SEMINAR

ON
HEMORRHAGE IN LATE PREGNANCY, PLACENTA
PREVIA AND ABRUPTIO PLACENTA

DATE OF SUBMISSION: 25.2.2020

SUBMITTED TO

JENISHA

ASSISTANT PROFESSOR

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGICAL

NURSING

THE OXFORD COLLEGE OF NURSING

SUBMITTED BY

RESHMA ANILKUMAR

M.SC NURSING 1ST YEAR

THE OXFORD COLLEGE OF NURSING

INTRODUCTION
Bleeding, also known as a hemorrhage or haemorrhage,
is blood escaping from the circulatory system from damaged blood
vessels. Bleeding can occur internally, or externally either through a natural
opening such as the mouth, nose, ear, urethra, vagina or anus, or through a
wound in the skin. Hypovolemia is a massive decrease in blood volume, and
death by excessive loss of blood is referred to as exsanguination. Typically, a
healthy person can endure a loss of 10–15% of the total blood volume without
serious medical difficulties (by comparison, blood donation typically takes 8–
10% of the donor's blood volume). The stopping or controlling of bleeding is
called hemostasis and is an important part of both first aid and surgery. The use
of cyanoacrylate glue to prevent bleeding and seal battle wounds was designed
and first used in the Vietnam War. Today many medical treatments use a
medical version of "super glue" instead of using traditional stitches used for
small wounds that need to be closed at the skin level.

ANTEPARTUM HAEMORRHAGE
Antepartum bleeding, also known as antepartum haemorrhage or prepartum
hemorrhage, is genital bleeding during pregnancy after the 20th to 24th week of
pregnancy up to delivery.
It can be associated with reduced fetal birth weight. Use of aspirin before 16
weeks of pregnancy to prevent pre-eclampsia also appears effective at
preventing antepartum bleeding. In regard to treatment, it should be considered
a medical emergency (regardless of whether there is pain), as if it is left
untreated it can lead to death of the mother or baby.

DEFINITION
It is defined as vaginal bleeding from 24 weeks to delivery of the baby.
Or
any bleeding occurring in the antenatal period after 20 weeks gestation.
Or
It is defined as bleeding from or into the genital tract after the 28th week /22nd
week of pregnancy but before the birth of baby. 
It complicates 2–5% of pregnancies. It is associated with increased risks of fetal
and maternal morbidity and mortality.

CAUSES OF APH

PLACENTA PREVIA
When placenta is implanted partially or completely over the lower uterine
segment it is called placenta previa.
INCIDENCE OF PLACENTA PREVIA
UNITED STATES:
 0.3-0.5% of all pregnancies.
 Risks increase 1.5- to 5-fold with a history of cesarean delivery.
 Meta analysis: Rate of placenta previa increases with a rate of 1% after 1
cesarean delivery, 2.8% after 3 cesarean deliveries, and as high as 3.7%
after 5 cesarean deliveries.
 Of all placenta previas, the frequency of complete placenta previa ranges
from 20-45%, partial placenta previa accounts for approximately 30%,
and marginal placenta previa accounts for the remaining 25-50%. 

ETIOLOGY
• Dropping down theory-due to poor decidual reaction in the upper uterine
segment fertilized ovum drops down & gets implanted in the lower segment.
• Persistence of chorionic activity in the decidua capsularis.
• Defective decidua results in spreading of the chorionic villi
• Big surface area of the placenta as in twins

RISK FACTORS

Placenta previa is dangerous if not detected early. However, it is also highly

preventable once you get to know the risk factors.

 Advanced maternal age. Women who are over the age of 35 years
old are at an increased risk of developing placenta previa.
 Multiple gestations. The uterus which has accommodated more than
one fetus has an increased risk for placenta previa.
 Increased parity. Women who have given birth to a lot of children
have an increased chance of having placenta previa.
 Past caesarean births. Giving birth via
caesarean delivery predisposes the woman to placenta previa on her
next childbearing.
 Past uterine curettage. Scars from a past curettage can affect the
implantation of the uterus and lead to placenta previa.
PATHOLOGICAL ANATOMY
PLACENTA:

• Placenta may be large and thin.

• Tongue shaped extension from the main placental mass.

• Extensive areas of degeneration with infarction and calcification may be

evident.

• Morbidly adherent placenta due to poor decidua formation in the lower

segment.

UMBILICAL CORD:

• Cord may be attached to the margin or onto the membranes.

