Normal Placenta

• The placenta is a new organ formed in the

uterus during pregnancy, and connect the
fetus to the uterus.
• The baby's umbilical cord arises from the
placenta.
• This structure provides oxygen and nutrients
to the growing baby and removes waste
products from baby's blood via umbilical
cord.
Normal Placenta
• Is blue-red in color and
discoid in shape.
• Is about 22 cm in diameter
and 2.5 cm thick in the
center.
• Normally, it attaches at the
top or side of the uterus.
• The normal umbilical cord
is 51-60 cm long, contains
two arteries and one vein.
 Placental Abnormalities and Hemorrhagic Complications

• Blood loss during pregnancy is a first

cause of both mother and fetal morbidity
and mortality (Death & defect).
• Up to 1,000 mL/min of maternal blood
flows through the placenta at term.
• Hemorrhage is a MEDICAL EMERGENCY
• All placental problems can be detected
and observed by ultrasound.
 Placental Abnormalities and
Hemorrhagic Complications

1. Antepartum Hemorrhage (APH)

2. Postpartum Hemorrhage (PPH)
3. Abortion
4. Ectopic Pregnancy
 1. Antepartum Hemorrhage (APH)
• Antepartum hemorrhage (APH) is a bleeding from
the birth canal (Vagina) after the 24th week (some
books would say after the 20th week) of
pregnancy.
• It can occur at any time until the second stage of
labor is complete.
• Bleeding before the week 24 of pregnancy is
miscarriage.
 APH Common Causes

a. Placenta Previa
b. Abruptio Placenta
Life threatening
c. Uterine Rupture
d. Vasa Previa

e. Reproductive system injuries

f. Neoplasia
a. Placenta Previa
• The condition in which the placenta partially
or totally covers the cervix (the lower part of
uterus).
• It may cause anemia and death due to
severe blood loss.
• The most common symptom of placenta
previa is painless vaginal bleeding (bright
red blood).
a. Placenta Previa
Risk factors:
• Previous Cesarean section
• Old mother (>35 years)
• Previous placenta previa
• Diabetes or hypertension
• Cigarette smoking
• Uterine problems and anomalies
• Multiple fetuses
a. Placenta Previa
Classification:
1. Total: The placenta completely covers the
cervix.
2. Partial: The placenta partially covers the
cervix.
3. Marginal: The placenta is near the edge of the
cervix.
a. Placenta Previa
Management:
• Treatment depends on gestational age, severity and type
of the previa, blood loss, and the health of the mother
and the baby.
• Reducing activities and bed rest.
• Medicines to prevent early labor.
• Blood transfusion for the mother as necessary.
• After 36 weeks AOG, a caesarean section is usually
performed.
• If the bleeding can't be controlled, an emergency C-
section is done even if the baby is premature.
b. Abruptio Placenta
• This involves the separation of a placenta
from the wall of the uterus before the
delivery.
• This condition can occur any time after the
20th week of pregnancy.
• When the placenta separates from the
uterus, the vessels within the placenta will be
detached and will cause bleeding.
b. Abruptio Placenta
Risk factors:
• Old mother (>35 years)
• Previous abruptio placenta
• High blood pressure
• Cigarette smoking
• Uterine problems and anomalies
• Multiple fetuses
• Abdominal trauma
b. Abruptio Placenta
Effects & Complications:
• Shock due to blood loss
• The need for a blood transfusion
• A serious blood clotting complication
• Poor blood flow and damage to kidneys or brain of
the mother
• Premature birth
• Fetus heart rate problems
• Fetal death
b. Abruptio Placenta
Symptoms and signs:
• Vaginal bleeding (dark red blood)
• Abdominal pain
• Uterine contractions that do not relax
• Blood in amniotic fluid
• Nausea
• Faint feeling
• Decreased fetal movements
b. Abruptio Placenta
Classification:
• Revealed (Visible – External bleeding):
Causes vaginal bleeding that helps with early
detection.

• Concealed (Internal): The blood gets trapped,

pooling and clotting behind the placenta. It can
only be detected through an ultrasound.
b. Abruptio Placenta
Management:
• The treatment depends on the amount of
bleeding, the gestational age, and condition of the
fetus.

• Before week 34, the client should rest.

