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APH
• Bleeding from or into genital tract after the age of viability of fetus or
after 28 weeks of pregnancy before the onset of labor.
APH
Unexplained Extra
Placental
70%
25% placental
5%
Placenta Abruptio
Cx Cx Varicose Local
Previa Placentae
polyp cancer vein trauma
35% 35%
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• Placenta previa = Complete or
partial implantation of placenta
in lower uterine segment.
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Placenta previa
• Predisposition factors:
• Multiparity
• Elderly>35yrs
• Uterine scars
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Pathology
• Placenta may be adherent to less decidualised lower
segment.Increased degeneration n infarction
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Types of placenta
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Types of placenta
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Types of placenta
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Types of placenta
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Types of placenta
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Types/Grades of placenta previa
1- Low lying
2- Marginal
– 2A- Anterior
– 2B- Posterior
3- Eccentric
4- Central
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1- Low lying
2- Marginal
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3- Eccentric
4- Central
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2- Marginal
2A- Anterior
2B- Posterior
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Cause of bleeding
Rate of placental growth slows down
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C/F:
1. Sudden, Painless, Causeless, Recurrent bleeding
2. Anemia proportionate to blood loss
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Diagnosis
1. USG:
– TAS
– TVS
– Color doppler flow study
2. MRI
3. MRI>TVS>TAS
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D/D:
1. Abruptio placentae
2. Vasa previa
3. Cx polyp/carcinoma
4. Circumvalate placenta
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Placenta previa Abruptio placentae
Nature of bleeding Painless, Causeless, Painful, with PET/Trauma,
Recurrent Continuous
Character of Revealed Concealed, Revealed or Mixed
C/F bleeding
Anemia Proportionate Out of proportion
PET Not relevant In 1/3rd
Uterine ht. Proportionate Bigger
Feel of uterus Soft n relaxed Tense, tender n rigid
O/E
Malpresentation Common Unrelated
FHS Usually +ve Usually -ve
Placentography In lower segment In upper segment
P/V Placenta can be felt Placenta can’t be felt
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Complication
Maternal:
Fetal:
1. Bleeding and shock
1. Prematurity
2. Malpresentation
2. Asphyxia
3. Cord prolapse
3. IUFD
4. Increased operative
intervention 4. Congenital
malformation
5. PPH
6. Retained placenta
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Mortality factor
Maternal:
Fetal:
1. Prematurity
2. Asphyxia
3. Congenital malformation
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Treatment
1. Assess general condition
5. No P/V examn
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Watchful T/T
Indication: Management:
• Preterm<37weeks • Steroid
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Active T/T: Vag.del/CS
1. >37weeks
2. Excessive bleeding
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Vaginal delivery: CS:
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Abruptio placentae
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Abruptio placentae
Types of bleeding:
2. Concealed bleed
3. Revealed bleed
4. Mixed
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Retroplacental clot (RPC)
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Concealed bleed
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Revealed bleed
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Mixed bleed
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Cause
1. Idiopathic
2. Advanced age >35yrs/Grandemultigravida
3. Smoking/Cocaine abuse
4. PET: Vasospasm Endothelial injury
Extravasations
5. Trauma: Assault/RTA,ECV, Amniocentesis
6. Sudden uterine decompression: Polyhydramnios,
PROM, 2nd twin
7. Short cord
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Amniocentesis: proper n faulty
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Pathogenesis
• Bleeding into decidua basalis
• Decidual hematoma
• Separation of placenta
• Degeneration n necrosis of decidual plate n adjacent
placenta
• Retroplacental hematoma formation
• Confined behind placenta
• Escapes between membrane n uterine wall
• Access to amniotic cavity after rupturing membrane
• Massive intravasation into uterine muscle
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Couvelaire uterus
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Complication
Maternal: Fetal:
• PPH
• Death
• Puerperal sepsis
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Coagulation profile
1. CT: Increased
2. PTT: Increased
5. FDP: Increased
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Clinical classification
Bleeding Uterus Shock FHS/Fetus DIC/Renal
failure
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C/F: Depends on amount of bleeding n separation
Revealed Concealed Mixed
Pain Continued discomfort or pain Intense continuous pain
Bleeding Dark colored blood Dark colored blood
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Amount of bleeding
1. Mild bleed: 3. Severe loss:
– <15% loss
– Asymptomatic – 30-40% loss
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D/D
1. Ruptured uterus
4. Intestinal/Appedicular perforation
5. Acute hydramnios
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Rupture of Uterus:
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Management
• Revealed type: ARM + Augmentation
1. In labor
2. Term not in labor
3. Preterm not in labor but continuous bleeding
• Concealed type:
1. ARM + Augmentation
2. If failed or complicated CS
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