• Insertion of cord may be close to the internal os or the fetal vessels may run
across the internal os in velamentous insertion giving rise to vasa previa

LOWER UTERINE SEGMENT:

• Lower uterine segment and the cervix becomes soft and more friable.

TYPES

These types of placenta previa are classified according to the degree of the
opening that is covered by the placenta.

 Low lying placenta. The placenta implants in the lower portion

instead of the upper portion of the uterus.
 Marginal implantation. The placenta’s edge is nearing the cervical
os.
 Partial placenta previa. A portion of the cervical os is already
covered by the placenta.
 Total placenta previa. The placenta occludes the entire cervical os.
CLINICAL FEATURES
SYMPTOMS:
• Painless, apparently causeless and recurrent hemorrhage
• Hemorrhage from the implantation site in the lower uterine segment may
continue after placental delivery.
SIGNS:
• General condition and anemia are proportionate to the visible blood loss.
ABDOMINAL EXAMINATION
– Size of uterus is proportionate to POG.
– Uterus feels relaxed, soft and elastic.
– Persistence of malpresentation like breech or transverse or unstable lie is more
frequent. There is also frequency of twin pregnancy.
– Head is free floating in contrast to POG.
– FHS is usually present, unless there is major separation of the placenta with
the patient in exsanguinated condition.
VULVAL INSPECTION
• Only inspection has to be done to note the amount, character of blood.
• Blood is bright red in colour.
VAGINAL EXAMINATION
• Must not be done outside the operation theater in the hospital.

DIAGNOSTIC TESTS

To diagnose placenta previa, the patient must undergo the following diagnostic

procedure.

Ultrasound. Early detection of placenta previa is always possible through

ultrasonography. It is the most common and initial diagnostic test that could
confirm the diagnosis.

LOCALIZATION OF PLACENTA

• Sonography: Transabdominal ultrasound (TAS)

• Transvaginal ultrasound (TVS)

• Transperineal ultrasound

• Colour Doppler flow study

CLINICAL

• By internal examination (Double setup examination)

• Direct visualization during caesarean section

• Examination of the placenta following vaginal delivery

COMPLICATION
Maternal

During pregnancy: During Labour:

APH with varying degrees of shock Early rupture of membrane
 • Malpresentation
• Cord prolapse
• Premature labour
• Slow dilatation of cervix

• Intrapartum hemorrhage

• Increased incidence of operative

interference

• PPH

• Retained placenta

Puerperium Fetal
Sepsis is increased due to – Increased Low birth weight
operative interference
• Asphyxia
– Placental site near to vagina and
anemia • Intrauterine death

– Subinvolution • Birth injuries

– Embolism • Congenital malformation

PROGNOSIS
MATERNAL

• Substantial reduction of maternal deaths in placenta previa throughout globe.

• Ultimate cause of death are hemorrhage and shock.

• Morbidity is raised due to hemorrhage and operative interference

FETAL
• Perinatal mortality ranges from 10-25%.

• The causes of death are prematurity, asphyxia and congenital malformation.

• Maternal mortality rate ranges from 2-3%.

• Maternal mortality is 0.03% in the United States.

• Neonatal mortality associated with placenta previa is as high as 1.2%

PREVENTION
• Adequate antenatal care to improve the health status of women and correction
of anemia

• Antenatal diagnosis of low lying placenta at 20 weeks with routine ultrasound

needs repeat ultrasound examination at 34 weeks to confirm diagnosis.

• Significance of warning hemorrhage should not be ignored

• Family planning and limitation of births reduce the incidence.

MANAGEMENT
At home:

• The patient is immediately put in bed.

• To assess the blood loss

• Inspection of clothing soaked with blood

• To note the pulse, blood pressure and degree of anemia

• Quick but gentle abdominal examination to mark height of uterus, to

auscultate the FHS and to note any tenderness on the uterus.

• Vaginal examination must not be done.

TREATMENT
1. IMMEDIATE ATTENTION: Quickly assess
• Amount of blood loss: General condition, pallor, pulse rate and blood
pressure.

• Blood samples: Cross matching, group and hemoglobin.

• An infusion of normal saline is started and blood transfusion

• Gentle abdominal palpation: Uterine tenderness and auscultation to note the

fetal heart rate.

• Inspection of vulva to note the presence of any active bleeding.

Confirmation of diagnosis: History, physical examination and sonographic

examination.

2. FORMULATION OF LINE OF TREATMENT

• Depends upon the duration of pregnancy, fetal and maternal status and extent
of the hemorrhage.

a. EXPECTANT TREATMENT

• Vital prerequisites: Availability of blood for transfusion, facilities for

caesarean section

• Selection of cases: – Mother is in good health status (Hemoglobin ≥ 10 gm%,

hematocrit > 30%), – Duration of pregnancy is <37 weeks, – Active vaginal
bleeding is absent, – Fetal well being is assured.