• After week 34:
− If the fetus is normal and the bleeding is
mild, vaginal labor is possible
− If not, C-Section is necessary
b. Abruptio Placenta
• There is no treatment to stop abruptio
placenta or reattach the placenta.

• After the baby is born, bleeding from the site

of the placental attachment is likely.
• If the bleeding can't be controlled,
emergency removal of the uterus might be
needed.
c. Uterine Rupture
• A uterine rupture is a tear in the wall of the
uterus.

Risk factors:
• Previous C-Section
• Previous uterine surgery
• Abdominal trauma
Uterine Rupture
c. Uterine Rupture
Signs and Symptoms:
• Excessive vaginal bleeding
• Sharp pain between contractions
• Contractions that slow down and relax
• Unusual abdominal pain or tenderness
• Rapid heart rate and abnormally low blood
pressure in the mother
c. Uterine Rupture
Management:
• Immediate C-section is necessary in uterine
rupture
• This is followed by repair of the uterus
• Antibiotics is important to prevent infection.
• If the damage to the woman's uterus is
extensive and the bleeding can't be controlled,
hysterectomy is done
d. Vasa Previa
This is a condition in
which blood vessels
within the placenta or
the umbilical cord are
trapped between the
fetus and the cervix,
causing hemorrhage
and lack of oxygen.
d. Vasa Previa
Symptoms:
• Painless vaginal bleeding

Risk factors:
• Previous C-Section
• Low-lying placenta (Inferior placenta)
• Multiple fetuses

Management:
• Steroid treatment to develop fetal lung maturity
• The C-section should be done early to avoid an emergency
Vasa Previa
baby
 2. Postpartum Hemorrhage (PPH)
• Postpartum Hemorrhage (PPH) is a
blood loss after delivery greater than:
- 500 mL for vaginal delivery, and
- 1,000 mL for cesarean delivery,
- with 10% drop in hematocrit

• PPH is responsible for around 25% of

maternal mortality.
 PPH Classification

• PPH is classified into:

− Primary (early) occurs within
the first 24 hours after delivery
− Secondary (late) occurs after 24
hours post-birth
 PPH Common Causes
The causes of PPH have been described as the
"four T"
1. Tone: uterine atony (“70%” failure of the uterus
to contract properly after delivery).
2. Trauma: lacerations of the uterus, cervix, or
vagina, and uterus inversion.
3. Tissue: retained placenta.
4. Thrombin: Coagulation abnormalities.
 PPH Risk factors
• Antepartum hemorrhage in this pregnancy.
• Multiple fetuses.
• Macrosomia (over 4 kg baby).
• Pre-eclampsia.
• Previous PPH.
• Maternal obesity.
• Uterine abnormalities.
• Maternal age (35 years or older).
• Maternal anemia.
• Operative vaginal delivery.
• Induction of labor.
• Prolonged first and second stage of labor (over 12 hours
labor).
 PPH Prevention
• Detect any abnormality (anemia, diabetes…) before the
delivery and try to control it.
• Ensure that the bladder of the mother is empty since a full
bladder makes it more difficult for the uterus to contract.
• We should know the mother’s blood type.
• IV access should be maintained.
• Slow IV infusion.
• Oxytocin medication (A drug used to stimulate uterine
contractions and control bleeding).
• Oxytocin should be routinely used in the third stage of labor.
• Massage the mother’s uterus to help it contract.
 PPH Management
Tone Tissue
• Massage • Manual removal of
• Drugs (Oxytocin) retained placenta

