2. Outlines
Overview of the anatomy of
placenta
Introduction about late bleeding in
pregnancy
Causes of APH
Placenta prenia
Placenta abruptio
Uterine Ruputre
Vasa previa
8. PLACENTA AT TERM
• Length—22cm
• Weight- 500gms(200-800gms)
• Thickness- 2-2.5 cm
• volume-30,000 cubic mm
9. PLACENTA con…
MATERNAL SURFACE
Fine granular,15-30
lobes
called cotyledons
separated by placental
septa
FETAL SURFACE
Smooth, covered by
amnion, shiny,
transparent, mottled
appearance, vascular.
Umbilical cord is
attached
10. Functions of Placenta
1.Organ of respiration
2. Nutrition
3. Excretion
4. Immunological protection
5. Protective barrier
6. Production of hormones
human chorionic gonadotropin(HCG)
estrogen
progesterone
somatomammotropin (human placental
lactogen)----
11. INTRODUCTION
CAUSES OF BLEEDING IN LATE PRENANCY
The four conditions that account for most cases of
serious or life-threatening hemorrhage are
Placenta previa,
Placental abruption,
Uterine scar disruption and
Vasa previa.
Non-emergent causes of bleeding include
cervical dilatation during normal labor, which is
commonly accompanied by a small amount of
blood or blood-tinged mucus (bloody show).
12. INTRODUCTION con…..
Many pregnant women experience spotting or
minor bleeding after sexual intercourse or a
digital vaginal examination.
Cervicitis,
cervical ectropion,
cervical polyps, and cervical cancer
are other possible causes of minor bleeding.
13. ANTEPARTUM HEMORRHAGE
Defi.
APH is defined as any bleeding from the genital
tract after the 20th week of gestation but before
the onset of labour.
It affects 4% of all pregnancies.
It is associated with increased risks of fetal
and maternal morbidity and mortality.
14. DEFINING THE SEVERITY OF APH
Minor Haemorrhage – blood loss less than 50
mL that has settled
Major Haemorrhage – blood loss of 50 – 1000
mL, with no signs of clinical shock
Massive Haemorrhage – blood loss greater
than 1000 mL and/or signs of clinical shock
16. 1.Placenta Previa
• Defined as the abnormal implantation of the
placenta in the lower uterine segment or
o This is where a placenta is inserted partially or
wholly in the lower uterine segment.
Placenta previa occurs when the placenta
implants in a location overlying or in close
proximity to
the internal cervical os
17. Placenta praevia
Grades:
•Grade 1: the placental edge is in the lower
uterine segment but does not reach the internal
os (low implantation).
•Grade 2: the placental edge reaches the internal
os but does not cover it.
•Grade 3: the placenta covers the internal os
when it is close and is asymmetrically situated
(partial).
•Grade 4: the placenta covers the internal os and
is centrally situated (complete) .
20. • Placenta praevia of Clinical presentation
Bleeding: usually mild but it could be severe;
recurrent,
painless.
Soft uterus.
Normal fetal heart rate (unless there is severe
bleeding or associated abruption).
High presenting part.
Fetal malpresentation
(breech/transverse/oblique).
N.B Vaginal examination is contraindicated.
21. Clinical presentation of PP con….
It characteristically presents with unprovoked and
repeated painless vaginal bleeding.
Severe blood loosing leads to several shock signs
such as paleness
weak and quick pulse
and hypotension.
22. Diagnosis of PP
•Clinical presentation.
History
Sign and symptoms
Ultrasonography
U/S: Transvaginal is better than
transabdominal; the woman does not need full
bladder and can determine the placental edge in
posterior PP.
•MRI: expensive.
24. Complications of Placenta praevia
Preterm delivery.
•Preterm premature rupture of membranes.
•IUGR (repeated bleeding).
•Malpresentation; breech, oblique, transverse.
•Fetal abnormalities
•↑ number of C/S.
•Morbid placenta
•Postpartum haemorrhage
25. Placenta Previa Management
Admit to hospital
NO VAGINAL EXAMINATION
Vaginal delivery: placenta 4.5 cm from the
internal os, low head, no bleeding.
Consider examination in theatre if in doubt .
C/S (of choice): grade 3, 4, placenta within 2cm of
the internal os, high head, bleeding, presence of
the added factors.
26. Placenta Previa Management con…
maternal & fetal monitoring
large bore IV & crystalloid & hemodynamic
stability & adequate urine out put .
Type a cross _ match for four units of packed
blood cells.
maternal cardiac monitor: BP &PR every 15
min/h
27. Placenta Previa Management con…
Urine output : hourly with Foley catheter
Laboratory monitoring
HB-HCT /q 4 -6 h
Serum electrocytes & indexs of renal
function:every 6-8 / h
PT _ PTT _ CBC _ PLT
28. Indication of cesarean section in PP
Complete previa
Fetal head not engaged
Non reassuring tracing
Brisk or persistence bleeding
Regional anesthesia is safe for mother
29. 2.Abruptio placenta
A.P : premature separation of a normally
implanted placenta after 20 weeks but prior to
delivery of infant or
It is the separation of the placenta from its site of
implantation before delivery of the fetus.
