2.Placenta Previa***- Types, Management 3.Abruptio Placenta -Varieties &M Management 4.Couvelaire Uterus **** – 3m 5.Vasa Previa*** Give me answers from Dutta obstetrics textbook to get 90%marks in MBBS exam -3m
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APH (Antepartum Hemorrhage) - MBBS Exam Guide
Topics: Placenta Previa | Abruptio Placenta | Couvelaire Uterus | Vasa Previa
(Based on Dutta's Obstetrics framework + Creasy & Resnik / Rosen's Emergency Medicine)
2. PLACENTA PREVIA ⭐⭐⭐
Definition
Placenta previa is the implantation of the placenta in the lower uterine segment, partially or completely covering the internal cervical os. It is a major cause of APH (bleeding after 28 weeks).
Types (Dutta's Classification)
| Type | Description |
|---|---|
| Type I - Low-lying | Placenta encroaches on lower uterine segment but does not reach the os |
| Type II - Marginal | Placental edge just reaches (touches) the internal os |
| Type III - Partial | Placenta partially covers the internal os |
| Type IV - Central/Complete | Placenta completely covers the internal os |
Exam Tip: Type III & IV = Major degrees. Type I & II = Minor degrees. Only Type IV cannot deliver vaginally under any circumstance.
Complete Placenta Previa:
Risk Factors (Remember: "MAPS-C")
- Multiparity
- Advanced maternal age
- Prior LSCS / uterine surgery
- Smoking
- Curettage / prior abortions, infertility treatment
Clinical Features
- Painless, bright red vaginal bleeding (hallmark) - sudden, without warning, usually after 28 weeks
- Uterus is soft and non-tender (key differentiator from abruption)
- Abnormal fetal lie common (unstable lie, oblique, transverse) due to lower segment occupation
- Fetal head high/not engaged
- Presenting part displaced upward on palpation
- Bleeding may be recurrent; each episode tends to be heavier
Diagnosis
- USG (Transvaginal ultrasound) - investigation of choice, safe even in previa
- Never perform digital vaginal examination in a suspected case (risk of catastrophic hemorrhage - "Double setup" examination is now abandoned)
- MRI if posterior placenta previa or accreta suspected
Management
Conservative Management (Expectant)
- Indicated when: preterm gestation (<37 weeks), no active bleeding, hemodynamically stable
- Admit to hospital; bed rest
- Two large-bore IV lines; Group & cross-match blood
- Baseline CBC, coagulation profile (fibrinogen normal in pregnancy = 400-450 mg/dL)
- Corticosteroids (betamethasone) for lung maturity if <34 weeks
- Tocolysis if contractions present
- Avoid digital examination
Active/Definitive Management
| Situation | Management |
|---|---|
| Type IV (Central) at any gestation with major bleed | Emergency LSCS |
| Type IV at 37 weeks | Elective LSCS |
| Type III at term | LSCS preferred |
| Type I/II at term, vertex, favorable | Trial of vaginal delivery possible |
| Fetal distress / maternal shock | Immediate LSCS |
Route of delivery:
- LSCS = definitive treatment for major degrees of placenta previa
- During LSCS: anticipate PPH, have blood ready; if accreta suspected, plan for hysterectomy
3. ABRUPTIO PLACENTAE ⭐⭐⭐
Definition
Abruptio placentae (placental abruption) is the premature separation of a normally situated placenta before delivery of the fetus, after 20 weeks of gestation. Complicates ~1% of pregnancies.
