Bleeding from the genital tract after pregnancy reaches viability (24 weeks).
Classification: These may be classified as:
1. Bleeding in relation to the site of placental attachment: Account for 70% cases.
Accidental haemorrhage or abruptio placenta refers to bleeding resulting from premature separation of a normally situated placenta.
Placenta praevia refers to bleeding accruing from the premature separation of a low-lying placenta, wherein a part of it or the whole placenta occupies the lower uterine segment.
Rupture of vasa praevia or marginal sinus is a rare cause of antepartum bleeding.
2. Bleeding from any extraplacental site: Account for nearly 30% cases. Local causes: Rupture of vulval vein or varicosity, extra show in labour.
Vascular cervical erosion: Cervical polyp, cervical cancer, trauma.
Other causes: Uterine rupture, colporrhexis, coagulopathy.
3. Unclassified: Idiopathic causes.
If the patient is seen at home, general assessment of the condition only AVOID VAGINAL EXAMINATION, arrange for immediate transfer to hospital.
Institute resuscitative measures—intravenous infusion, sedatives, arrange for blood grouping and cross-matching and haemoglobin estimation, bleeding time and coagulation time.
Urgent sonography to determine location of placenta, viability of foetus.
Bleeding bouts of placenta praevia are often self-limiting. In case the bleeding episode comes under control, the foetus is alive and the gestational maturity <37 weeks, consider expectant line of treatment consisting of the following:
Total bed rest.
Monitor vital signs and FHR periodically.
Continue prenatal medication.
Prescribe a mild aperient to avoid constipation.
Consider antenatal steroid administration as a precautionary measure.
Be prepared to interfere if bleeding recurs, active management is also indicated after attaining 37 weeks gestational maturity.
Elective caesarean section is the procedure of choice in all cases with major degrees of placenta praevia, in patients with the dangerous posterior placenta wherein during the process of labour, the descending foetal head compresses the placenta and causes foetal hypoxia, when there is additionally a foetal malpresentation or any other risk factor like elderly maternal age, bad obstetric history.
Once the bleeding bout is controlled, a simple speculum examination helps to exclude a local cause like traumatic bleeding, vascular erosion, local pathology like a polyp or growth.
Accidental haemorrhage occurs commonly in patients suffering from hypertension or when there is history of trauma. Sonography will confirm the location of the placenta. If the haemorrhage is slight and revealed, the uterus relaxed and the foetus is alive, conservative management has a place, but in all cases of severe accidental haemorrhage, the principles of management centre around resuscitation, close observation, induction of labour if cervix is favourable, or terminate pregnancy with timely caesarean section to safeguard the mother against serious life-threatening complications like haemorrhage and shock, renal failure, and consumptive coagulopathy.
When the placenta is situated wholly or partially in the lower uterine segmenti it is termed as placenta praevia.
Incidence: Placenta praevia occurs in about 1 : 250-300 pregnancies.
Pathophysiology: As the pregnancy advances, there is a tendency to stretching and thinning out of the lower uterine segment in preparation of descent and engagement of the foetal presenting part, this causes alteration in the site of a low implanted placenta, the avulsion of the anchoring villi from the underlying decidua leads to disruption of the venous sinuses resulting in a bout of bleeding, such bouts tend to recur as painless bouts as pregnancy progresses,, since there is no obvious cause to which the patient can attribute the bleeding episode like trauma or fall, she perceives it as causeless. The initial bouts are often small and self-limiting.
Grades or types of placenta praevia
These could be described as follows:
Total placenta praevia or central placenta praevia: This is a condition in which the internal cervical os is completely covered by the placental tissue which is unlikely to move away to permit a vaginal delivery.
Type 1: The lower margin of the placenta dips into the lower segment ('low implantation')
Type 2: The placenta reaches the internal os when closed but does not cover it ('marginal')
Type 3: Part of the placenta covers the internal os
Type 4: Placenta overlies the internal os
Partial placenta praevia or incomplete central placenta praevia: In this condition the internal cervical os is partly covered by the placenta which may move away from the os and allow a normal vaginal delivery.
