SEMINAR ON

ANTEPARTUM HAEMORRAGE

Submitted to, Submitted by,

Mrs. Fouzia Madam, kathyayani

Asst. professor, [Link] ( N) 2nd year,

Dept. OBG nursing, Speciality: OBG- II,

ycon ycon,

Hyderabad. Hyderabad.
 ANTEPARTUM HEMORRAGE

OBJECTIVES:

1. GENERAL OBJECTIVE:
At the end of the seminar the group will be able to get the knowledge about
the ante partum hemorrhage. Hence, develops a positive attitude towards it
and practice this knowledge and improve their skills in teaching and clinical
areas.

2. SPECIFIC OBECTIVES:

At the end of the class the students will be able to:

 Define ante partum hemorrhage.

 Enlist the causes of ante partum hemorrhage.
 Explain in detail about placenta previa.
 Describe the management of placenta previa.
 Explain in detail about placental abruption.
 Discuss in detail about the management of placental abruption.
INTRODUCTION:

In obstetrics, ante partum hemorrhage is a bleeding from the vagina during pregnancy from twenty

weeks gestational age to term. It should be considered a medical emergency (regardless of whether
there is pain) and medical attention should be sought immediately, as if it is left untreated it can lead
to death of the mother and/or fetus. Bleeding without pain is most frequently bloody show, which is
benign; however, it may also be placenta previa (in which both the mother and fetus are in danger).
Painful APH is most frequently placental abruption.

MEANING:

Ante partum hemorrhage (APH) is a bleeding from or in to the genital tract, occurring from 24+0
weeks of pregnancy and prior to the birth of the baby. The most important causes of APH are
placenta praevia and placental abruption, although these are not the most common.

DEFINITION:

 Ante partum hemorrhage (APH) is defined as a bleeding from or in to the genital tract, occurring
after 28 weeks of pregnancy till the birth of the baby.

- NIMA BHASKAR

 It is defined as bleeding from or into the genital tract after 28th week of pregnancy but before the
birth of the baby.
- DC DUTTA
ANATOMY AND PHYSIOLOGY OF REPRODUCTIVE SYSTEM:

The female reproductive anatomy includes the study of the external and internal structures.

EXTERNAL FEMALE REPRODUCTIVE SYSTEM:

The external genitalia, also called the vulva, includes the Mons pubis (a fatty mound which covers
the pubic bone), the labia majora (outer lips of the vagina), the labia minora (the inner lips of the
vagina), the vaginal opening, the urethral opening (opening of the urethra, a tube which carries
urine from the bladder outside of the body), the clitoris (a small structure with sensitive nerve
endings located within the labia minora, the sole purpose of which is for sexual arousal and
pleasure), and the perineum (the space between the anus (the rectal opening), and the vaginal
opening).
INTERNAL FEMALE REPRODUCTIVE SYSTEM:

The internal reproductive anatomy includes the uterus, two ovaries, two fallopian

tubes, the urethra, the pubic bone, and the rectum. The uterus contains an inner lining called
the endometrium (which builds ups and sheds monthly in response to hormonal stimulation). The
lower portion of the uterus is called the cervix, which contains a small opening called the os.
Menstrual blood flows through the os into the vagina during menstruation. Semen travels through
the os into the uterus and the fallopian tubes following ejaculation during sexual intercourse. The
cervical os dilates (opens) during childbirth.

The ovaries, two small almond-shaped structures located on each side of the uterus, are the
female gonads (reproductive glands). Female babies are born with over 400,000 ova (the gametes,
also referred to as egg cells or oocytes), which are stored in the ovaries. The female body does not
produce any additional ova. The ovaries produce estrogen and progesterone. The ovaries are close to,
but not actually connected to the fallopian tubes, thin tube-like structures that are the site
of fertilization, the fusion of the male and female gametes.