Varieties (Classification)
By Degree of Separation:
| Grade | Features |
|---|---|
| Grade 0 | Asymptomatic; retroplacental clot found on placental examination post-delivery |
| Grade 1 (Mild) | Slight vaginal bleeding, mild uterine tenderness, no fetal distress, normal coagulation, fibrinogen >150 mg/dL |
| Grade 2 (Moderate) | Moderate bleeding, uterine tenderness + tetanic contractions, fetal distress present, fibrinogen 100-150 mg/dL |
| Grade 3 (Severe) | Heavy bleeding (may be concealed), woody-hard uterus, maternal shock, fetal death, fibrinogen <100 mg/dL, DIC |
By Type of Bleeding:
| Type | Description |
|---|---|
| Revealed (External) | Blood tracks down between membranes and decidua and escapes through cervix (~80%) |
| Concealed | Blood accumulates behind the placenta (retroplacental hematoma), no visible PV bleeding (~20%) - MORE DANGEROUS |
| Mixed | Both revealed and concealed components |
Risk Factors (Remember: "HATCH-PT")
- Hypertension (preeclampsia most important - 8x risk with superimposed PE)
- Abruption in prior pregnancy (most significant - 20x risk of recurrence)
- Trauma (MVA, domestic violence)
- Cocaine / smoking (vasospasm)
- High parity
- PPROM, Polyhydramnios (sudden decompression)
- Thrombophilia (Factor V Leiden, hyperhomocysteinemia)
Clinical Features
Classic Triad: Painful dark bleeding + Tender woody uterus + Fetal distress
| Feature | Placenta Previa | Abruptio Placentae |
|---|---|---|
| Bleeding | Painless, bright red | Painful, dark red |
| Uterus | Soft, non-tender | Tender, board-like (Grade 3) |
| Fetal parts | Easily palpable | Difficult to feel |
| Fetal heart | Usually normal | Distress / absent |
| Coagulation | Normal | DIC may occur |
| Presentation | Malpresentation common | Normal |
Diagnosis
- Clinical - most important
- USG: NOT reliable (sensitivity <50%); may show retroplacental hematoma - used mainly to exclude placenta previa
- CTG: uterine contractions, fetal distress
- Lab: CBC, fibrinogen (<150 mg/dL significant; <100 mg/dL = severe DIC), PT, aPTT, D-dimer, Kleihauer-Betke test (feto-maternal hemorrhage)
Management
Immediate Resuscitation (ALL grades):
- Secure 2 large-bore IV lines
- Draw blood: CBC, coagulation profile, G&S, crossmatch
- IV fluids; maintain urine output >30 mL/hr (Foley catheter)
- Continuous CTG monitoring
- Rh-negative mother: give anti-D if not given at 28 weeks
Grade 1 (Mild) - Expectant:
- Admit, bed rest, monitor
- Deliver vaginally if term and labour is progressing
- Watch for deterioration
Grade 2 (Moderate):
- Deliver promptly
- If cervix favourable + fetal heart present = ARM (artificial rupture of membranes) + Oxytocin induction
- If no progress or fetal distress = LSCS
- Correct coagulopathy with FFP, cryoprecipitate, platelets
Grade 3 (Severe) - Fetal Death:
- Goal = maternal safety
- Correct coagulopathy aggressively
- Vaginal delivery preferred (DIC may worsen with surgery)
- ARM + Oxytocin augmentation
- LSCS only if vaginal delivery not imminent or maternal condition deteriorating
- Fibrinogen <150 mg/dL: give FFP / cryoprecipitate
- May need hysterectomy for Couvelaire uterus with uncontrollable PPH
4. COUVELAIRE UTERUS ⭐⭐⭐⭐ (3 marks)
Definition
Couvelaire uterus (also called uteroplacental apoplexy) is the extravasation of blood into the myometrium and beneath the serosal surface of the uterus, occurring as a complication of severe concealed abruptio placentae.
Pathogenesis
In severe abruptio placentae, the massive retroplacental hematoma is unable to escape. The pressure forces blood to track between the myometrial muscle fibers, producing:
- Bluish-purple ecchymotic discoloration of the uterus
- Blood seeping under the peritoneum, into broad ligaments, ovaries, and fallopian tubes
- Myometrial muscle fiber disruption
- Uterine atony (myometrium becomes flabby, loses its contractility)
"Bleeding into the myometrial tissue can lead to a Couvelaire uterus, which becomes atonic and increases the risk of uterine hemorrhage after delivery." - Creasy & Resnik
Gross Appearance
- Uterus appears copper-colored or purple-blue
- Ecchymotic patches throughout the uterine wall
- Blood-stained peritoneum
- Described as "chocolate-colored" uterus
Clinical Significance
| Feature | Detail |
|---|---|
| Tone | Uterine atony - main clinical consequence |
| PPH | Massive postpartum hemorrhage |
| DIC | Coagulopathy frequently associated |
| Rupture | Rarely, myometrium may rupture |
| Diagnosis | Clinical/intraoperative finding |
Management
- Identified at Caesarean section or laparotomy
- The uterus may still contract after delivery despite its appearance - do NOT rush to hysterectomy
- Steps:
- Deliver the baby and placenta
- Check for tone with bimanual compression
- Oxytocin infusion + Ergometrine + Misoprostol
- Surgical uterine compression sutures (B-Lynch, etc.)