Conduct of expectant treatment:

• Bed rest with bathroom facilities

• Investigations: Hemoglobin estimation, blood grouping and urine for protein

• Periodic inspection of the vulval pads and fetal surveillance with USG at
interval of 2-3 weeks

• Supplementary hematinics if the patient is anemic.

• When patient is allowed out of bed a gentle speculum examination is made to

exclude local cervical and vaginal lesions for bleeding.

TERMINATION OF THE EXPECTANT TREATMENT:

Expectant treatment is carried upto 37 weeks of pregnancy.

• Premature termination may have to be done in conditions, such as –

Recurrence of brisk hemorrhage and which is continuing – The fetus is dead –
The fetus is found congenitally malformed on investigation

• Steriod therapy: If the duration of pregnancy is less than 34 weeks.

Active interference:

• Bleeding occurs at or after 37 weeks of pregnancy.

• Patient is in labour

• Patient is in exsanguinated state on admission

• Bleeding is continuing and of moderate degree

• Baby is dead of known to be congenitally deformed.

DEFINITIVE TREATMENT
1. Vaginal examination in operation theatre followed by low rupture of
membranes or Caesarean section.

2. Caesarean section without internal examination

1. Vaginal examination:

Double setup examination should be done in operation theatre keeping

everything ready for caesarean section.

• Contraindications of vaginal examination are: –

Patient is in exsanguinated state

– Major degree of placenta previa

– Associated complicating factors: Malpresentation, elderly primigravida,

history of previous caesarean section, contracted pelvis etc.

a. Low rupture of membrane: Done in lesser degree of placenta previa (Type I

and Type II anterior).
b. Caesarean section: The indication are:

– Severe degree of placenta

– Lesser degree of placenta previa where amniotomy fails to stop bleeding or

fetal distress appears.

– Complicating factors associated with lesser degrees of placenta previa where

vaginal delivery is unsafe.

– Caesarean section without internal examination

NURSING ASSESSMENT
• Determine the amount and type of bleeding; also, review any history of
bleeding throughout this pregnancy.
• Inquire as to the presence or absence of pain in association with the bleeding.
• Record maternal and fetal vital signs.
• Palpate for the presence of uterine contractions.
• Evaluate laboratory data on hemoglobin and hematocrit status.
• Assess fetal status with continuous fetal monitoring.
NURSING DIAGNOSES
• Ineffective Tissue Perfusion, Placental, related to excessive bleeding causing
fetal compromise
• Deficient Fluid Volume related to excessive bleeding
• Risk for Infection related to excessive blood loss and open vessels near cervix
• Anxiety related to excessive bleeding, procedures, and possible maternal-fetal
complications

ABRUPTIO PLACENTA

DEFINITION
It is one form of antepartum hemorrhage where bleeding occurs due to
premature separation of normally situated placenta.
PATHOLOGY
• Initiated by hemorrhage into the decidua basalis.
• The decidua then splits, leaving a thin layer adhered to the myometrium.
• Consequently, the process in its earliest stages consists of the development of
a decidual hematoma that leads to separation, compression, and ultimate
destruction of the placenta adjacent to it.
• Inflammation—infection—may be a contributor to causal pathways.
• Early stage: May be no clinical symptoms, and separation is discovered upon
examination of the freshly delivered placenta.
– There is a circumscribed depression on the placenta's maternal surface.
– Usually measures a few centimeters in diameter and is covered by dark,
clotted blood.
• In some instances, a decidual spiral artery ruptures to cause a retroplacental
hematoma, which as it expands, disrupts more vessels to separate more
placenta.
• The area of separation rapidly becomes more extensive and reaches the margin
of the placenta.
• Because the uterus is still distended by the products of conception, it is unable
to contract sufficiently to compress the torn vessels that supply the placental
site.
• The escaping blood may dissect the membranes from the uterine wall and
eventually appear externally or may be completely retained within the uterus.

