OBSTETRIC HAEMORRHAGE

JAYAKUSUMA
FETOMATERNAL DIVISION
OBSGYN DEPT
FAC,MED UDAYANA UNIVERSITY

DEFINITION

ABORTION IS THE TERMINATION OF

PREGNANCY,EITHER SPONTANEUSLY OR
INTENTIONALY , BEFORE THE FETUS
DEVELOPS SUFFICIENTLY TO SURVIVE.
USUALY DEFINE AS PREGNANCY
TERMINATION PRIOR TO 20 WEEKS
GESTATION OR LESS THAN 500 GRAM BIRTH
WEIGHT
DEFINITION VARY, ACCORDING TO ABILITY
TO TREAT THE EXTREMELY PRETERM
UNBORN BABY.

SPONTANEOUS ABORTION

Abortion occurring without medical or

mechanical means to empty the uterus.
Etiology :
- > 80% occur in the first 12 weeks of
pregnancy and the etiology is
chromosomal anomalies
- after 12 weeks incidence of abortion
and chromosomal anomalies are
decrease .

etiology
1.

2.

Fetal factors :
- abnormal zygotic development
- aneupoid abortion
Maternal factors :
- infections
- endocrines disorders( progesterone def, diabetes
mellitus)
- nutrition
- drug use ( tobacco,alcohol,radiation,toxins)
- immunological factors ( APA)
- trauma
- uterine defects
- cervix incompetence

Etiology (2)

3. Paternal factors :
- sperm chromosomal anomalies.

Spontaneus Abortion
( cont)
Pathology :
early abortion : beginning with bleeding
into the decidua basalis necrosis of
tissues adjacent the bleeding
conceptus detaches uterine contraction
expulsion
Later abortion : retained conceptus
maceration the skull bone
collapse,abdomen distended when
amniotic fluid absorbed fetus become
compressed fetus compresus fetus
become dry fetus papyraceus.

Subgroup of spontaneus
abortion

Clinically spontaneous abortion separate

into 3 subgroup :
1. Threatened abortion
2. Inevitable abortion
3. Complete abortion or incomplete

Threatened abortion
Bleeding appears through a closed cervical os
Bleeding maybe spooting or heavier, may persist for
days-weeks
Half of this condition will abort, especially if fetal
cardiac activity is absent
Clinic manifestations :
bleeding and abdominal cramping ( dull, midline
and supra pubic discomfort)
DD/ : polyps, cx erosions, ectopic pregnancy
R/ : bed rest
Analgesics
follow up : USG, bHCG levels

Inevitable Abortion
Rupture of membrane, followed by escape of
amniotic fluid, bleeding, pain, fever.
Clinical manifestations :
- rupture of membrane
- evidence of leaking amniotic fluid
- bleeding and pain
- cervical dilatation
- fever
Management : bed rest, observed for 2-3 days
usual activities (+), except for vaginal
examination

Incomplete abortion
Expulsion of the fetus, placenta in part from the
uterus or the conceptus remain entirely in utero may
partially extrude through the cervical dilated os.
Bleeding may severe
Clinical manifestations :
- bleeding, pain, abdominal cramp
- cervical os remain open
- retained placental tissue lies in cervical canal
Management :
- stabilize hemodynamic by fluid replacement
- extracting the retain placenta by ring forceps
- if bleeding occur heavily suction curettage ASAP

Complete abortion
Expulsion of the fetus, placenta in whole
from the uterus or the conceptus escape
completely from uterus
Clinical manifestations :
- cervical os closes
Management :
-observed

Ectopic pregnancy

Implantation of the conceptus anywhere

out of endometrial lining of the uterine
cavity
Could be uterine or extra uterine
Uterine : cervical
Extra uterine : fallopian tube, fimbriae,
broad ligament, ovarial or abdominal
Almost 95% occurred in the fallopian
tube.
The chance of successful pregnancy after
ectopic pregnancy decreased

Ectopic pregnancy (cont)