Marginal placenta praevia: In this condition the placenta covers the lower uterine segment, its edge reaching up to the margin of the internal os but does not cover it.
Lateral placenta praevia: A part of the placenta dips into the lower uterine segment, but its edge lies well away from the internal os, a vaginal delivery is easily possible.
In the condition of velamentous insertion of the cord, the foetal umbilical cord vessels run through the membranes overlying the internal os. If these give way during labour or during an amniotomy procedure, there will be a bout of bleeding of foetal origin.
The clinical manifestations are a triad of events of rupture of membranes, a bout of bleeding and sudden severe foetal bradycardia/ distress. If vasa praevia is suspected, Sanger's test for foetal haemoglobin will be positive on the blood discharge. Unless immediate delivery is accomplished, the foetus will rapidly die because of exsanguination.
Clinical features: The patient usually in the latter half of pregnancy, presents with a painless, causeless, often recurring bout of bleeding. The initial bouts have often been small and self-limiting. On examination the general condition is often stable. The uterine fundus corresponds to the expected gestational size, the uterus is relaxed, the presenting part may be high floating cephalic or there may be an abnormal foetal lie or presentation. The foetal heart sounds are regular and audible. If the duration of gestation is <37 weeks, consider hospitalization and institute expectant treatment. However, in case of emergency admission for severe bleeding, the patient will appear pale, there would be tachycardia, and postural hypotension. In extreme cases, the patient will be in hypovolaemic shock and manifest air-hunger. She is in need of immediate resuscitation followed by quick termination of the pregnancy. All measures for intensive care should be promptly instituted.
The conditions to be kept in mind in any case of antepartum bleeding will include:
Dehiscence or rupture of a previous caesarean scar.
Risk factors for third trimester bleeding
Previous placenta previa
Previous classical scar
Misuse of oxytocics
Uterine over distension
Hydramnios: rapid draining of fluid
Maternal abuse of drugs/tobacco
Accidental haemorrhage or abruptio placenta is a condition characterised by premature separation of the normally implanted placenta.
Affects about 1-3% of pregnancies.
Haemorrhage occurs in the decidua basalis, separating the normally implanted placenta in the upper uterine section causing painful bleeding.
The blood may remain retroplacental forming a large retroplacental clot, or may break into the amniotic sac at the placental edge.
Effused blood makes its way between the membranes and between the uterine wall and may trickle out externally.
In severe forms, described as Couvelaire uterus or uteroplacental apoplexy, there occurs extensive extravasation of blood into the myometrium.
Types of abruptio placenta:
Diagnosis and management
This is based on history, clinical examination and investigations.
Important indicators are:
Past history of abruptio placenta.
History of trauma—direct accidental injury, indirect injury following a fall, obstetric trauma like vigorous attempts at version, rapid draining of a hydramnios.
Clinical examination: In the milder revealed variety there may be external bleeding which may be bright red, or dark with passage of clots. The uterus may be relaxed, the foetal heart sounds are normal. It is common in women suffering from pre-eclampsia or hypertensive disorders. Sonography confi the location of the placenta in the upper uterine segment. If the patient is clo to term, it may be a wise option to induce labour by amniotomy followed b oxytocin infusion. In the severe concealed variety. The blood pressure may appe to be within normal limits, but in reality there has been an actual fall in bloo pressure from a previously high level. There may be other evidences of pr eclampsia like pedal oedema and proteinuria present. Clinically, the uterus i often irritable and feels hard, the foetal heart sounds are generally absent b the time the patient arrives in the hospital. The patient is often already in labour. Vaginal examination reveals an open cervix with tense membranes Artificial rupture of the membranes reveals brownish amniotic fluid.
Oxytocin infusion helps further progress of labour.
In all these cases of severe concealed accidental haemorrhage, the clinician should closely monitor the maternal vital parameters, urine output, and bleeding and clotting
time at the patient's bedside as she is prone to life-threatening complications,
Maternal risks increase with passage of time. Blood transfusion is necessary in most cases. In the occasional patient in whom the foetal heart sounds are present at the time of admission, a quick delivery by caesarean section may save the • baby.
The following reasons can be life threatening:
Infection and death.