VARIETIES OF ABRUPTIO PLACENTA

• Concealed Hemorrhage
• Revealed
• Mixed
RISK FACTORS
• Increased age, poor socioeconomic condition and parity
• Preeclampsia
• Chronic hypertension
• Preterm ruptured membranes
• Folic acid deficiency
• Short cord
• Multifetal gestation
• Low birth weight
• Hydramnios
• Cigarette smoking
• Thrombophilias
• Cocaine use
• Prior abruption
• Uterine leiomyoma

COUVELAIRE UTERUS
• Widespread extravasation of blood into the uterine musculature and beneath
the uterine serosa.
• Such effusions of blood are also occasionally seen beneath the tubal serosa,
between the leaves of the broad ligaments, in the substance of the ovaries, and
free in the peritoneal cavity.
• Incidence is unknown, can be demonstrated only at laparotomy.
• These myometrial hemorrhages seldom interfere with myometrial contraction
to cause atony, and they are not an indication for hysterectomy.

CHANGES IN OTHER ORGANS

• Liver: fibrin knots in the hepatic sinusoids
• Kidney: Acute cortical necrosis or acute tubular necrosis
• Shock proteinuria: is due to renal anoxia which usually disappears two days
after delivery.

BLOOD COAGULOPATHY:
• It is due to excess consumption of plasma fibrinogen due to DIC and
retroplacental bleeding.
• There is overt hypofibrinogenemia (<150mg/dl) and elevated levels of fibrin
degradation products and D dimer.

CLINICAL CLASSIFICATION
Depending upon the degree of placental abruption and its clinical effects, the
cases are graded as follows:
• Grade 0: Clinical feature may be absent.
• Grade 1: External bleeding is slight. Uterus is irritable; tenderness may or may
not be present. Shock is absent. FHS is good.
• Grade 2: External bleeding is mild to moderate. Uterine tenderness is always
present. Shock is absent. Fetal distress or even fetal death occurs.
• Grade 3: Bleeding is moderate to severe or may be concealed. Uterine
tenderness is marked. Shock is pronounced. Fetal death is the rule. Associated
coagulation defect or anuria is present.
CLINICAL FEATURES
Depends upon
• Degree of separation of placenta
• Speed at which separation occurs and
• Amount of blood concealed inside the uterine cavity.

Revealed Mixed

Symptoms: Abdominal discomfort or Active intense pain

pain followed by vaginal abdomen followed by
bleeding slight vaginal bleeding.
The pain becomes
continuous.

Character of bleeding Continuous dark colour Continuous dark colour

(slight to moderate) (usually slight) or blood
stained serous discharge.

General condition Proportionate to visible Shock is pronounced

blood loss, shock is which is out of
usually absent proportion with the
visible blood loss.

Pallor Related with visible Pallor is usually severe

blood loss and out of proportion to
visible blood loss.

Features of preeclampsia May be absent Frequent association

either preexisting or
appear.

Uterine height Proportionate to POG Disproportionately

enlarged and globular.

Uterine feel Normal feel with Uterus is tense, tender

localized tenderness, and rigid
contractions frequent and
local amplitude

Fetal parts Can be identified easily Difficult to make out

 FHS Usually present Usually present Usually absent
Usually absent

Urine output Normal Usually diminished

Laboratory Blood Hb% Low value proportionate Markedly lower, out of

to blood loss proportion to blood loss

Coagulation profile Usually unchanged Variable changes :

Clotting time increased
(>6 min) Fibrinogen
level low (<150mg/dl)
Platelet count low
Increased PTT Increased
FDPand D dimer

Urine for protein May be absent Usually present

Confusion in diagnosis With placenta previa. With acute obstetrical

gynecological surgical
complication
MANAGEMENT
• Depending on gestational age and status of mother and fetus.
• With a fetus of viable age, and if vaginal delivery is not imminent, then
emergency cesarean delivery is chosen.
• Resuscitation and acute management, with massive external bleeding,
intensive resuscitation with blood plus crystalloid and prompt delivery to
control hemorrhage are lifesaving for the mother and hopefully, for the fetus.
• If the diagnosis is uncertain and the fetus is alive but without evidence of
compromise, then close observation can be practiced in facilities capable of
immediate intervention.
PREVENTION
• Prevention, early diagnosis and effective therapy of preeclampsia and other
hypertensive disorders of pregnancy.
• Needle puncture during amniocentesis should be under ultrasound guidance.
• Avoidance of trauma specially forceful external cephalic version under
anesthesia
• To avoid sudden decompression of the uterus
• To avoid supine hypotension
• Routine administration of folic acid from early pregnancy.

