings
Labour usually present
Presenting part fixed
Liquor uniformly blood stained after ARM
6.4 Ultrasound
Role
Less useful than in placenta praevia.
Uses
1. Exclude placenta praevia
2. Confirm fetal viability
Important Point
⭐ Abruptio placentae is primarily a clinical diagnosis.
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Normal ultrasound does NOT exclude abruption.
Types of Hematoma Seen
Subchorionic
Between:
Placenta
Membranes
Retroplacental
Between:
Placenta
Myometrium
⭐ Worst prognosis
Preplacental
Between:
Placenta
Amniotic fluid
6.5 Differential Diagnosis
1. Placenta praevia
2. Other causes of APH
3. Preterm labour
4. Acute polyhydramnios
5. Rupture uterus
6. Red degeneration of fibroid
7. Pyelonephritis
8. Acute abdomen
Important
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Placenta praevia and abruption coexist in about 10% of cases.
7. COMPLICATIONS
7.1 Maternal Complications
1. Shock
Often out of proportion to visible blood loss.
2. Acute Renal Failure
Cause
Hypovolaemia
Types
Acute tubular necrosis (common)
Cortical necrosis (rare)
3. Disseminated Intravascular Coagulation (DIC)
Frequency
Occurs in about 30% severe abruptions.
Mechanism
Placental thromboplastin release → Widespread coagulation → Consumption of clotting factors →
Severe bleeding
Laboratory Findings
Low fibrinogen ⭐ Best severity marker
Increased FDP
Thrombocytopenia
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4. Postpartum Haemorrhage (PPH)
Causes
Uterine atony
Coagulation failure
Treatment
Uterotonics
Uterine massage
Blood products
7.2 Fetal Complications
1. Prematurity
2. Fetal Hypoxia
3. Fetal Death
8. MANAGEMENT
8.1 Immediate Management
Resuscitation
1. IV fluids
2. Blood transfusion
3. Oxygen
Monitoring
1. Foley catheter
2. Intake-output chart
Target
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Urine output ≥30 mL/hour
Investigations
1. Hb
2. PCV
3. Blood grouping
4. Cross-match
5. Coagulation profile
Coagulation Profile
1. Fibrinogen ⭐ Best marker
2. PT
3. aPTT
4. Platelet count
5. FDP
Bedside Clot Observation Test
Normal
Firm clot
Stable clot
Abnormal
Fragile clot
Indicates fibrin degradation products
8.2 Obstetric Management
Principle
⭐ Immediate delivery is vital.
A. Fetus Alive
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Preferred Method
Caesarean section
Exception
If vaginal delivery imminent:
1. ARM
2. Oxytocin infusion
3. Continuous CTG monitoring
If CTG abnormal
➡ Caesarean section
B. Fetus Dead
Preferred Method
Vaginal delivery
Management
1. ARM
2. Oxytocin infusion
Caesarean Section Only If
Severe bleeding
Obstetric indications
Labour not progressing
8.3 Indications for Caesarean Section
1. Live fetus capable of survival
2. Severe bleeding with no imminent vaginal delivery
3. Failure to progress after ARM and oxytocin
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8.4 Management of Coagulation Failure
Blood Products
1. Packed RBC
2. Fresh frozen plasma (FFP)
3. Platelets
4. Cryoprecipitate
Severe Cases
Recombinant Activated Factor VII
Very effective
Expensive
8.5 Expectant Management
Role
Very limited
Indications
Mild abruption
<34 weeks
No maternal complications
Reassuring fetal status
Monitoring Required
Hospital admission
Close fetal surveillance
Risks During Follow-up
Oligohydramnios
Fetal growth restriction
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8.6 Recurrence
Future Pregnancy Risk
About 10% recurrence
Evaluation
Consider testing for:
1. Antiphospholipid antibodies
2. Hyperhomocysteinaemia
Next Pregnancy
Careful antenatal surveillance
Serial ultrasound scans
Monitor for:
Preeclampsia
FGR
9. High-Yield Comparison
9.1 Placenta Praevia
1. Painless bleeding
2. Bright red blood
3. Soft uterus
4. Floating head
5. Malpresentation common
6. FHS usually present
7. DIC uncommon
8. TVS = investigation of choice
9.2 Abruptio Placentae
1. Painful bleeding
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2. Dark blood
3. Tender rigid uterus
4. Head usually fixed
5. Fetal distress common
6. Hypertension common
7. DIC common
8. Clinical diagnosis
9. Low fibrinogen = best severity marker
10. Immediate delivery is key management principle.
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