Definition--All cases of bleeding from any part of the genital tract after 20 weeks (24 weeks for developing world) of pregnancy but before the birth of the baby.

Causes

Mainly 3 categories:

•           Placental cause(more common 70%incldes placenta previa and abruption placenta)

•           Extra-placental causes(cervical polyp, cacervix, varicosevein, local trauma)

•           Unexplained orindetermininate

Placenta previa

Clinical types:mild degree (type 1, 2)major degree (type 3,4)

Type 2 posterior placenta previa is dangerous because the major thickness of placenta overlies the sacral promontory, so decreases the a.p diameter of inlet and prevents engagement of presenting part.

Symptoms

Recurrent, painless and causeless vaginal bleeding is the hallmark of placenta previa.

Signs:

•           The size of uterus corresponds to pog.

•           The uterus in normally relaxed and soft, so the fetal parts are easily palpable and no area of tenderness is found

•           In about 1/3 rd cases malpresentations are observed, more commonly breech & transverse. Twin pregnancy is frequent.

•           The presenting part is usually high or floating in major degree & posterior placenta previa.

•           If the placenta is lateral or marginal, the presenting part may be just at the pelvic brim or even get fixed in early labour.

•           Fhs is present if bleeding is small. However if major amount of placenta is separated & the patient is in shock fhs may not be present.

•           In case of posterior placenta previa, fetal heart may become slow or irregular if fetal head is forced into the pelvis due to compression of placenta. (stallworthy sign)..

Vulval examination- only inspection is to be done to note the amount of bleeding & color of blood. The blood is bright red in placenta previa.

*refer patients of aph to tertiary care hospital for further management.

Vaginal examination should never be done

Diagnosis ultrasound localisation of placenta is done as a routine usg in the second trimester of pregnancy or may be done as a diganostic procedure in a case of aph, this is the most accurate method to localise the placenta.

Colour-doppler prominent venous flow in the hypoechoic areas near the cervix indicates placenta previa.

Per speculum examintation should be done.

Management

•           These days the localisation of placenta on routine usg has made the management easy. If placenta is in lower segment the patient is advised bed rest ,avoid travelling,to avoid intercourse and to avoid heavy work

•           Gentle abdominal examination to note the height of uterus, area of uterine tenderness and f.h.s. Diagnosis is made by history, physical examination and confirmed by ultrasound

•           Management protocol mainly depends on the maternal condition and gestation is divided into two groups

-conservative or expectant

-definitive or active

Conservative

•           also known as johnson and macafee protocol

•           this comprises judicious non interference and extensive monitoring

•           it is based on the understanding that

1)    in most cases the first bleeding occurs when the fetus is premature

2)    the first bleeding is seldom fatal to the mother and fetus

3)    the bleeding often stops on its own, to recur later at indefinite intervals

•           The main objective is to allow the pregnancy to continue at least for 37 weeks to improve fetal prognosis

•           Approximately threedays after all bleeding has stopped a gentle speculum examination should be performed to rule out any local cause of bleeding.

•           2 doses of betamethasone 12 mg j/m 12 hours apart are given for fetal lung maturation.

•  

- the expectant treatment should be discontinued

-37 weeks of pregnancy are completed

-severe bout of bleeding occurs

-the patient goes into labour

-if the fetus is dead or congenitally malformed

Definitive management

Comprises prompt delivery:

-  the patient has her first episode of bleeding very severe

-the first bout of bleeding is at or after 37 weeks of pregnancy

-  successful conservative treatment brings the patient upto 37 weeks

-the patient is in labour

-the fetus is dead or congenitally malformed

Usg localises the placenta and also defines the extent to which the placenta covers the as thereby predicting the likelihood of vaginal delivery or c.s. Vaginal delivery in type 1 and type 2 anterior placenta previa Ceasearen section: major degree placenta previa (3 and 4) and type 2 posterior, the lscs is the treatment of choice

Accidental hemorrhage

Defined as separation of normally situated placenta after 20 weeks of pregnancy (24 weeks in developing world) but before the birth of the child

3 varieties

-  Revealed: the hemorrhage is external and is most common, occurs in 80% cases.

-   Concealed: hemorrhage is intrauterine in which no hemorrhage occurs at the vulva. it is rare.

-  Mixed: some blood is concealed and some is revealed at the vulva.

The patient may present with variable degrees of shock and acidosis.

Lab tests        -

Bleeding time: 2-4 mins

Clotting time (3-8 min if the clotting time is prolonged, it indicates deficiency of clotting factors. Absence of clotting indicates fibrinogen levels less than 50 microgm/dl.