MENSTRUAL /HORMONAL CYCLE:

The hormonal cycle facilitates maturation and rupture of the ovarian follicle resulting in the release
of an ovum (the female reproductive or germ cell). Each month a series of changes take place which
prepares the uterus for pregnancy. This cycle (menstrual cycle) is described below:

 The first day of menstruation (referred to as Day 1) occurs when levels of estrogen and
progesterone are low. In response to these low levels, the hypothalamus secretes gonadotrophin
releasing hormone (GnRH) which triggers the anterior pituitary gland to release two
hormones: follicle stimulating hormone (FSH), and luteinizing hormone (LH).
 FSH stimulates the development of many follicles within the ovary. One dominant follicle takes
over. As it continues to grow, it produces increasing amounts of estrogen, which stimulates the
release of LH, and inhibits FSH, which suppresses further follicular development.
 When LH levels are highest (LH surge), the ovarian follicle “ruptures” and releases one ovum,
which is “swept” into the fallopian tube by hair-like projections called cilia that line
the fimbriae (the fringe-like end of the fallopian tube that is closest to the ovary). This process is
called ovulation. Increasing estrogen levels causes the cervical mucus (vaginal secretions) to
become clear and profuse and the os to dilate. These two actions may facilitate the transport of
semen (containing sperm) from the vagina, through the uterus, and into the fallopian tube.
 Following ovulation, the ruptured follicle is transformed into the corpus luteum, a glandular mass
that continues to produce estrogen and high levels of progesterone. The progesterone causes the
endometrium to thicken, preparing it for implantation of a fertilized egg. If fertilization takes
 place during ovulation, hormonal levels remain high, essential for the maintenance of the
pregnancy.

 If fertilization does not occur, the corpus luteum shrinks and levels of both estrogen and
progesterone decrease. The withdrawal of estrogen and progesterone cause the blood vessels of
the endometrial (uterine) lining to “break” resulting in vaginal bleeding (menstruation). The
average menstrual cycle is 28-35 days, and menstrual flow usually continues for three to seven
days, although there are variations among women.
 Following menstruation, estrogen and progesterone levels are low, triggering the hypothalamus
to once again release GnRH, starting the entire cycle again. If fertilization does take place,
menstruation will not reoccur for the duration of the pregnancy
CAUSES OF ANTE PARTUM HEMORRHAGE:

Placenta praevia:
Placenta praevia refers to when the placenta of a growing fetus is attached abnormally low within
the uterus. Intermittent ante partum hemorrhaging occurs in 72% of women living with placenta
praevia. 
ETIOLOGY:
 Dropping theory:
The fertilized ovum drops down and implanted in the lower uterine segment. Poor decidual
reaction in the upper uterine segment may be the cause. Failure of zona pellucid to disappear at
time can be hypothetical possibility. This explains the formation of central placenta previa.

 Persistence of chorionic activity:

Chorionic activity in the deciduas capsular is and its subsequent development into capsular
placenta which comes in contact with deciduas Vera of the lower segment can explain the
formation of lesser degrees of placenta previa.

 Defective deciduas:
It results in spreading of the chorionic villi over a wide area in the uterine wall to get
nourishment. During this process, not only the placenta becomes membranous but encroaches
onto the lower segment, such a placenta praevia may invade the underlying deciduas or
myometrium to cause placenta accreta, increta or percreta.

 Big surface area of the placenta:

As twins may encroach onto the lower segment.

TYPES OR DEGREES OF PLACENTA PRAEVIA:

There are four types of placenta praevia depending upon the degree of extension of placenta to the
lower segment.
The severity of a patient's placenta praevia depends on the location of placental attachment;

Type Location of Placental Attachment

Type 1 Lower segment of uterus, no attachment to the cervix

Type 2 Touching but not covering the internal orifice of the cervix

Type 3 Partially covering the internal orifice of the cervix

Type 4 Completely covering the internal orifice of the cervix

 Types 1 and 2 are classified as minor placental praevia as these typically result in minor ante
partum hemorrhaging.
 Types 3 and 4 are referred to as major placental praevia due to the risk of heavy hemorrhaging in
the case of a rupture due to the location of placental attachment.

