Placenta praevia
Premature separation of abnormally placed placenta in part or whole ( rarely ) causes unavoidable haemorrhage. It is always revealed.
What is antepartum haemorrhage?
Bleeding from genital tract during pregnancy after 28th week is called antepartum haemorrhage.
What are the types of antepartum haemorrhage?
They are of two types—Accidental & Placenta praevia
What is accidental haemorrhage?
It is the bleeding from normally situated placenta.
What are the causes of accidental haemorrhage?
Trauma—any fall or injury and blow on abdomen.
Pre-eclampsia Eclampsia
What will you find on USG?
A retroplacental clot with normally situated placenta.
What are the types of bleeding in accidental haemorrhage?
They are:
Concealed
Revealed and
Mixed type
What are the signs and symptoms of accidental haemorrhage?
It depends upon the amount of bleeding.
In concealed type patient comes with abdominal discomfort and pain.if bleeding is more then signs of shock will be there. If retroplacental clot is big then the size of uterus will be more than the expected dates. USG differentiates between concealed , revealed or placenta praevia.
One should never try to do per vaginal examination in the outdoor as low lying placenta may bleed profusely.Strict instructions should be given to RMO’s and nursing staff not to do PV in such cases. Simply take the pulse , BP , start IV line after taking the blood sample for routine haemogram, Blood grouping, BT, CT and platelet count. Immediately prepare OT in case LSCS is required and meanwhile an USG can be done.
What are the features of mild accidental haemorrhage?
Abdominal discomfort , reddish-brown discharge, number of signs of shock, abdominal size corresponding with gestational period , slight rigidity and tenderness, symptoms of pre-eclampsia or history of fall, audible fetal heart sounds.
What are the signs and symptoms of severe bleeding ?
Intense abdominal pain, headache , faintness, vomiting and visual disturbances due to pre- eclampsia, shock–pallor, tachycardia, low -BP. Height of uterus more than the expected dates, board like rigidity, extremely tense uterus, fetal parts and heart sounds can not be felt and heard.
What is the treatment of mild accidental haemorrhage ?
Hospitalization for bed rest and observation and investigations for few days, treatment of pre-eclampsia, mild sedation, bed rest at home, frequent follow ups for BP check up and repeated USG. Admit the patient when baby is mature.
What is the line of treatment in case of severe bleeding ?
Start IV line, immediate blood transfusions, anti-hypertensives and empty the uterus as soon as possible.Normal labour or LSCS depending upon the dilatation and station of the head. Suppose it is 3-4 fingers, thin and head is lower down in pelvis and amount of bleeding is less, then one can do ARM and accelerate the labour. Complication of PPH should always be kept in mind. Emptying of bladder, oxytocin, methergine, prostaglandins after watching BP, bimanual massage can prevent it.
If cervix is not favourable and bleeding is profuse then one has to go for C-section immaterial of whether the fetus is mature or alive.During LSCS , PPH can be due to atony of uterus which can be managed with methergine, pitocin, prostaglandins. If can not be controlled then possibility of DIC should always be kept in mind .It is a life threatening condition. FFP should be kept ready. If bleeding is due to atonic uterus and not due to DIC, then an expert obstetrician can always go for uterine artery ligation, internal iliac ligation, B-lynch stitch or subtotal hysterectomy depending upon the expertise and severity of the condition
Placenta praevia
Premature separation of abnormally placed placenta in part or whole (rarely) causes unavoidable haemorrhage. It is always revealed.Placenta is situated in lower uterine segment.
What are the signs of placenta praevia ?
Warning bleeding during early pregnancy and its recurrence. USG confirms the diagnosis.
Why a placenta in lower uterine segment is prone to bleeding ?
Since lower uterine segment is slowly but constantly stretched and taken up as a result of rhythmic contractions of pregnancy, a part of it gets detached and gives rise to bleeding.
Can it present as threatened abortion in early pregnancy ?
Yes, in some cases.
What are the predisposing factors of placenta praevia ?
Multigravida. malpresentations. Fibroids. Bicornuate uterus.
What are the degrees of placenta praevia ?
First–
lateral—lower margin encroaching on to the lower uterine segment.
Second–
marginal—It reaches down to internal OS.
Third–
complete—It covers the internal OS when cervix is undilated.
Fourth–
central–It completely covers the OS in fully dilated cervix.
What are the features of bleeding in placenta praevia ?
It is bright red, painless with no history of trauma.
What are the signs ?
No shock if less bleeding, signs of shock if severe bleeding, usually no signs of pre-eclampsia, no enlargement of uterus, no guarding, no rigidity, malpresentations, normal uterine consistency, high head, breech, transverse lie, no difficulty in feeling fetal parts, audible fetal heart sounds.
What is the aim of conservative treatment ?
To prolong the pregnancy till fetus has reached the maturity without endangering the life of the mother.
What is done in conservative treatment ?
Absolute bed rest. Mild sedatives.
Investigations—Haemogram, BT, CT, platelet count, grouping, USG. Slow blood transfusion if bleeding is less.
No vaginal examination should be done.
Visualisation of the cervix for the local cause in OT with speculum after complete stoppage of the bleeding for more than 24 hrs.
Discharge the patient if it is first or second degree and bleeding stops but tell her to take complete bed rest at home and vehicle should always be kept ready as need can arise at any time for admitting her in the hospital. Hospital should be near by and donors for blood transfusion should always be ready.
Meanwhile regular USG and vitals can be observed so call her regularly for follow ups.
What is the active treatment of first degree and second degree placenta praevia ?
Normal labour can be tried under strict watch and all the preparations for C- section should be kept ready.Anesthetist and Paediatrician should be informed in advance.
How do you treat other degrees ?
By C- section.
How do you proceed after incising through placenta ?
A loop of umbilical cord is sought and divided, the placenta is rapidly removed followed by quick extraction of the baby.
How will you prevent PPH during C- section ?
Placental bed keeps on oozing, so quick suturing , inj oxytocin , inj methergine , inj prostaglandins , B- lynch suture , internal iliac artery ligation and sometimes sub total hysterectomy is the only answer. So early diagnosis , early blood transfusions , early decision of LSCS saves the mother having placenta praevia.