Tan Zhi Hong 1402365

Ante-partum haemorrhage
Definition:Ante-partum haemorrhage is bleeding from the genital tract after the 24th week of
pregnancy and before the birth of the baby.
It occur in 3% of the pregnancy and Placenta Praevia (inevitable haemorrhage) and Placental
Abruption (accidental haemorrhage) make up 1% each.. The remaining 1% include trauma in
vagina, cervix carcinoma, and other unexplained causes even when the placenta is examined after
delivery for signs of premature separation.

Placenta Preavia
A low implantation of the placenta in the uterus, causing it to lie alongside or in front of the
presenting part. It can be classified into two types clinically, which are minor and major type.
Aetiology:
The cause is unknown but one of the cause may be sexual intercourse during pregnancy
because the patients with known placenta preavia diagnosed by ultrasound and admitted to
hospital are unlikely to have severe bleeding.
Signs and Symptoms
The loss may be slight or considerable and tends to be recurrent. The bleeding is painless
because blood is not normally retained within the uterine cavity.
Management
Give sedation to the patient as she might be worried about the bleeding. Next, perform full
blood count and Hb level test to assess the severity of bleeding. Blood pressure chart and heart
rate are also monitor to look for hypotension and palpitation due to blood lost. Input and output
chart is also done to monitor the changes in fluid level in patients body. Besides that, ultrasound
is used to deduce the gestational age and also to note for any fetal abnormalities.
Although placenta preavia used to be a very dangerous condition to the mother in the old
time and induce labor is done early, Mc Caffy state that the baby should be allowed to develop
until 36 to 38 weeks before labor. However, this principle is abandoned if one of the factors as
stated below happen, which include excessive bleeding from placenta preavia, patient goes into a
state of shock, uterus get irritable, presence of fetal distress or fetal death in-utero.

Placenta Abruption
This means the separation of a normally situated placenta. It usually leads to vagina bleeding
but often blood remains in the uterus as a retro-placental clot and sometimes there is no external
bleeding. Where there is both external bleeding and evidence of retro-placental clot the
haemorrhage is described as 'mixed'.

Aetiology
The aetiology of abruption is unknown but several factors have been postulated as linked
causes:

Signs and Symptoms

1. The patient complains of abdominal pain which may be severe and constant. Pain is
greatest when blood remains in uterus and form a clot, but the pain may be minimal or absent
when there is vaginal bleeding.
2. Vaginal bleeding, where present, usually makes the diagnosis straightforward.
3. The uterus may be tense and tender due to the retention of clot and the extravasation of
blood into the uterine wall. In severe cases blood may spread into the broad ligament or
peritoneal cavity.
4. There may be evidence of hypovolaemia depending on the extent of haemorrhage.
5. In severe cases the fetus is dead.
Management
1. Minor or uncertain cases
Treatment is by bed-rest, sedation if required and observation. The haemoglobin should be
estimated and a clotting screen should be carried out to prevent coagulation failure due to
excessive consumption of coagulation factors.. Confirmation of placental separation may be
obtained by a positive Kleihauer test, indicating fetomaternal bleeding.
2. Established Abruption
(a) Rapid assessment of maternal and fetal state.
(b) Blood taken for haemoglobin, cross-match and clotting screen.
(c) Analgesia to treat shock and pain.
(d) Blood transfusion to correct hypovolaemia.The rate and volume of transfusion are best
monitored by a central venous pressure (CVP) line in severe cases as blood loss is always likely
to be underestimated.
(e) Expedite delivery.
3. Delivery

There may be poor retraction of the uterus following the delivery of the placenta due to high
levels of circulating fibrin degradation products, and thus an atonic post partum haemorrhage
may cause danger to the mother. Intravenous oxytocics should therefore be given and
ergometrine, with its tonic action on the uterus, is the drug of choice. Following delivery careful
supervision of urinary output is essential and the presence of anemia should be sought.