CLINICAL FEATURES OF PLACENTA PREVIA:

SYMPTOMS:

 The only symptom of placenta previa is vaginal bleeding.

 Bleeding- sudden, painless, apparently causeless and recurrent.
 The bleeding is unassociated with pain unless labor starts simultaneously.

SIGNS:

 General condition and anemia are proportionate to the visible blood loss.
 ON EXAMINATION:
 The uterus is not tender on palpation.
 The height of uterus corresponds to the gestational age as calculated from the LMP.
 FHR is usually normal.
 The presenting part of the fetus is high up and can be easily palpated through the abdomen.
 There may be abnormal presentations like breech or face presentation.

VAGINAL EXAMINATION:
P/V is indicated only if active treatment is initiated. This may provoke a severe attack of
bleeding so it should be done with the following precautions:
In the operating room,
 Under general anesthesia
 Cross- matched blood is in hand,
 Operating room is ready for immediate caesarean section.
 If index finger is introduced gently through the dilated cervix, the placenta can be felt as a
tough fibrous mass.
TEST FOR PLACENTA PREVIA:

Ultrasonography is the most valuable aid in the diagnosis of placenta previa.

TREATMENT:

AT HOME:

 Arrange for immediate transfer to the hospital.

 No vaginal examination or pack, only a sterile vulval pad is applied.
 Anti-shock measures as Pethidine IM, fluids and blood transfusion may be given in the way to
the hospital if bleeding is severe.

AT HOSPITAL:

 Assessment of the patient’s condition, general and abdominal examination and resuscitation if
needed.
 At least 2 units of cross matched blood should be available.
 Ultrasonography for differentiation between abruption placentae, marginal bleeding and
placenta praevia.
 Assessment of fetal viability age, position and presentation.

MANAGEMENT:

I. IF THE MOTHER IS NOT IN LABOR:

 LOOK FOR AMOUNT OF BLEEDING:
 If the bleeding is severe, continue anti-shock measures and do immediate caesarean section.
 If completed 37 weeks or more, pregnancy is terminated by induction of labor or caesarean
section.
  If less than 37 weeks, conservative treatment is indicated till the end of 37 weeks but not
more.
 CONSERVATIVE TREATMENT:
 The patient is kept hospitalized with bed rest and observation till delivery.
 Observation of fetal wellbeing.
 Anti- D immunoglobulin is given for the Rh-negative mother.

II. IF THE MOTHER IS IN LABOR:

Vaginal delivery is allowed if the following findings are fulfilled:
 Placenta praevia is lateralis or marginalis anterior.
 Bleeding is slight.
 Vertex presentation.
 Partially dilated cervix to allow amniotomy. As it allows descent of head so it compresses
the placental site preventing further bleeding.

III. CAESAREAN SECTION IS INDICATED IN:

 Placenta praevia centralis whether complete or incomplete or incomplete even if the fetus is
dead.
 Placenta praevia marginalis posterior.
 Severe bleeding.
 Presentation other than vertex.
 Other obstetric indications as contracted pelvis, cord prolapsed and elderly primigravida.
 It allows better control of bleeding from the placental site.

COMPLICATIONS:
MATERNAL:
a. During pregnancy:
- Abortion.
- Premature labor.
- Ante partum hemorrhage.
- Malpresentation and non-engagement.
b. During labor:
- Premature rupture of membranes.
- Cord prolapsed
- Inertia.
- Postpartum hemorrhage.
- Retained placenta.

FETAL:

- Fetal mortality is 20%.

- Prematurity.
- Asphyxia.
- Malformations (2%).
 DEFINITION:

Placental abruption is also called “abruption”. It is type of ante partum hemorrhage where there is
premature separation of a normally situated placenta in the upper part of the uterus before delivery of
the baby, or sometimes even before labor begins.