- Uterine/iliac artery ligation
- Hysterectomy - only if all else fails and hemorrhage is uncontrollable
Key exam point: Couvelaire uterus per se is NOT an indication for hysterectomy. Hysterectomy is done only for uncontrollable PPH from uterine atony.
5. VASA PREVIA ⭐⭐⭐ (3 marks)
Definition
Vasa previa is a condition in which umbilical blood vessels (fetal vessels) run unprotected through the amniotic membranes and cross (or lie near) the internal cervical os, ahead of the presenting part, without the support of the cord or placental tissue.
Pathological Basis
The vessels are vulnerable because:
- They are not protected by Wharton's jelly
- When membranes rupture (spontaneous or artificial), these vessels are torn
- Hemorrhage is fetal blood (not maternal) - rapid fetal exsanguination occurs
Types
| Type | Description |
|---|---|
| Type 1 | Associated with velamentous cord insertion - vessels travel between lobes of a bilobed/succenturiate lobe placenta |
| Type 2 | Vessels connecting lobes of a bilobed or succenturiate lobe placenta that cross the os |
Risk Factors (Remember: "VIVA-B")
- Velamentous insertion of the umbilical cord
- IVF / In vitro fertilization (most important - 10x risk)
- Vasa previa in previous pregnancy
- Accessory (succenturiate) lobe / Bilobed placenta
- Bilobed placenta / Placenta previa
Clinical Features
- Triad: Rupture of membranes + Painless bright red PV bleeding + Sudden fetal bradycardia/distress
- Bleeding is FETAL blood - even small amount (30 mL) can be fatal to the fetus
- Classic scenario: bleeding starts immediately at membrane rupture
Diagnosis
| Method | Detail |
|---|---|
| Colour Doppler USG (antenatal) | Gold standard for prenatal diagnosis; identifies vessels at the os |
| Transvaginal USG | Shows vessels overlying internal os |
| Apt test / Kleihauer-Betke test | Tests whether blood is fetal in origin (fetal Hb resists NaOH denaturation = Apt test positive) |
| Direct visualization | Amniscope/membrane examination at rupture |
| Palpation | Pulsatile vessels felt on vaginal examination (dangerous - vessel may rupture) |
Management
Antenatal (Diagnosed before labour):
- Hospital admission at ~30-32 weeks
- Corticosteroids for lung maturity
- Elective LSCS at 35-36 weeks (before labour/membrane rupture)
- Avoid amniotomy
Emergency (Rupture of membranes with bleeding):
- Immediate emergency LSCS - this is a true obstetric emergency
- Perinatal mortality is >50% if undiagnosed before rupture
- Prognosis dramatically improves with antenatal diagnosis (perinatal mortality drops from ~60% to <3%)
Key exam point: In vasa previa, hemorrhage is FETAL blood. The fetal blood volume is only ~250 mL - even a small bleed is catastrophic for the fetus. The baby, not the mother, is at risk.
QUICK COMPARISON TABLE (for MCQs)
| Feature | Placenta Previa | Abruptio Placentae | Vasa Previa |
|---|---|---|---|
| Bleeding | Painless, bright red | Painful, dark | Painless at ROM |
| Blood type | Maternal | Maternal | Fetal |
| Uterus | Soft | Tender/woody | Normal |
| Fetal distress | Late | Early | Immediate + severe |
| USG | Diagnostic | Not reliable | Colour Doppler |
| Shock | Maternal | Maternal + worse | Fetal |
| Delivery | LSCS | Depends on grade | Emergency LSCS |
HIGH-YIELD EXAM POINTS SUMMARY
- Placenta Previa: Painless PV bleed + soft uterus + malpresentation. NEVER do digital exam. TVS is safe. LSCS for major degrees.
- Abruptio: Painful dark bleed + woody uterus + DIC risk. Grade by severity. Fetal death = vaginal delivery preferred. Fibrinogen <150 = DIC.
- Couvelaire Uterus: Blood in myometrium → purple uterus → atony → PPH. NOT automatic indication for hysterectomy.
- Vasa Previa: Fetal vessels at os → fetal hemorrhage at ROM. Apt test confirms fetal blood. Emergency LSCS. Antenatal diagnosis by Colour Doppler = best outcome.
Sources: Creasy & Resnik's Maternal-Fetal Medicine, Rosen's Emergency Medicine, Textbook of Family Medicine 9e, with framework aligned to DC Dutta's Textbook of Obstetrics standard curriculum
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