Topic of Obstetrics and gynecology from Beckman 7th edition

1. ANTEPARTUM
HEMORRHAGE
 Bleeding from or into the genital tract occurring
from 24th weeks of pregnancy and prior to the birth
of the baby
(third trimester bleeding)
Topic presentation by:
Dr. Noria Afghan
Intern , MBBS graduate 2016

2.  It complicates 3-5% of pregnancies & is a leading
cause of perinatal & maternal mortality world wide.
 May be a sequelae relating to poor placental
function, IUGR & premature delivery.
 1/5 of every preterm babies are born in association
with APH & known association of APH with cerebral
palsy ( CP) can be explained by preterm delivery

3. CAUSES OF ANTEPARTUM HEMORRHAGE
Placental bleeding
70%
Unexplained 20%
or
Indeterminate
(excluding
placental
bleeding and local
lesions
Extra placental causes 5%
local cervico-vaginal lestions:
-cervical polyp
-carcinoma cervix
-varicose vein
-local trauma
Placenta
previa
35%
Abruptio
placenta
35%

4.  Bleeding ranges from spotting to life-threatening hemorrhage.
 Intercourse, trichomonas cervicitis, and recent pelvic examinations
are common precipitants of spotting because the cervix is more
vascular and friable in pregnancy.
 Bleeding from hemorrhoids may be mistaken for vaginal bleeding,
but the difference is easily distinguished by examination.
 At term, a woman’s total blood volume increases by about 40%
and her cardiac output by about 30%.
 About 20% of this term cardiac output is shunted to the pregnant
uterus, so significant bleeding can be quickly catastrophic.
 Severe hemorrhage is much less common than spotting but
remains a leading cause of maternal and fetal morbidity and
mortality.

5.  The paradigm is that painful bleeding usually
means placental abruption, whereas painless
bleeding usually means placenta previa.
 Other important causes of bleeding include preterm
cervical change, preterm labor, and uterine rupture .
 In many cases, bleeding remains unexplained or is
attributed to local lesions.
 It is also important to consider bleeding from other
organs, such as hemorrhoids from the anus or
gross hematuria from acute cystitis

6.  A common finding in pregnancy is a significant ectropion
of the cervix, particularly among women with a history of
using oral contraceptives.
 The ectropion is an area on the ectocervix where columnar
epithelium has been exposed to vaginal acidity due to eversion
of the endocervix.
 The ectropion may appear reddened and “raw looking,” and
mild bleeding can occur.
 These findings may raise concerns about cancer, but they are
actually benign.

7. CAUSES OF BLEEDING IN THE SECOND HALF OF
PREGNANCY
 Hemorrhoids
 Vulva
 Varicose veins
 Tears or lacerations
 Vagina
 Cervix
 Polyp
 Ectropion
 Glandular tissue (normal), which is friable
 Severe cervicitis
 Carcinoma
 Intrauterine
 Uterine rupture
 Placenta previa
 Placental abruption
 Placenta accreta, increta, or percreta
 Vasa previa

8. FOCUSED HX & PHYSICAL EXAM ARE CRUCIAL
 How much Bleeding (quantity)
 Associated symptoms eg.abdominal pain or contractions
 Triggering factors (trauma, hypertension)
 Baby movement
 Personal & family Hx of bleeding disorders (von Willebrand )
 Recent pap smear (carcinoma )
 Vitals (PR, BP) ((blood loss >10-15%))
 Inspect for petechiae , bruising (bleeding disorder &
coagulopathy)
 Uterine palpation(soft, tender, firm), signs of hemiperitoneum.
 FHR auscultation / US(fetal presentation, placental position)
 Inspect the vulva & Speculum vaginal examination to exclude
cervical & vaginal causes
*** Bimanual pelvic exam should not be done until placental
position is confirmed by US
 Full blood count , coagulation profile
 Cross-match blood (4-6 units in suspected placenta pravia)

