1. Antepartum haemorrhage Qu Quanxin Tianjin First Centre Hospital

2. Definition and Classification Definition The volume of bleeding from vagina occurs at any time of pregnancy and before the birth of the child. Classification Placenta praevia Abruptio placenta

3. Causes of 763 Pregnancy-related Deaths Due to Hemorrhage 32 (4) Retained placenta 44 (6) Placenta accreta/increta/percreta 47 (6) Uterine bleeding 50 (7) Placenta previa 108 (14) Coagulopathies 115 (15) Uterine atony 125 (16) Laceration/uterine rupture 141 (19) Placental abruption Number (%) Causes of Hemorrhage

4. Placenta Praevia

5. Definition The condition that the placenta is wholly or partly attached to the lower uterine segment Classification Type I Type II Type III Type IV

12. Signs and symptoms During the trimester of pregnancy Slight or severe bleeding from the vagina without evident cause and without any pain on the abdomen. During delivery Severe haemorrhage is inevitable as the cervix dilates, especially in type I and type II. During the third stage of labour Postpartum haemorrhage

15. Abruptio placentae

16. Definition and Classification Definition The separation of the placenta from its site of implantation before delivery has been variously called placental abruption, or abruptio placentae Classification Revealed Hemorrhage Concealed Hemorrhage

19. Etiology Hypertension Proteinuria Folic acid deficiency Trauma

20. Risk Factors for Placental Abruption 10-25 Prior abruption 37 Thrombophilias 1.4-1.9 Cigarette smoking 2.0 Hydramnios 2.1 Multifetal gestation 2.4-4.9 Preterm ruptured membranes 1.8-3.0 Chronic hypertension 2.1-4.0 Preeclampsia 1.3-1.5 Increased age and parity Relative Risk Risk Factor

21. Pathology Revealed hemorrhage The bleeding may track down between the membrane and the wall of the uterus and escape at the cervix Concealed hemorrhage The blood remain inside the uterine cavity

24. Signs and symptoms Revealed hemorrhage The patients often appear bleeding from the vagina without any obvious signs and symptoms or just slight abdominal discomfort and tenderness over the placental site. The size of uterus is accordant with the period of gestation reached.

25. Concealed hemorrhage The patient often complains of a sudden attack of abdominal pain and at the same time feels faint and suffers from nausea. When abdominal examination is done, the uterine tenderness is discovered. In severe cases, shock often occurs and the degree of shock is out of all proportion to the external loss. The uterus may be larger than would be expected for the period of gestation. The fetal outline cannot be made out and the fetal heart sounds become inaudible, even cannot be heard.

26. Diagnosis Revealed hemorrhage The history, signs and symptoms and ultrasound investigation help diagnosis. If the case is questionable, the vaginal examination must not be done in order to avoid severe bleeding. Concealed hemorrhage Ultrasound investigation of the uterus can provide invaluable in the diagnosis of concealed accidental hemorrhage since the retroplacental clot can often be visualized.

29. Differentiate between abruptio placenta and placenta praevia The distance <7cm The old clotting behind the placenta Ultrasonography No Normal or abnormal No Often exist, especially on the lesion site Often abnormal or disappear Obviously on the site of placenta bleeding Signs and symptoms Pain on abdomen Fetal heart rate Tenderness Multiparity, multiple gestation, prior cesarean section Hypertension, Trauma History Placenta praevia Abruptio placenta