Risk :
1. Pelvic inflammatory diseases
2. Tubal surgery
3. infertility
Pathogenesis :
the fertilized ovum, implanted in ectopic place ( fallopian
tube )the tube lacks of submucosal layer zygote comes to
lie in the muscular wall tropoblast rapidly growing and
invades/ erodes the muscular wall bleeding to the tube
canal to abdominal cavity or backward to the uterine cavity
( TUBAL ABORTION)
Location of tubal abortion : ampulla
if the tube ruptured abdominal bleeding ( TUBAL RUPTURED)
Location of tubal ruptured : istmic

Ectopic pregnancy ( cont

3)

Clinical manifestations and Diagnosis :

- Clinical manifestation is depend on whether rupture has occurred or not
- early and prompt diagnosis identify the tube before rupture
- pelvic or abdominal pain
- amenore
- spotting or bleeding
- abdominal or pelvic tenderness
- uterine changes push to one side by ectopic mass
- passes of uterine decidual cast bleeding
- Blood pressure and pulse
- Pelvic mass -- > pain and tenderness
- Culocentesis to identify the hemoperitoneum by inserted the
needle through the posterior fornix into the cul de sac.
- Laboratory : B HCG and USG

Ectopic pregnancy (cont 4)

Treatment :
1. Surgical :
Conservative surgery : tubal salvage (salphyngostomy)
Radical Surgery
: Salphyngectomy
2. Medical :
Methotrexate : highly effective against active tropoblast
dose : Mtx
Variable dose : 1 mg/kg IM, days 1,3,5,7
3. Expectant Management :
- criteria : tubal pregnancy only, b HCG decreased, no
abdominal bleeding, diameter of ectopic mass < 3,5 cm

Placenta previa

Placenta is located over or very near the internal os.

Four degrees of placenta previa :
1. Total Placenta previa: the internal cervical os
is covered completely by placenta
2. Partial placenta previa : the internal os is
partially covered by placenta
3. Marginal placenta previa : the edge of
placenta is at the margin of internal os
4. Low lying placenta : the placenta is implanted
in the lower uterine segment such that the placental
edge actually doesnt reach the internal os but in
close proximity to it

Placenta previa (cont 2)

Etiology :
1. Advance maternal age
2. Multiparity
3. Previous CS
Clinical findings :
painless hemorrhage at the of the 2
trimester or 3 rd trimester
its onset without warning
initial bleeding is not previous, subsequent
bleeding heavier

Placenta previa (cont 3)

Management :
--> depend on :
1. fetus preterm or aterm
2. bleeding severe or not
management with preterm fetus and no active bleeding is
Conservative, bed rest to prolong pregnancy until the fetus
mature
informed the family regarding the problem of placenta
previa
every placenta previa should be manage in the tertiary
hospital.
- delivery by CS : term baby and or active bleeding
!!! Dont perform the vaginal examination can cause severe
bleeding .

Placental abruption

Separation of the placenta from its normal

site of implantation before delivery
If bleeding escapes through the cervix
external hemorrhage
If bleeding retained in uterus concealed
hemorrhage.
Etiology :
primary causes is unknown
risk factors : increased age and parity,
preeclampsia, PROM, hydramnios .

Placenta abruption (cont

2)
Pathogenesis:
initially there is hemorrhage into the
decidua basalis decidual hematoma
separation and compression of the
placenta.
Signs and symptoms depend on the size
of the hematoma.

Placental abruption ( cont

3)

Clinical diagnosis :
1. external bleeding can be profuse
compromise mother and fetus directly
2. abdominal cramp and pain
3. Blood pressure and pulse shock
4. blood loss anemia
USG to confirm diagnosis

Placental abruption ( cont4

)

Complication :
Maternal : shock, consumptive
coagulopathy ,uterine couvelar, and renal
failure
Fetal : intra uterine fetal death
MANAGEMENT :
1, Expectant : delaying delivery when
fetus preterm and maternal
hemodynamic stable
2, delivery : vaginal delivery if bleeding
so severe n fetus is dead. If fetal

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