Bleeding occurs between the placenta and the uterine wall and can either trickle out between the
amniotic membranes or collect as a blood clot that gradually increases in size.

CLINICAL TYPES OF PLACENTAL ABRUPTION:

There are three clinical types of placental abruption:

i. Revealed type.
ii. Concealed type.
iii. Mixed type.
i. REVEALED TYPE: This is a mild type of placental abruption. In this type of placental
abruption, the bleeding that occurs behind the placenta trickles down between the
membranes and the uterine walls to be revealed at the vaginal opening. Since there is no
collection of blood behind the placenta, separation of the placenta from the uterus is usually
less than in the other types.

ii. CONCEALED TYPE: The blood fails to trickle down and collects between the placenta
and the uterine wall. The enlarging blood clot further dissects out the placenta from its bed
and placental separation can occur over a large area.

iii. MIXED TYPE: in this type, part of the blood trickles down and part collects behind the
placenta. Like the concealed type, this is also a dangerous type of placental abruption as the
blood clot continues to dissect out the placenta from the placental bed.

DEGREES OF PLACENTAL ABRUPTION:

Abruption placenta may be classified in three types of separation:

1. Marginal/ low separation.

2. Moderate/ high separation.
3. Severe/ complete separation.

1. MARGINAL/ LOW SEPARATION:

This occurs when the separation is low and is not complete and is not complete; vaginal
hemorrhage is evident.

2. MODERATE / HIGH SEPARATION:

This occurs when the separation is high in the uterine segment; causing the fundus of the
uterus to rise. The fetus is in grave danger because of lack of oxygen. External hemorrhage
will probably not be present here, whereas the amniotic fluid will be a port-wine color.

3. SEVERE/ COMPLETE SEPARATION:

This occurs when the fetus head is present in the cervical os that prevents external
hemorrhage. The fetus is in grave danger, and an immediate cesarean section will probably be
needed in order to save the baby’s and mother’s lives.

CAUSES OF PLACENTAL ABRUPTION:

  PREMATURE RU PTURE OF MEMBRANES: It can lead to acute infection inside the
uterus. This infection is believed to be a leading cause of placental abruption.

 TOXEMIA OF PREGNANCY: The high blood pressure associated with pre-eclamptic

toxemia (PET) or toxemia of pregnancy is frequently associated with placental abruption.

 CHRONIC HYPERTENSION: High blood pressure present even before the start of
pregnancy can also cause placental abruption.

 TRAUMATIC: Mechanical traumas such as forceful cephalic version, a fall on the abdomen,
a short cord that pulls on the placenta during labor pains or overstimulation of the uterus during
induction of labor.

 UNKNOWN CAUSE: sometimes no cause can be identified.

SIGNS AND SYMPTOMS:

The signs and symptoms vary depending on whether the placental abruption is of the revealed or
concealed type.

Revealed placental abruption:

 Vaginal bleeding : The bleeding is mild to moderate. The blood is blackish red in color
and trickles continuously from the vagina.
 Pain: Pain may be mild or absent. But most patients complain of a general discomfort over the
abdomen.
 Symptoms of other diseases: symptoms of other disease processes like PET,
diabetes or essential hypertension may be present.
 On examination: Localized pain may be present over the uterus at the site of implantation
of the placenta.

CONCEALED PLAECNTAL ABRUPTION:

 Vaginal bleeding: There may be no bleeding in the concealed type but in the mixed
type, a little trickle of blood may be seen.
 Pain : Pain is acute, agonizing and occurs suddenly ,may be severe .
 Symptoms of other diseases: other diseases like PET, diabetes or essential
hypertension may be present.
 Shock: the patient may be unconscious when brought to the hospital and show all the signs
and symptoms of acute blood loss like a thin thread pulse, low blood pressure, cold , clammy
arms and legs, etc.
 On examination: the patient appears pale and anemic. The uterus is tense, tender and
hard. The fetal parts are felt easily.
TREATMENT OF PLACENTAL ABRUPTION:

REVEALED PLACENTAL ABRUPTION:

 If bleeding is slight:
 If the patient is stable and USG shows minimal retro placental bleeding with a healthy
immature fetus- conservative treatment with hospital admission, bed rest and careful
monitoring is done.
 A caesarean section is done once the fetus reaches maturity.