Clot retraction time: normal is 30 mins. A weak friable clot indicates hypofibrinogenemia and early dissolution indicates enhanced fibrinolysis. Peripheral smear and platelet count: peripheral smear shows thrombocytopenia, leucocytosis and evidence of haemolysis like schistocytes, platelet count

Special investigations (for tertiary care)

Prothrombin time: normal is 11 -1 7 seconds. It tests the integrity of extrinsic and common pathway. It is prolonged in deficiency of factors i, ii, v, vii orx .the test is most sensitive to a fall in factor vii which is one of the vitamin k dependent factors.

Partial thromboplastin time: normal 25-35 seconds. It tests the integrity of extrinsic and common pathway.

Thrombin time: normal is 10- 15 sec

Fibrinogen degradation products (fdp's): in normal pregnancy usually they are absent. They are elevated and can be detected in dic.

D-dimer assay: it is specific component of fibrinogen breakdown. Levels more than 200 mg/I can be found in dic.

Coagulation inhibitors: low plasma levels of coagulation inhibitors like antithrombin iii, protein c may help in diagnosis and to determine the prognosis.

Clinical features

Clinical features are dependent on the degree of placental abruption.

-   the uterus is hard and eventually tender to touch, that the patient resents even gentle palpation.

-  uterine height is more than period of gestation. - thefetus is most often dead and fhs is inaudible.

-  the systolic BP is at shock levels below 80mm of Hg and pulse very rapid.

-  sometimes in patients with hypertension the systolic pressure may be normal but they could be in a state of shock as the pressure would have been much above the normal before abruption. This factor has to be borne in mind.

-  coagulation failure and renal failure are more often associated with this type.

-  all cases of concealed accidental hemorrhage fall under this category.

Diagnosis

Ultrasonography for diagnosing placental abruption

Management of abruptio placentae

·       Treatment of abruption depends on maternal and fetal condition, gestational age and cervical status.

•           These patients should be managed in a well equipped hospital with medical team and resources capable of delivery with all the complications of abruptioplacentae like coagulopathy.

·       A quick assessment of the general condition of the patient is made by checking the vitals,

•           The two important criteria are-

•           to keep the hoematocrit at least 30% • urinary output at least 30 mt/hour

•           Unless there is malpresentation every effort should be made to deliver the patients with abruptio placentae, and fetal death vaginally with careful attention paid to coagulation status during labour induction.

•           Third stage must be managed activelyand preparation must be made to deal with PPH if it occurs.

•           Measure urinary output .Watch for renal failure and clotting defects which in some appear after delivery for the first time.

Expectant management:

-            In mild cases of abruption which present before 34 weeks with stable maternal and fetal condition and normal lab findings - a conservative approach is adopted. The main objective is to achieve fetal maturity. The patient is kept in the hospital.

-            Regular assessment of maternal condition.

-            Frequent assessment of maternal hematocrit and coagulation profile.

-            Antepartum fetalsurvillence with non stress test and biophysical profile.

-            Administration of betamethasone

-            Anti D if needed.

Management of abruptio with live fetus:

There are 2 main subgroups of such patients:

-            those with hypertonic uterus

-            those with soft uterus

If the fetus is alive and uterus is rigid the abruption is probably large, LSCS should be done.

If the uterus is soft and fetus alive —the abruption is not greater than 25% and the chances of coagulopathy are extremely low and the prospects for vaginal delivery and favourable outcome are excellent. Induction of labour should be done by ARM and oxytocin infusion.

-            If during labourthe uterus becomes hypertonic or fetal distress occurs Non progress of labourinduction of labour fails, ceasearen should be done

Management of coagulopathy (In tertiary center)

-            Plasma fibrinogen levels may be 100- 150 mg /dldecreased.PTF( partial thromboplastin                                                                                                  time)

and PT (prothrombin time) increasedD-dimer concentration increased Platelet count decreased

-            One unit of packed cells increases the hematocrit by 3-5 %. One unit of FFP (200-250 ml) increases fibrinogen by 10 mg/dl.

-            Alternatively fibrinogen orcryoprecipitate may be given. Platelets are given if there is thrombocytopenia.

-            Heparin should be avoided in these patients.

-            ArdifiwombinIII is preferred over Heparin.

-            Muman recombinant factor 'Ill a is a remarkable drug for the control of obstetric bleeding.

-            It is given as a bolus injection of 60-100 ugm/kg. The results are obtained after 10 units.

-            -Any type of operative interference should be avoided. –

Extra placental causes of bleeding

Rare causes includes cervicitis,cervica I erosions,endocervica I polyps,cancer of cervix,vagina I, valvar and cervical varicosities,vagina I infections,Foreign bodies,Genital lacerations, Excessive show,Vasa previaandMarginal separation of placenta

-            A direct cervical examination with a speculum should be done. Delivery at term is done accordingly.