1. ANTEPARTAM
HAEMORRHAGE

IMMEDIATE DELIVERY

2. Significant bleeding from
th
birth canal after 24 week
of gestation till de.

3. CAUSES
PLACENTAL



Placenta Praevia
Placental Abruption
Vasa Praevia
NON PLACENTAL




Labour (Heavy show )
Uterine rupture
Local / Non obstetrical
Cervicitis
Polyp
Lacerations
Bleeding Disorders
Conginital
acquired

4. PLACENTA PRAEVIA
Implantation of
placenta in lower
uterine segment


Partial
Complete

5. DEGREES
MINOR
MAJOR
M
a
j
o
r

6. ETIOLOGY
Scarred or poorly vascularized endometrium
 Advancing age
 Multiparity
 Previous uterine surgeries
caeserian, myomectomy, D&C,
ERPC

7. Bleeding
Mechanical Seperation
Rupture of
Cervical dilalatation
Venous lakes
effacement
intravaginal
manipulation

8. DIAGNOSIS
Presenting complaints
Painless vaginal bleeding
Mild
Moderate
Profuse
SHOCK

9. CLINICAL FINDINGS

Pallor

Vital Signs
Stable
Unstable

Hemorrhage
Abdomen
Soft , relaxed , non tender
Lie
transverse/oblique
Presenting part
high
Fetal hearts
present

10. DIAGNOSIS
 History
 Clinical
examination
 Ultrasonography
 Colour Doppler
 C T scan
 MRI

11. MRI
USG

12. MANAGEMENT
Depends
Amount of hemorrhage
Gestational age

13. MANAGEMENT
 Airway
 I/V Line
 Fluids
16 / 18 Gauge cannula
crystalloids / colloids
 Blood transfusion /FFP
 Indwelling urinary catheter
 Inform Senior Obstetrician
 Avoid pelvic examination

14. MANAGEMENT
 Investigations
 Blood grouping & cross match
 Complete blood counts
 Coagulation profile (Platelet count,
APTT,PT,FDPs)
 Ultrasound scan ( full bladder )

15. EXPECTANT MANAGEMENT
(Preterm fetus)

AIM

Haemodynamically stable with mild bleeding and
no uterine contractions
Close observation vital signs & vaginal bleeding
Correction of anaemia
Steroids for fetal lung maturation
Counseled and prepared for Caeserian section




To prolong pregnancy till Term

16. IMMEDIATE DELIVERY
 Caeserian Section /
Hysterotomy
Haemodynamically unstable.
Profuse vaginal bleeding.
After 37 completed weeks of gestation.
If patients has palpable uterine contractions.
SURGEON / ANAESTHETIST
GENERAL ANAESTHESIA
SENIOR

17. COMPLICATIONS
 Maternal
Anaemia
Shock
Complications of surgery & Anaesthesia
Post Partam hemorrhage
Maternal mortaliy
 Fetal
Morbidity / Mortality

18. PLACENTAL ABRUPTION

Bleeding following
premature
separation of a
normally situated
placenta.

19. AETIOLOGY
Advance age
 Multiparity
 Poor nutritional status
 Past History ( recurrence 15 –20% )
 Hypertention
 Abdominal Trauma
 Smoking
 Uterine Decompression ( polyhydramniose , Twins )
 Chorio amnionitis
 Fibroid, Folic Acid deficiency


20. PATHOPHYSIOLOGY
Local Vascular injury (Pre eclampsia)
Haematoma Formation in
Decidua Basalis
Separation of Placenta
Venous Engorgement
Abrupt
uterine venous
pressure

21. Revealed
Concealed

22. SIGNS & SYMPTOMS
Small separation of
the placenta :


Vaginal bleeding
±
Mild pain or discomfort.
Abdominal pain.
Back pain

Vital signs
Stable
Abdomen
Soft/ Tenderness ±

Foetus

uncompromised

23. Large separation of the placenta:

Heavy vaginal bleeding.

Severe pain in the lower abdomen or back.

Hard, tender abdomen.

Shock (tachycardia, fall in BP rapid breathing, and dizziness).

Fetal distress;

Coagulopathy [DIC]) – Thromboplastine from
fetal heart sounds inaudible.
placenta is
released into the mother's circulation causing blood clotting
defects.

Renal cortical necrosis
----
Anurea

24. EXAMINATIOBN

GPE
depends upon Hemorrhage.
 Pallor
 Pulse
 B.P

ABDOMINAL EXAMINATION
 Fundal height larger than dates
 Hard and tender
 Fetal Part and FHS

PELVIC EXAMINATION
Exclude placenta praevia by USG
P/S examination
P/V examination

25. INVESTIGATIONS
 Blood grouping.
Blood Complete picture.
 Coagulation Profile,
Platelet counts, PT, APTT, FDPs
Serum Fibrinogen
 Renal Profile
 Viral Serology


26. INVESTIGATION
: Ultrasonography (Useful but not reliable )

27. MANAGEMENT
 I/V access






Two large bore cannulas.
Save blood for cross match/ investigation(20 ml)
I/V fluids
Crystelloids /colloids
Indwelling urinary catheter
Analgesia
Blood transfusions / Fresh frozen plasma
( Screened & Cross matched )
Vital Signs monitoring

28. MANAGEMENT

Expectant :
Mild marginal Abruption with stable mother &
Strict maternal & fetal monitoring.

fetus .
Vaginal Delivery:
If degree of separation is limited ,
revealed hemorrhage
After amniotomy & oxytocin infusion short labour is
expected.
Dead fetus
No complications

29. MANAGEMENT
 Caeserian
Section:
Maternal Indications
Uncontrollable revealed hemorrhage
Rapidly expanding concealed hemorrhage
Vaginal delivery is not imminent
Fetal Indications
Alive fetus with reasonable chances of survival

30. COMPLICATIONS
 MATERNAL
Shock (Hypovolemic, / Neurogenic )
DIC
Renal failure
PPH ( Couvelier uterus ,uterine atony , DIC )
Maternal mortality ( 0.5% --- 5 % )
 FETAL
Perinatal mortality ( 50 % --- 80 % )

31. FOLLOW UP
 Follow up visits
 Contraception
 Counsel for chances of recurrence in next
pregnancy ,
 early antenatal booking