Antepartum Hemorrahge

1. Placental abruption (=abruptio placentae)
(1) Definition : The separation of the placenta from its site of implantation before the delivery of the fetus
- External hemorrhage : the blood escapes though the cervix
- Concealed hemorrhage : the blood retained between the detached placenta and the uterus

(2) Epidemiology
- Incidence : about 1 in 200 deliveries (variable diagnosis from center to center)
- Perinatal mortality : about 25%
- Perinatal morbidity : 14% - significant neurological deficits within the first year of life
- High recurrent rate : severe abruption in 1 in 8 pregnancies
(3) Etiology
- The primary cause : unknown
- Risk factors
ⅰ) Increased maternal age
ⅱ) Multiple parity
ⅲ) Maternal hypertension
ⅳ) Preterm premature rupture of the membranes(PPROM)
ⅴ) Cigarette smoking
ⅵ) Cocaine abuse
ⅶ) Thrombophilias
ⅷ) External trauma
ⅸ) Uterine leiomyoma
ⅹ) Prior abruption
(4) Diagnosis
; symptoms & signs can vary considerably =>
: Complications
I) Consumptive coagulopathy
- ↓fibrinogen, ↑fibrinogen-fibrin degradation products, ↑D-dimer, ↓coagulation factors
- coagulation site : intravascular > retroplacental
ii) Renal failure - impaired renal perfusion due to massive hemorrhage
iii) Shock - sometimes can be seen

iv) Couvelaire uterus (=uteroplacental apoplexy)
- widespread extravasation of blood into the uterine musculature and beneath the uterine serosa
: Negative findings with USG -> do not exclude placental abruption

(5) Treatment
-> depend on gestational age and the status of the mother and fetus
1) Full term pregnancy
: cesarean delivery
: itensive resuscitation with blood and crystalloid
: if uncertain diagnosis & no fetal compromise -> close observation
2) Preterm pregnancy
: delaying delivery is beneficial
: but delivered within a few days due to severe hemorrhage, fetal distress or both
: tocolytic therapy의 효과는 불명확
3) Deaded fetus
: coagulation defect로 인해 cesarian section으로 massive bleeding의 위험이 있으므로 특별한 이유가 없는 한 vaginal delivery 선호

2. Placenta previa
(1) Definition : the placenta is located over or very near the internal os
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 the placenta is at the margin of the internal os
4) Low-lying placenta
: The placenta is implanted in the lower uterine segment such that the placenta edge actually dose not reach the internal os but is in close proximity to it
(※참고 vasa previa : the fetal vessels course through membranes and present at the cervical os)
(2) Incidence : about 0.5% deliveries
(3) Etiology
ⅰ) Increased materal age
ⅱ) Multiparity
ⅲ) Prior cesarean delivery
ⅳ) Smoking
(4) Clinical findings
: Painless hemorrhage
(formation of the lower uterine segment and the dilatation of the internal os -> tearing of placental attachments)
: Coagulopathy is rare

(5) Diagnosis
; digital examination => 하지 않는 것이 좋음
- a finger is pssed through the cervix and the placenta is palpated
- too risky due to massive bleeding
: USG - localization of the placenta with considerable accuracy(98%)

※Placental migration

(6) Treatment
1) Preterm fetus with no active bleeding -> close observation후 bleeding 소견 없어지면 퇴원하여 F/U
2) Cesarean delivery : necessary in practically all cases of placenta previa
: 이후 bleeding control 안되면 hysterectomy필요