ANTEPARTUM HAEMORRHAGE

Abruptio Placentae and Placenta Praevia

Vaginal bleeding occurring after 28 weeks of pregnancy, and up to second stage of labour.

Causes

  • Local causes from genital tract
  • Placenta praevia: All or part of the placenta is found in the lower segment of the uterus
  • Abruptio placentae: Premature separation of a normally placed placenta

Comparison of Clinical features

SIGN/SYMPTOM PLACENTA PRAEVIA ABRUPTIO
PLACENTAE
Abdominal
pain
Painless Severe pain
Foetal
movements
Foetal movements
usually present
Loss of foetal
movements
common
Amount
of vaginal
bleeding
Significant
bleeding from the
vagina
Significant
bleeding may be
absent; only serous
fluid in some cases
(bleeding is behind
the placenta)
Maternal
general
condition
Shock and
anaemia if
bleeding is heavy
Shock and
anaemia, even
when no frank
bleeding
Uterine
consistency
Uterus soft and not
tender
Uterus hard and
tender
Position
of foetal
presenting
part
High presenting
part (head) or
malpresentation
(the part in the
lower uterus not
head)
Foetal parts
difficult to feel
because of hard
uterus
Foetal heart
sounds
Foetal heart
sounds usually
heard
Foetal heart
sounds often
absent

Differential diagnosis

  • Ruptured uterus especially in a patient with previous caesarean section or grand multipara
  • Local causes, e.g. cervical cancer

Investigations

  • Ultrasound: To find the site of the placenta and viability of the baby, this may not be conclusive for AP (take note of clinical signs and symptoms)
  • Blood:
    • Grouping, cross-matching
    • Haemoglobin, fibrinogen levels
    • Clotting time and bleeding time

MANAGEMENT

  • Any bleeding in late pregnancy needs immediate referral to hospital
  • Give IV normal saline infusion
  • Admit, inspect the vulva to ascertain colour and amount of bleeding but DO NOT perform a digital
    vaginal examination if you suspect placenta praevia
  • Any bleeding in late pregnancy needs immediate referral to hospital
  • Give IV normal saline infusion
  • Admit, inspect the vulva to ascertain colour and amount of bleeding but DO NOT perform a digital
    vaginal examination if you suspect placenta praevia
  • Correct anaemia and coagulation defects (transfuse blood and fresh frozen plasma)
  • In case of confirmed Abruptio Placentae where the baby is dead, and facilities for theatre
    and blood transfusion are available, with no contraindication to vaginal delivery:

    • Rupture membranes and start oxytocin 10 IU in 500 mL of Normal saline to induce labour
  • In case of Abruptio Placentae where the baby is alive
    • Deliver by emergency caesarean section (ensure you have enough blood)
  • In case of placenta praevia
    • Give steroids (as for PPROM) if <34 weeks
    • Emergency cesarean section if bleeding is uncontrolled, mother’s or baby’s life in danger or
      pregnancy >37 weeks
    • If bleeding resolves, keep mother in hospital and deliver at >37 weeks