• Antepartum haemorrhage (APH) is defined as any
vaginal bleeding occurring during pregnancy,
starting from 20 weeks gestation until delivery of
• APH remains one of the leading causes of maternal
mortality throughout the world. It may also have and
adverse effect on the fetal and neonatal outcome.
• In many cases the bleeding in APH is unavoidable, and
if severe an urgent intervention will be life saving both to
the mother and the fetus.
CAUSES OF ANTEPARTUM
• I. Maternal (placental site causes):
– Bleeding is due to premature separation of the placenta. They
are the most worrying causes as both the mother and her
fetus are in danger, it includes:
• Placenta praevia (bleeding from separation of an abnormally
• Placental abruption (bleeding from separation of a normally
• II. Fetal (rupture vasa praevia):
– Vasa praevia (velamentous insertion of the cord with rupture
of fetal vessels).
• LOCAL GYNAECOLOGICAL CAUSES
– Local causes are less worrying. They are
due to local gynecological condition
• Cervicitis and cervical erosion.
• Benign cervical polyp or rarely malignant
• Severe vaginal infections or rarely vaginal
DEFINITION and INCIDENCE
• Placenta praevia (PP) is a placenta that is encroaching on the
lower uterine segment. It may be located over or very near
the internal os.
• Placenta praevia is relatively rare (1/300 to 1/500
pregnancies), however it may be the cause of one of the most
serious and life threatening obstetric emergencies.
• Placenta praevia may be associated with mild or severe bleeding
which may be provoked or spontaneous. Such bleeding is from
maternal and not fetal circulation, and is more likely to
compromise the mother before it affects fetal condition
CLASSIFICATION OF THE DEGREES OF
• Total placenta praevia (complete): The placenta completely covers the internal
• Partial placenta praevia (incomplete): The placenta partially covers the internal
• Marginal placenta praevia: The edge of the placenta is at the margin of the
• Low lying placenta (PP lateralis): The placental encroaches on the lower uterine
segment but its edge does not reach the internal os. (it is of little clinical
• N.B.: the nearer the placenta to the internal os, the more is the liability for
earlier separation leading to more severe bleeding attacks, and liability to preterm
termination of pregnancy.
• N.B.: PP marginalis posterior is more dangerous than marginalis anterior because:
• It encroaches on the true conjugate delaying engagement of the head.
• Engagement of the head will compress the intact part of the placenta against the
sacrum causing fetal asphyxia while leaving the lower separated part of placenta
uncompressed leading to uncontrolled bleeding.
AETIOLOGY AND RISK FACTORS
• Advancing maternal age (>35 years).
• Multiparity (para five or greater).
• Prior caesarian delivery: the incidence
increases with the number of previous C.S.
• Multifetal pregnancy: the incidence reaches up
to 40% in twin pregnancy.
• Other causes of large placentae: as placenta
membranacaea or multiple lobes (as bipartite).
MECHANISM OF BLEEDING
• During the 2nd half of pregnancy the
lower uterine segment is progressively
passively and painlessly stretching and
elongating but the inelastic placenta
cannot stretch in a similar pattern, so
inevitable separation occurs (shearing
effect) leading to unavoidable bleeding.
PATHOLOGY OF PLACENTA PRAEVIA
• The lower uterine segment: It is thin,
vascular, and friable thus more liable to
• The placenta:
– Extends to the lower uterine segment, may reach or
cover the internal os.
– Higher incidence of placenta accreta, due to poor
decidual reaction in the lower segment.
• The umbilical cord: there is higher
incidence of velamentous insertion and vasa
CLINICAL DIAGNOSIS OF PLACENTA
• Clinical Symptoms of APH due to PP:
• Vaginal bleeding in placenta praevia is
characterized by being:
– Causeless (unless it follows intercourse or vaginal
– Painless (unless it is associated with labour pains)
– Recurrent (unless pregnancy is terminated with the first
– Bleeding is always revealed and bright red in colour.
Clinical Signs in APH due to PP:
• General signs related to bleeding:
– The general condition is proportionate to amount of
– Anaemia is present if bleeding is severe or
– No signs of toxaemia of pregnancy as in some cases
of placental abruption (see later).
– Signs of hypovolaemic shock, if present, include:
– Drowsiness, delirium or loss of consciousness.
– Pallor, tachypnia, hypotension, and tachycardia
(rapid and rising pulse).
• N.B.: In APH due to PP, signs of hypovolaemic shock
correlate with the severity of bleeding (amount of blood
lost), the rate of blood loss (duration of bleeding), and the
previous general condition of the patient (haemoglobin
level and anaemia).
Abdominal Examination in PP:
• The abdomen and uterus are lax and not
tender, so fetal parts and movements are
• Fundal level corresponds to the period of
• Malpresentations are common, and there is
usually delayed engagement of the presenting
part in the last weeks of pregnancy.
• Fetal heart sounds (FHS) are usually audible
and regular, except if severe bleeding
compromises the fetal condition.
Pelvic vaginal Examination:
• Vaginal examination (PV) in PP is generally
contra-indicated, as it may provoke an
uncontrollable attack of bleeding due to placental
– Indications of PV examination: Only when active
management is decided.
– Aim of PV examination: To obtain the following data:
• The degree of cervical effacement and dilatation, and
the condition of the membranes.
• The type and station of the presenting part and
assessment of pelvic adequacy.
• The degree of PP if present (placenta is felt as tough
spongy mass by the index finger while a blood clot is
Precautions during vaginal examination if
• It should NOT be done at home or even in
hospital outpatient or emergency room.
