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Presenter: Oriba Dan Langoya, MBchB V
Makerere university College of Health Sciences
Dr. Nakabembe, Dept. of Obstetrics& Gynecology
• It is defined as bleeding from or into the genital
tract after the 28th week of pregnancy but before the
birth of the baby
• (the first and second stage of labor are thus
• Slight vaginal bleeding is common during active
• This “bloody show” is the consequence of
effacement and dilatation of the cervix, with tearing
of small vessels.
• Uterine bleeding, however, coming from above the
cervix, is concerning.
• “Any pregnancy with antepartum bleeding remains
at increased risk for an adverse outcome even
though bleeding has stopped and placenta previa
has been excludedsonographically.”
• When the placenta is implanted partially or
completely over the lower uterine segment (over
and adjacent to the internal os)
• Workshop sponsored by the National Institutes of
Health (Dashe, 2013)
• Placenta previa.
• The internal os is covered partially or completely by
• Low-lying placenta—
• Implantation in the lower uterine segment is such that the
placental edge does not reach the internal os and remains
outside a 2-cm wide perimeter around the os.
Incidence and Associated Factors
• Reported incidences for placenta previa average 0.3
percent or 1 case per 300 to 400 deliveries.
• Increased maternal age (> 35 years)
• History of previous cesarean section or any other scar in the
uterus (myomectomy or hysterotomy)
• Placental size and abnormality (succenturiate lobes)
• Smoking — causes placental hypertrophy to compensate
carbon monoxide induced hypoxemia.
• Prior curettage.
• Elevated Prenatal Screening MSAFP Levels
• Painless bleeding is the most characteristic event
with placenta previa.
• Sudden onset, painless, apparently causeless and
• Bleeding usually does not appear until near the end
of the second trimester or later, but it can begin even
before mid pregnancy.
• The size of the uterus is proportionate to the period of
• The uterus feels relaxed, soft and elastic without any
localized area of tenderness.
• Persistence of malpresentation like breech or transverse
or unstable lie is more frequent.
• The head is floating
• Fetal heart sound is usually present, unless there is major
separation of the placenta
• Vulval inspection: Only inspection is to be done to note
whether the bleeding is still occurring or has ceased,
• In placenta praevia, the blood is bright red as the
bleeding occurs from the separated utero-placental
• Women with a previa are managed depending on
their individual clinical circumstances.
• The three factors that usually are considered include
fetal age and thus maturity;
bleeding and its severity
If the fetus is preterm and there is no persistent
active bleeding, management favours close
observation in an obstetrical unit.
• After bleeding has ceased for about 2 days and the fetus
is judged to be healthy, the woman can usually be
• In other cases, prolonged hospitalization may be ideal.
• For women who are near term and who are not
bleeding, plans are made for scheduled cesarean
• Timing is important to maximize fetal growth but to
minimize the possibility of antepartum hemorrhage
• A National Institutes of Health workshop concluded that
women with a previa are best served by elective
delivery at 36 to 37 completed weeks
• Practically all women with placenta previa undergo
• Following placental removal, there may be
uncontrollable hemorrhage because of poorly
contracted smooth muscle of the lower uterine
ADMISSION TO HOSPITAL
• All cases of APH, even if the bleeding is slight or
absent by the time the patient reaches the hospital,
should be admitted.
• TREATMENT ON ADMISSION
TREATMENT ON ADMISSION
• IMMEDIATE ATTENTION:
• Overall assessment of the case is quickly made as
1. Amount of the blood loss — by noting the general
condition, pallor, pulse rate and blood pressure
2. Blood samples are taken for group, cross matching
and estimation of haemoglobin
3. A large-bore IV cannula is sited and an infusion of
normal saline is started and compatible cross matched
blood transfusion should be arranged
4. Gentle abdominal palpation to ascertain any uterine
tenderness and auscultation to note the fetal heart rate
5. Inspection of the vulva to note the presence of any
• Admit, bed rest
• Hb, hct, type & screen
• No D/C, unless transport
• Deliver- @ 37/40
- Severe bleed
• Bed rest
• Hb, hct, type & screen
• Deliver if severe bleed
• NVD-low lying placenta
- > 60% success
• C/S-Grade 2-4
COMPLICATIONS OF PLACENTA PREVIA
• During pregnancy—
with varying degrees of
Death due to massive
hemorrhage during the
or postpartum period.