9. BLEEDING
 Significant bleeding is an obstetric emergency requiring
immediate management, including ongoing monitoring of vital
signs and sufficient large-bore IV lines for the rapid
administration of crystalloid fluid, blood, and blood products.
 Blood studies should include CBC, coagulation profile, and a
type and cross match for four units.
 Regardless of the amount of bleeding, blood type and screen
are necessary.
 Patients who are Rh D-negative may require immunoglobulin
to protect against the Rh D antigen, and a Kleihauer-Betke
test to determine fetomaternal bleeding (to determine the
amount of immunoglobulin needed once the bleeding has
been controlled .)

10.  Staff should be ready for delivery, which is facilitated by
having a rapid response system in place for such
emergency situations.
 Most likely, this will require an emergency caesarean
delivery and, possibly, a general anesthetic.
 If the bleeding is not sufficient to warrant emergency
delivery and/or the fetus is preterm, then blood studies
should be continued and IV access maintained.
 An ultrasound examination should be performed to
assess placental location and condition of the fetus.
 The patient should be admitted to the hospital to allow
for close monitoring.
 Vaginal hemorrhage in the third trimester is one of the
few real obstetric emergencies.

11. PLACENTA PREVIA
When the placenta is implanted partially or
completely over the lower uterine segment
(over and adjacent to the internal os)

12.  About 75% of women with placenta previa will have
at least one episode of bleeding.
 On average, this episode occurs at around 29 to 30
weeks of gestation.
 The incidence of placenta previa earlier in
pregnancy (approximately 24 weeks) is 4% to 5%
and decreases with increasing gestational age.

13. AETIOLOGY
 Dropping down theory- fertilized ovum
drops down and is implanted in lower
segment.
 Persistance of chorionic activity- in the
decidua capsularis and its subsequent
development into capsular placenta
which comes in contact with the
decidua vera of the lower segment.
 Defective deciduaresults in
spreading of chorionic villi over a wide
are in the uterine wall to get
nourishement.
 Big surface area for the placenta
(twins)

14. RISK FACTORS
 Increased maternal age >35 years
 Multiparity
 Previous placenta previa (risk 4-8%)
 History of previous c-section or any other scar in
the uterus
 Prior curettage
 Placental size and abnormality
(succenturiate lobe)
 Smoking

15. TYPES
 Type I (low lying)- the major part of placenta is attached to
upper segment and only the lower margin encroaches the
lower segment but not up to the os.
 Type II (marginal)- the placenta reaches the margin of IO
but does not cover it.
 Type III (incomplete/partial central)
the placenta covers the internal os partially
(covers the IO when closed, but not entirely do so when fully
dilated)
 Type IV (central/total) –completely covers the IO even
after it is fully dilated.
 Partial & low-lying PP will often resolve by 32 -35 weeks of
gestationStretching & thinning of the lower uterine segment
which move the placenta away from the os (not upward migration of
the placenta)
 Mild degree- I and II anterior
 Major degree- II posterior, III and IV

16. CAUSES OF BLEEDING
 Placental growth slows down in later
months
 Lower segment progressively dilates
 The inelastic placenta is sheared off the
wall of vessels episode of bleeding
 However, the separation can be
provoked by trauma.
 The blood is almost always maternal.

17. CLINICAL FEATURES
SYMPTOMS
 Only symptom is unprovoked vaginal bleeding.
 Classical features- sudden onset, painless
apparently causeless and recurrent
 Slight bleeding- “warning haemorrhage” in 2nd tri
 Unrelated to activity- often occurs in sleep
 50% cases Bleeding occurs before 36 weeks and
earlier is more likely in major degrees.
 No bleeding in central type until labour starts.
 **Absence of pain is regarded as a distinguish
factor between placenta previa and placental
abruption

