ANTEPARTUM

HAEMORRHAGE:PLACEN
TA PREVIA
Definition/Introduction
Antepartum haemorrhage is bleeding from the
genital tract that occurs between the age of fetal
viability(28th week of pregnancy) and the delivery of
the fetus.
It is an obstetric emergency and also a significant
cause of both maternal and perinatal morbidity and
mortality.
It occurs in about 3% of all pregnant women.
In UPTH, it accounted for 4.8% of admissions into
the Ante-natal Ward in 2003 (Annual Report).
 Causes of APH
 Placenta praevia
 Placental abruption (abruptio
placenta)
 Local causes: cervical polyps,
cervicitis, cancer of the cervix, post-
coital genital laceration
 Vasa praevia
 Unknown
 PLACENTA PRAEVIA
 Literally means afterbirth first
 It is the location of the placenta either
partially or completely in the lower uterine
segment.
 It is believed to occur due to a delay in
implantation of the blastocyst in the
uterine cavity.
 The extent of the attachment to the lower
uterine segment determines both the
management and prognosis.
 Incidence varies between 0.4-0.8%. In
UPTH- 2.8% in 2003.
 Aetiology
.Cause unknown
.Multiparity
.Multiple pregnancy
.Previous Caesarean delivery
.Previous myomectomy
.Previous induced abortion
.Older women
.Cigarette smoking/cocaine use
.Uterine fibroids/other uterine abnormalities
 Pathophysiology
 Placenta praevia typically occurs as a result of
abnormally low implantation believed to result
from abnormal endometrial vascularisation
related to atrophy or scarring from prior trauma
or inflammation.
 The margins of the abnormally implanted
placenta are altered as the lower uterine segment
thins out in late pregnancy.
 Various degrees of placental detachment may
develop with ensuing maternal haemorrhage from
the intervillous spaces.
 In the absence of the decidua basalis, the
placenta can attach directly to the myometrium
(Accreta), invade the myometrium (Increta),or
penetrate it (percreta).
 Placenta accreta occurs in ~ 1 in 2500 deliveries
and the rate is increased to 10% in women with
placenta praevia.
 CLASSIFICATIONS
 Type I- the placenta is located in the lower uterine segment
but does not reach the internal os
 Type II- it is attached to the lower uterine segment with its
lower margin reaching the internal os but does not cross it
to the opposite side. IIA- anterior, IIB- posterior.
 Type III- the placenta is in the lower uterine segment and
covers the internal os but not completely
 Type IV- the placenta is centrally placed and completely
covers the internal os
 Placenta praevia types I and IIA may also be classified as
Minor degree placenta praevia and types IIB-IV as Major
degree.
 Another method of classification labels the occurrence of
placenta praevia as i) Marginal when the placenta
approaches the border of the internal os, ii) Partial when it
partially covers the internal os and iii) Total when the
internal os is completely covered.
 Differential Diagnosis
 Abruptio placenta
 Cervicitis
 Cervical laceration
 Heavy show
 Vasa praevia