• It should be done ONLY in the operating
theater under complete aseptic
• Anaesthesia should be ready and blood
transfusion is readily available
• The settings for performing an immediate
caesarean section are prepared
Ultrasound diagnosis of PP:
• Ultrasonography (US) is the gold standard in the
diagnosis of placenta praeviae (PP). Placental
localization can be easily made by US at the middle of
the second trimester. By beginning of the third
trimester partial and complete types of PP can be
easily excluded during any attack of vaginal bleeding.
• US, is also the gold standard in the differentiation
between APH due to PP from that due to placental
• Other additional US benefits include accurate
estimation of fetal gestational age, amniotic fluid
volume evaluation, assessment of fetal well being, and
exclusion of major fetal anomalies.
• Laboratory Investigations:
– Complete blood picture (CBC), to detect
anaemia necessitating blood transfusion.
– Urine analysis: to exclude albuminuria
associated with preeclampsia (PE).
• DIFFERENTIAL DIAGNOSIS of APH
due to PP:
• Other causes of APH (placental abruption, vasa
praevia, and local gynecologic causes).
• Other causes of bleeding as severe hypertension
and thrombocytopenic purpura, etc...
MANAGEMENT OF APH due to PP:
• Factors affecting the management of APH
secondary to PP:
– The severity of bleeding and its effect on the patient's
– The duration of gestational age and its effect on fetal
• The main lines of management in Placenta
– Expectant (conservative) Management (continuation
– Active management (termination of pregnancy)
• The aim of conservative (expectant)
management is to allow pregnancy to continue
until either fetal maturity is achieved, or labor
pains start spontaneously.
• Indications of expectant management:
– Pregnancy < 37 weeks, with mild bleeding and
absent labour pains.
– Patient is in good general condition
– Fetus is living and with no associated gross fetal
Lines of expectant management:
• Complete bed rest, diet and vitamin support.
• Correction of anaemia, if present, by oral or
parentral iron therapy.
• Localization of the placenta by US, to exclude
• Laboratory investigations to check on the
bleeding and coagulation profiles.
• After complete cessation of bleeding, a local
gynaecologic examination could be performed
(speculum examination) to exclude local organic
ACTIVE MANAGEMENT (TERMINATION
• The aim of active management is the immediate
termination of pregnancy whenever the fetus is mature
or the bleeding is so severe compromising maternal and
• Indications of active management:
– Any bleeding > 37 weeks gestation (even if mild or moderate).
– Any severe bleeding irrespective of gestation age.
– Patient with hypovolaemic shock or in poor general condition
– Labour pains have already started.
– Recurrent and persistent mild to moderate bleeding during
– Fetus is dead or with major fetal anomalies incompatible with
• Indications specific to Placenta praevia:
– Total (complete), or partial (incomplete), or marginal
posterior types of PP.
– Severe bleeding or patient in shock.
– Moderate bleeding and cervix is closed.
– Continuous bleeding during trial for vaginal delivery.
– Fetal distress due to severe bleeding during
pregnancy or during labour.
• Other indications associated with PP:
– Elderly primigravida, previous caesarean section,
associated malpresentations, any degree of pelvic
contraction, associated pregnancy complications as
toxaemia or diabetes.
Precautions during performing C.S. for
• Anti-shock measurements including blood transfusion if needed.
• The technique is by a lower segment C.S.
• After performing the uterine incision the fetus is delivered before
• IV Oxytocin (syntocinon), ergometrin (methergin), prostaglandins,
or mesoprostol (cytotec), can be used single or in combination to
assure excellent uterine contractions capable of controlling expected
• In cases of uncontrollable bleeding with failure of above measures,
we may do:
– Bilateral ligation of the uterine arteries.
– Unilateral or bilateral ligation of the anterior division of internal
– Abdominal hysterectomy if above measures fail (or in grand
Trial of vaginal delivery:
– Absence of any of the previously discussed indications
for caesarean section.
– PP lateralis or marginalis anterior, with minimal
separation and bleeding.
– Normal fetal well being (no fetal distress, no IUGR).
– Fetus is in a cephalic presentation (best
– Favorable local pelvic examination (cervix is ripe,
sufficiently dilated, pelvis adequate and head not in a
Method: Should be done in the following
• Artificial rupture of membranes (ROM) :
– Stops the shearing effect and separation of the
placenta from lower segemnt
– Allows more rapid descent of the head and
compression of the bleeding sinuses.
– Stimulates uterine contractions (prostaglandin
• Intravenous oxytocin (unless
contraindicated), in order to augment uterine
• Care of the 3rd stage and puerperium to
avoid postpartum haemorrhage and treat
Complications and effects of PP on
pregnancy, labour and puerperium:
• Unavoidable haemorrhage causing hypovolaemic shock if severe
and anaemia if mild and recurrent.
• Abortion, IUGR and IUFD (intrauterine fetal death).
• Premature delivery (with all complications of prematurity).
• Malpresentations and non-engagement of the presenting part
• Predisposition to presentation and prolapse of cord.
• Postpartum haemorrhage due to:
– Defective retraction in the lower uterine segment so unable to close
the bleeding sinuses.
– Inertia of the upper uterine segment due to anaemia.
– Retention of parts of the placenta due to abnormal adhesion to lower
– Lower uterine segment is thin and vascular so liable to be torn during
• Puerperal sepsis (due to anaemia and laceration).