18. CLINICAL FEATURES
SIGNS
 Signs of anemia
Abdominal examination:
 Size of uterus proportionate to GA
 Uterus feels relaxed, soft and elastic without
tenderness
 Persistence of malpresentation, increased
frequency of twin pregnancy.
 The head is floating in contrast to GA.
 FHS is present.
 Vulval inspection to check the character of the
blood bright red
 PVE is contraindicated outside OT

19. CONFIRMATION OF DIAGNOSIS
 Painless and recurrent vaginal bleeding in the 2nd
half of pregnancy should be considered as placenta
previa unless proven otherwise.
 US is the initial procedure to confirm/rule out.
1-Sonography
TAS -high accuracy after 30th week
TVS- 100% accurate than TAS
TPS
colour doppler flow study- prominent
venous flow in the hypoechoic area
2-MRI
CLINICAL
-internal examination
-direct visualization
during c-section
- Examination of placenta
after Vaginal delivery
-tongue shaped thin segment
of placental tissue, rent on
membranes on margin, abnormal
attachement of cord.
PLACENTOGRAPHY
(Localization of placenta)

20. DIFFERENTIAL DIAGNOSIS
 Abruptio placentae
 Local cervical lesions (polyps, carcinoma)
 Placenta accreta/increta/percreta
 Vasa previa

21. MANAGEMENT
 PREVENTION
 Adequate antenatal care
 Antenatal diagnosis of low lying placenta at 20 weeks with US
and repeat US at 34weeks to confirm Dx
 Significance of warning hemorrhage should not be ignored.
 Colour flow doppler US to detect any placenta accreta.
At HOME
• Patient put to
bed
• To assess the
blood loss
• Quick abdominal
examination
• Vaginal
examination
must not be
done
TRANSFER TO
HOSPITAL
• Equipped
hospital with
blood
transfusion, ER-
cesarean and
NICU
• IV dextrose-
saline started
ADMISSION TO
HOSPITAL
• All cases of APH
even if slight or
absent

22. All APH are to be admitted
• general and Abd ex along with vulval
inspection
• clinical assessment of blood loss
• blood samples (Hb%,Hct, ABO, Rh group)
• Resuscitation ( IV NS/transfusion using
wide bore canula)
• localization of placenta (US)
EXPECTANT TREATMENT ACTIVE INTERFERENCE
• no active vaginal bleeding
• preg <37 weeks
• good maternal status
(Hb≥10gm%, Hct>30%)
• good FHS
• fetal well being is assured
( CTG reactive)
• periodic inspection of the vulval pads
and fetal surviellance at interval of
2-3 weeks.
• supplementary hematinics and/transfusions
• Tocolysis MgSO4 if bleeding associated
with contractions
•dexamethasone
• Rh Ig to all Rh negative women.
• if bleeding continous
• preg >37 weeks
• patient is in labour
•FHS is absent
• gross fetal malformation

23. 37 weeks
US evidence
Placental edge is clearly 2-3cm
away from the IO
Placental edge within 2cm of IO
Or placenta previa > type I
No internal examintaion
Caesarean section
Internal examination in OT
ARM ± oxytocin
Satisfactory progress
of labour
-Bleeding continues
-no labour initiation
C-sectionVaginal delivery
• Delivery via caesarean birth is the rule unless
it occurs earlier in pregnancy
(i.e., at 20 weeks).
• In a patient whose condition is stable, at 36 to
37 weeks of gestation, following amniocentesis
to confirm fetal lung maturity.
• If lung maturity is not demonstrated, the
patient should be delivered at 37 to 38 weeks of
gestation.
• Earlier caesarean delivery may be required if
bleeding occurs or if the patient goes into labor.