IN THE HOSPITAL
1. Revealed type: assessment is to be done as regards:
– Amount of blood loss
– Maturity of fetus
– Whether the patient is in labour or not Preliminaries
• Blood for Hemoglobin and hematocrit estimation, coagulation profile, ABO
and Rh grouping and urine for detection of protein.
• RL solution drip started with wide bore cannula and arrangement for blood
transfusion.
• Close monitoring of maternal and fetal condition.
PATIENT IS IN LABOUR
• Labour is accelerated by low rupture of membranes.
• Oxytocin drip is started to accelerate labour.
The patient is not in labour:
• Pregnancy 37 weeks or more: induction of labour is to be done by low rupture
of membrane with or without oxytocin.
• Pregnancy less than 37 weeks:
– Bleeding moderate to severe and continuing
—low rupture of membrane, administration of oxytocin drip
– Bleeding slight or has stopped
—the patient is put on conservative management, close observation of the
mother and careful monitoring is essential.
2. Mixed or concealed type Principles of management of concealed type are:
• To correct hypovolemia and to restore blood loss. Normal saline or hemaccel
infusion is started
• To bring about effective uterine contraction and termination of the abruption
process.
• To observe blood coagulation profiles at two hourly interval.
• Close monitoring of maternal and fetal condition is maintained.
• Vaginal delivery
• Caesarean section: – Early: Unfavourable cervix where speedy vaginal
delivery is not possible and there is good prospect of fetal survival.
– Late: If inspite of amniotomy and oxytocin, the progress of labour is delayed
(6-8 hours) and instead, the general condition gradually deteriorates with
appearance of complicating factors like oliguria or falling fibrinogen level or
there is evidence of fetal distress.
NURSING DIAGNOSES
• Ineffective Tissue Perfusion: Placental related to excessive bleeding,
hypotension, and decreased cardiac output, causing fetal compromise
• Deficient Fluid Volume related to excessive bleeding
• Fear related to excessive bleeding, procedures, and unknown outcome

CONCLUSIONS:

As a midwife we must have the knowledge regarding bleeding in late

pregnancy, its effects on pregnancy, complications to identify the mothers with
bleeding in late pregnancy and to provide comprehensive nursing care for the
mothers in prevention and promotion of health in various health care settings.

BIBLIOGRAPHY:

 D.C.Dutta (2008) text book of obstetrics sixth edition, published by

new central book agency, page no.256-264.
 Mudaliar and Menon’s clinical obstetrics, eleventh edition, published
by universities press private limited, page no.264-266.
  Raman A.V. text book of maternity nursing, Walters Kluwer
publications, 21st edition, page no.320-321.
 Reeder a text book of maternity nursing, Walters Kluwer publishers,
page no:150-154.
 Myles text book for midwives (2009), 16th edition, Elsevier
publications, page no.62-69, 373-374.
 Williams text book of obstetrics, 23rd edition, Mc.Graw Hill
publications, p. no.1362-1366.
 Annamma Jacob textbook of midwifery nursing, 2nd edition,
published by Jaypee brothers, page no. 302-306.

JOURNALS

Isabelle Trop1 and Deborah Levine. Hemorrhage During Pregnancy

Sonography and MR Imaging. March 2001, Volume 176, Number 3

ABSTRACT

Vaginal bleeding is the most frequent indication for first-trimester sonography.

In the presence of a live embryo, the most frequently encountered sonographic
finding is a subchorionic hematoma. Bleeding in the second and third trimesters
is less common. Bleeding restricted by the placenta, the amniotic or chorionic
membranes, or both has characteristic sonographic features that are important to
recognize because the prognosis varies with location. Bleeding within the fetus
is uncommon. This pictorial essay presents the varied sonographic and MR
imaging manifestations of bleeding throughout pregnancy.

James R. Scott, M.D. Vaginal bleeding in the midtrimester of pregnancy.

Volume 113, Issue 3, Pages 329–334

Abstract
One hundred and two cases of vaginal bleeding during the midtrimester of
pregnancy occurring over a 10 year period were reviewed. This condition is
more common than generally recognized, and the perinatal mortality rate is
extremely high. The etiology of the bleeding was found to fall into five general
categories: hydatidiform mole, placenta previa, premature placental separation,
extrinsic causes, and undetermined causes. The prognosis for the fetus becomes
progressively more grave with increased amount of bleeding, the number of
bleeding episodes, and if accompanied by uterine cramps. The perinatal
mortality rate was 42 per cent when the bleeding was due to placenta previa, 83
per cent when secondary to premature placental separation, and 33 per cent
when due to an unknown cause. Cases of second-trimester bleeding severe
enough to require transfusion were associated with a perinatal mortality rate of
84 per cent. In view of these findings, heroic measures are not indicated, and a
suggested therapeutic regimen is discussed.