31. Classification of AP
Grade 0. Asymptomatic, small retroplacental clot
after delivery
Grade 1.
External vaginal bleeding
Uterine tetany and tenderness may be present
No signs of maternal shock
No evidence of fetal distress
32. …
Classification con…..
Grade 2. *External vaginal bleeding may or may
not be present
Uterine tender and tetanic.
No signs of maternal shock
Signs of fetal distress present
Grade 3. *External bleeding may or may not be
present
Marked uterine tetanic
Maternal shock
Fetal death or distress
Coagulopathy
35. Diagnosis of Placenta Abruption
The diagnosis is
sign and symptoms/clinically/
U/S Ultrasonography
: is to •Confirm fetal viability, assess fetal growth &
normality, measure liquor, do umbilical artery
Doppler velocities.
37. Management of Placenta Abruption
Principle of management:
1.Early delivery
2.Adequate blood transfusion.
3.Adequate analgesia.
4.Detailed maternal and fetal monitoring.
Coagulation profile develop DIC).
C/S: distressed baby ,severe bleeding, alive baby &
not in advanced labour.
Vaginal delivery: very low gestation, dead baby,
cervix is fully dilated.
Conservative: small abruption, well mother and
fetus, if the gestational age < 34, give steroids.
38. Management of Placenta Abruption con…
Anticipate PPH.
In cases of previous CS, discuss hysterectomy.
Treatment of consumptive coagulopathy
1. Supplement of coagulation factors: fresh blood,
frozen blood plasma, fibrinogen, blood platelet.
2. Heparin: high coagulation
40. 3. UTERINE RUPTURE
Uterine rupture is a serious event during child birth
by which the integrity of myometrial wall is
breached secondary to previous cesarean section
delivery requires emergency laparotomy
Previous cesarean incision is the most common
etiology for uterine rupture.
Other causes includes
previous uterine curettage or
perforation,
inappropriate oxytocin usage
trauma
41. UTERINE RUPTURE con…
Conditions that predispose to uterine scar disruption
include previous uterine surgery (e.g. myomectomy)
that involves the full thickness of the myometrium,
congenital uterine anomaly,
uterine overdistension,
gestational trophoblastic neoplasia,
maternal obesity.
Polyhydraminous
42. UTERINE RUPTURE con….
Conditions present during delivery that
predispose to uterine rupture include:-
fetal anomaly
vigorous uterine pressure
difficult manual removal of the placenta
abnormalities of placental implantation
43. UTERINE RUPTURE con….
Clinical Presentation
The classic presentation for symptomatic
significant uterine rupture includes
vaginal bleeding
pain
cessation of contraction,
absence of fetal heart tones
easily palpable fetal parts through the maternal
abdomen
profound maternal tachycardia and
hypotension.
44. Management of uterine rupture
Intravenous fluids,
Discontinuation of oxytocin
Oxygen administration
Blood transfusion
Emergent cesarean uterine repair or
hysterectomy
45. 4
.
4.VASA PREVIA
Definition
Vasa previa refers to fetal vessels running
through the membranes over the cervix and
under the fetal presenting part, unprotected by
placenta or umbilical
cord.
Vasa previa is the velamentous insertion of the
umbilical cord into the membranes in the lower
uterine segment resulting in the presence of fetal
vessels between the cervix and presenting part.
46. Clinical importance of
Vasa previa is a condition which is undiagnosed, is
associated with a perinatal mortality of
approximately
60%.
the fetal blood volume is only about 80–100
mL/kg, loss
of even small amounts of blood could prove
disastrous
to the fetus.
Pressure on the unprotected vessels by the
presenting part could lead to fetal asphyxia and
death.
47. Diagnostic Approach
Vasa previa is most commonly diagnosed when
rupture of the membranes is accompanied by
vaginal
bleeding and fetal distress or death.
The diagnosis is often confirmed only when the
placenta is inspected after delivery.
48. Diagnosis con…
The diagnosis of vasa previa is considered if
vaginal bleeding occurs upon rupture of the
membranes.
Concomitant fetal heart rate abnormalities.
Ideally, vasa previa is diagnosed antenatally by
US with color flow Doppler.
51. Associated Conditions/Risk factors
Low-lying placenta.
Bilobed placenta. .
Succenturiate-lobed placenta.
Multiple pregnancies.
Maternal history of uterine surgery
53. Vasa Previa - Diagnosis in the Acute Setting
Clinical scenarios suggesting vasa previa:
-significant bleeding at the time of membrane
rupture
-fetal heart rate abnormalities associated with
vaginal bleeding
-palpable vessels on vaginal examination
54. Antenatal Management
Consider hospitalization in the third
trimester to provide proximity to
facilities for emergency cesarean
delivery.
Fetal monitoring to detect compression
of vessels.
Antenatal corticosteroids to promote
lung maturity.
Elective cesarean delivery at 35 to 36
weeks of gestation
Immediate C/S in it is detected on labor.