24. MATERNAL COMPLICATION
pregnancy
• APH, with varying
degrees of shock
• malpresentation
• Premature labour
• Death due to massive
hmg
• Abnormal placental
adhesion to uterine wall
• Accreta : placental
tissue extends into
superficial layer of the
myometrium
 with a history of
CS delivery
• Increta: extends
completely through
the myometrium
• Percreta : extends
completely through
the myometrium to the
serosa, s.t to bladder .
Labour
• PROM
• Cord prolapse
• Slow dilation of cervix
• IPH-further sep
• Operative delivery
• PPH
• Retained placenta
• Risk of requiring
hysterectomy
following CS delivery
puerperium
• sepsis
• Subinvolution
• embolism

25. FETAL COMPLICATIONS
 LBW babies and repeated small bouts of hmg while
expectant treatment (chronic placental insufficiency
and IUGR)
 Asphyxia
 IUFD
 Birth injuries
 Congenital malformation

26. PLACENTAL ABRUPTION
(ACCIDENTAL HAEMORRHAGE)

27. PLACENTAL ABRUPTION
 refers to an abnormal premature separation of an
otherwise normally implanted placenta.
 There are various types of abruption, depending upon
the extent and region of separation.
 A complete abruption occurs when the entire placenta
separates.
 A partial abruption exists when part of the placenta
separates from the uterine wall.
 A marginal abruption occurs when the separation is limited
to the edge of the placenta
 A significant abruption
requiring delivery
occurs in 1% of births

28.  Abruption occurs when bleeding in
the decidua basalis causes separation
of the placenta and further bleeding.
 The classic presentation of abruption is
vaginal bleeding with abdominal pain.
 Smaller or marginal abruptions may present with
bleeding only.
 Concealed hemorrhage occurs when blood is
trapped behind the placenta and is unable to exit.
 Severe cases Painful uterine contractions, significant
fetal heart rate abnormalities, and fetal demise

29. RISK FACTORS
1. Maternal hypertension & preeclampsia
2. Multiple gestation
3. Advanced maternal age
4. Multiparity
5. Smoking , cocaine use
6. Chorioamnionitis
7. Trauma (major risk factor)
*FHR monitoring for a minimum of 4 hours is performed.
8. Previous abruption (  by 15-20 fold)
9. Elevated 2nd T. maternal serum AFP (10 fold)
due to possible entry of AFP into the maternal circulation
through the placental uterine interface

30. CLINICAL PRESENTATION
 Vaginal bleeding
 Common findings seen in 80% of cases (Dark red and non clotting)
 Abdominal pain
 Due to extravasations of blood into the myometrium (Couvelaire uterus)
 Uterine contractions and tenderness
 very frequent ,but S.T silent abruption described
 Sign of hypovolemic shock if the blood loss is significant (↑ PR, ↓BP,
peripheral vasoconstriction)
 Nausea, anxiety, restlessness & fainting attack
 Patients may present with absent or reduced fetal movements
 Palpation:
 In concealed & complete type
Tender uterus described as woody hard ,the uterus may be larger than
suggested gestation , the fetus is difficult to palpate
 In partial type
the uterine size is correlated with gestational age , the fetus may be
easily palpated .
 fetus may be unaffected or in distress or may be dead depending on
the size of abruption & area of placental separation

31.  Clinical grounds of
painful vaginal bleeding
in association with
uterine tenderness &
hyperactivity
 US demonstrate retro-
placental clots & to
exclude placenta preavia
 Abruption may occur in
the absence of US
findings.
 In some cases the
diagnosis may be only
made by inspection of
placenta after 3rd stage of
labour
 Careful maternal
haemodynamic monitoring
 Fetal monitoring
 fluid administration
 Serial evaluation of the
haematocrit & coagulation
profile
 Expectant management
(preterm patients with less severe
abruptions and minimal bleeding)
 Delivery of the fetus
 Vaginal (ARM & oxytoxin)
-fetal death
-mild to mod abruption with
no fetal distress or CI
 Cesarean
-fetal distress
DIGNOSIS MANAGEMENT