• During labor
• Early rupture of the
• Cord prolapse due to
abnormal attachment of
• Slow dilatation
• Intrapartum hemorrhage
• Increased incidence of
• Postpartum hemorrhage
Placenta previa is one of the inherent obstetric hazards
and in majority the cause is unknown.
Thus to minimize the risks, the following guidelines are
• — Adequate antenatal care to improve the health status
of women and correction of anemia.
• — Antenatal diagnosis of low lying placenta at 20
weeks with routine ultrasound needs repeat ultrasound
• — Examination at 34 weeks to confirm the
• — Significance of “warning hemorrhage” should not
• from the latin abruptio placentae - “rending
asunder of the placenta,”
• Is a form of antepartum haemorrhage occuring due
to premature separation of the normally implanted
• significant cause of perinatal mortality (15–20%)
and maternal mortality (2–5%).
a. Concealed: the blood is retained between the
membranes and the decidua(rare)
b. Revealed: the blood insinuates downwards
between the membranes and the decidua (
c. Mixed: some part of the blood collects inside
(concealed) and a part is expelled out (revealed)
• Unknown in the majority of cases
• there is an association with defective trophoblastic
invasion, as with pre-eclampsia and FGR.
• Other associations include direct abdominal trauma,
high parity, uterine over-distension, sudden
decompression of the uterus.
• initiated by hemorrhage into the decidua basalis
• expands to cause separation and compression of the
• depending upon the extent of pathology, there may
be degeneration and necrosis of the decidua basalis
as well as the placenta adjacent to it.
• Most blood in the retroplacental hematoma in
a nontraumatic placental abruption is
• This is because hemorrhage is caused by
separation within the maternal decidua, and
placental villi are usually initially intact.
Clinical features and diagnosis
• Most women with a placental abruption have
sudden-onset abdominal pain, vaginal bleeding,
and uterine tenderness( usually tense=‘woody
• Bleeding may be concealed so its absence does
not preclude the diagnosis.
• Large abruptions may present with maternal
shock and/or collapse.
• Depending on the size and location of the
abruption, the fetus may be dead, in distress or
• Diagnosis is usually made on clinical grounds.
• Sonography has limited use because the
placenta and fresh clots may have similar
• negative findings with sonographic
examination do not exclude placental
• Hypovolemic shock
• Consumptive coagulopathy
• Fetal death
• Couvelaire uterus
Differs depending on gestational, maternal and fetal
• Call for help
• Talk to the patient
• Assess ABCs – manage accordingly
• Insert two large bore cannulae
• Blood grouping + xmatching
• DIC screen- CBC, bleeding and clotting time,d-
• Asssess fetal well being
• Placental localization
• Plasma expanders
• Blood transfusion/FFP/platelets
Placental abruption - mgt
Fetus viable, any gestation age: emergency c/s
• Fetal death confirmed on ultrasonography, no
continuing bleeding: do EUA to rule out
placenta previa. If no previa, do ARM,
augment labour, AIM for vaginal delivery
Placental abruption - mgt
Any gestation age, fetus dead, continuing severe
• Resuscitate pt, correct volume deficit Correct
anaemia, preferably with fresh blood products
• check for and correct coagulopathy,
• deliver by c/s if coagulopathy corrected or absent
Vaginal delivery is a much safer and preferred option
for delivery in case fetus is dead (not viable)
• Confirm fetal death by ultrasonography, not
(due to uterine spasm which may make fetal heart