 If bleeding is considerable:
 If it is believed that the bleeding is enough to compromise the life of the mother, a
caesarean section is done, regardless of whether fetus is mature or not.

CONCEALED PLACENTAL ABRUPTION:

 If the patient has come in shock, she is promptly resuscitated with IV fluids, blood
transfusion, etc.
 An emergency caesarean section is done as early as possible to cut down blood loss.
 If the patient is in labor, she is allowed to proceed, keeping her ready for a caesarean
section.
 In most cases, the fetus is dead at the time of treatment.

CESSARIAN HYSETERECTOMY:

 There may be even bleeding into the muscle and blood vessels of the uterus, causing injury
and damage.
 A caesarian hysterectomy (removal of uterus) becomes necessary to control the hemorrhage.
Journal: Ante partum hemorrhage and its feto-maternal
outcome- retrospective study.
Saloni K. Gandhi, Ayushi P. Vamja, Kishor P. Chauhan

DOI: [Link]

Published: 2020-10-27

Abstract

Background: Ante partum hemorrhage (APH) is defined as any bleeding from or into the genital
tract after the period of viability and before the delivery of the baby. Aim of the research was to
study the feto-maternal outcome in patients with APH.

Methods: The present study was a retrospective observational study undertaken in Obstetrics and
Gynecology department of Dhiraj General Hospital, during a period of 1.5 years from November
2018 to May 2020 in 84 cases of ante partum hemorrhage. Only patients with APH >28 weeks
gestational age and willing to participate in study were included. Open STAT statistical software has
been used to analyze the data in this study.

Results: The incidence of ante partum hemorrhage was 2.86%. Maximum patients of APH lie
between the age group of 26-34 years. In abruptio placenta (AP) 65% and in placenta previa (PP)
77.2% of the patients were multiparous. APH presents mostly between 34-36 weeks. Around 90%
patients of APH required blood transfusion. APH overall shows increased rate of cesarean sections
up to 62%. Around 9.5% patients went into shock, 4.7% had disseminated intravascular coagulation
(DIC), 3.5% postpartum hemorrhage (PPH) and 8.3% had wound gap and puerperal pyrexia. 23.8%
babies had asphyxia of which 60% were contributed to PP and 40% were in AP group. Respiratory
distress syndrome was in 7.1% babies of which both groups equally contributed. Septicemia was
seen in 13% and jaundice in 29.8%.

Conclusions: Higher rates of neonatal intensive care unit (NICU) admission and stay were seen with
these complications. This study showed 20.2% perinatal deaths as outcome of APH and 14.2% still
births.

 
SUMMARY:

The knowledge about ante partum hemorrhage is very important for nurses to know the cause, signs
and symptoms in order to render effective nursing care and management of ante partum hemoorhage.

CONCLUSION:

Till now we discussed about ante partum hemorrhage. Hence, this knowledge will help the nurses to
apply practical skills in clinical areas, nursing education and in research programmes.

BIBLIOGRAPHY:

Books:

1. D. C. DUTTA, “A TEXTBOOK OF OBSTETRICS”, published by new central agency , 7th

edition (2014), page no: 241-259.
2. NIMA BHASKAR, “MIDWIFERY AND OBSTETRICAL NURSING”, published by Emmess
medical publishers, 3rd edition, page no: 319-327.
3. GLORIA HOFFMANN WOLD, “CONTEMPORARY MATERNITY NURSING”, Mosby
publications, Philadelphia (1997), page no: 459-467.

Journals:

-Ante partum hemorrhage and its effects on feto-maternal outcome-International journal of

reproduction, contraception, obstetrics and gynecology (IJRCOG).

Websites:

[Link]

[Link]

[Link]