32. COMPLICATIONS
1. Maternal mortality 1%
2. Recurrence of APH in 10% & ↑to
25% after 2nd episodes
3. Hypovolemic shock -concealed
4. Acute renal failure- ATN
5. DIC- Abruption is the most
common cause of coagulopathy
in pregnancy
- low plt and fibrongen, prolonged
PT/aPTT
6. PPH -coagulation failure /Couvelaire
uterus-Rarely, blood penetrates the
uterus to such an extent that the serosa
becomes blue or purple in color.
7. Feto-maternal haemorrhage lead to
severe Rh sensitization in Rh
negative mother
- A Kleihauer-Betke or similar
test is essential
1. Perinatal mortality:
4.5 % - 60% depending on
neonatal facilities & closely
related to the gestational
age & associated
complication like HTN &
growth restriction
2. IUGR due to presence of
maternal hypertension & pre
eclampsia
3. Neonatal anemia
MATERNAL FETAL

33. DISTINGUISHING FEATURESPLACENTA PREVIA ABRUPTIO PLACENTAE
Clinical features
• nature of bleeding
• character of blood
• general condition
and anemia
• features of pre-
eclempsia
•Bleeding (duration)
• painless -causeless and recurrent,
always revealed
•bright red
• proportionate to visible blood loss
-------
Often ceases within 1-2 hr
• painful, cont.
revealed/concealed
•dark coloured
• out of proportion in
concealed or mixed
• present in one third cases
Continuous
Abdominal examination
• height of the uterus
• feel of uterus
• malpresentation
• FHS
•DIC
•Associated history
• proportionate
• soft and relaxed
• common, head is high floating
•Present
•Normal
•rare
• disproportionate(conceled)
• tense, tender and rigid
---------------
• absent in concealed.
TC then BC, Loss of
variability,Decelerations,
IUFD
Severe
•Trauma, hypertension
Multiple gestation
Polyhydramnios
Placentography US placenta in lower segment Placenta in upper segment
Vaginal examination Placenta felt on the lower segment Placenta not felt

34. VASA PREVIA

35. VASA PREVIA
 Passage of fetal blood vessels over the internal os below the
presenting part of fetus
 Velamontous insertion of the cord the vessels inserted into the
membrane between the amnion & chorion instead of into placenta
and are not protected by Wharton jelly or when there is a
succenturiate lobe across the os from the main placenta
 Incidence 1:2500 pregnancies
 Rupture of a fetal vessel occurs rarely in pregnancy, but the
risk is greatest with vasa previa
 In case of rupture of the membrane these vessels may be torn &
vaginal bleeding occur quickly lead to fetal death as fetal blood
volume is so small
 Blood loss is fetal blood
 Fetal mortality approaches 60% if rupture is not detected
before delivery.

36. DIAGNOSIS
 Apt test help distinguish fetal blood from maternal blood and may be
useful if the test is rapidly available and bleeding is worrisome but not
significant enough to warrant emergency delivery.
Blood + water hemolysis
Centrifuged Supernatent + sodium hydroxide  (fetal blood pink,
maternal yellow brown)
 TVS with color Doppler
 FHR abnormality seen
(fetal TC , BC & sinusoidal pattern indicate severe fetal
anemia)
 When performing ARM it is important to ensure that no pulsating
vessels are present
 In suspicion of vasa previa, fetus should be delivered as quickly as
possible usually by CS

37. UTERINE RUPTURE
 spontaneous complete transection of the uterus from the
endometrium to the serosa
 Most cases of uterine rupture occur at the site of a prior
cesarean delivery.
 partial rupture/uterine dehiscence
If the peritoneum remains intact
 With complete rupture and fetal expulsion into the
abdomen, fetal mortality ranges from 50% to 75%.
 Fetal survival depends in large part on whether a
substantial portion of the placenta remains attached to
the uterine wall until delivery is accomplished.
 Cesarean delivery is imperative to ensure neonatal
survival and decrease maternal morbidity