Trauma Thrombin
• Manual fixation of • Drugs (according to
uterus inversion the cause)
• Repair the rupture • Platelet and blood
and laceration transfusion
Uterus inversion and how to fix it back
 Manual Removal of
Uterine massage
the Placenta
 PPH Management
• Large-bore intravenous access, and increase
oxytocin.
• A blood clotting medication.
• Transfuse blood.
• Laparotomy: Surgery to open the abdomen to
find the cause of bleeding.
• If the blood does not stop, we need to do
Hysterectomy (this is always a last resort in all
condition).
 3. Abortion
• Abortion is the spontaneous or
elective ending of pregnancy
before the fetus is able to survive
on its own in the first 24 weeks of
pregnancy.
• Losing of the fetus after the 24th
week is called Stillbirth. 38
 3. Abortion
• There are two types:
1. Elective abortion (Induced): this
refers to the ending of pregnancy at
the request of the mother. it may
done medically or surgically.
2. Spontaneous abortion: this refers to
the end of the pregnancy on its own.
39
 Types
1. Threatened abortion:
• Miscarriage has started but
recovery is possible.
• Or woman with miscarriage
signs but loss of the pregnancy
has not yet occurred.
• Management:
− Rest
− Good nutrition (folic acid
should be taken)
− Fetus and uterus monitoring 40
2. Complete abortion:
• This is the most common
type of miscarriage, when
all of the contents of the
uterus leave the body.
• Management:
− Control bleeding
− Ultrasound to observe the
uterus
41
3. Incomplete abortion:
• Only some of the products of
uterus leave the body.
• Treatment:
− Dilatation and Curettage (D&C): is
a procedure to remove tissue
from inside the uterus, by
opening (dilate) the cervix and
using a surgical instrument called
a curette to remove any
remaining pregnancy tissue.
− Antibiotics
− Complete uterine evacuation 42
Dilatation
and
Curettage
(D&C)

43
4. Missed abortion:
• The pregnancy is ended
without any symptoms and the
products of uterus do not
leave the body. In this type the
death will be discovered at a
routine scan.
• Treatment:
− Oxytocin
− Antibiotics
− Complete uterine evacuation
− D&C 44
5. Septic infected abortion:
• The lining of the uterus and any remaining
products of pregnancy become infected after
miscarriage.
• Treatment:
− Hospitalization IV antibiotics
− Complete uterine evacuation
− D&C

45
 General Management
• Medical management depends on the
type and signs and symptoms.
• The main goal of treatment during or
after a miscarriage is to prevent
hemorrhage and/or infection.
• We should support the mother
psychologically. 46
4-5 Weeks miscarriage 6 Weeks miscarriage
47
7-8 Weeks miscarriage 10 Weeks miscarriage
48
12 Weeks miscarriage 16 Weeks miscarriage
49
 4. Ectopic Pregnancy
• An ectopic pregnancy is the implanting
of the zygote somewhere other than the
inner endometrial lining of the uterus
(pregnancy that occurs outside the
uterus).
• It occurs in 1%-2% of all pregnancies.
• It is life-threatening to the mother.
50
 4. Ectopic Pregnancy
• The vast majority of ectopic
pregnancies occur in the fallopian
tube “tubal pregnancy’’ (95%), but the
fertilized ovum can also implant in
the ovary, cervix, or abdominal cavity
(5%).
• Doctors usually discover it between
week 5 and week 14 of pregnancy . 51
52
Sites of ectopic pregnancy

53
 Ectopic Pregnancy symptoms
• Abnormal vaginal bleeding.
• Abdominal pain, typically just in one side, which
can range from mild to severe.
• An absence of menstruation (amenorrhea), and
other symptoms of pregnancy.
• Shoulder pain (unknown cause).
• If the fallopian tube ruptures, the pain and
bleeding could be severe enough to cause
fainting.
54
 Ectopic Pregnancy Causes
• The most common cause is damaged fallopian tube.
• Zygote abnormality.
• Previous ectopic pregnancy.
• Sexual diseases (typically chlamydia).
• Reproductive organs infections and inflammations.
• Smoking.
• Endometriosis (abnormal uterus lining).
• Using fertility drugs.
• Getting pregnant while having an intrauterine device
(IUD).
55
Intrauterine
device (IUD)

56
Ectopic Pregnancy Complications

• The major health risk of ectopic

pregnancy is rupture leading to
internal bleeding.
• Decreased fertility related to removal
of fallopian tube.

57
Ectopic Pregnancy Management
• In early stage, a medication is used to
stop the egg from developing. The
pregnancy tissue is then absorbed into
the woman’s body.
• In more advanced stage, a surgery is
required to remove the egg.

58
 Ectopic Pregnancy Management
• If the fallopian tube has ruptured,
emergency surgery is necessary to
stop the bleeding and fix the tube.
• In some cases, the fallopian tube and
ovary may be damaged and will have
to be removed.

59
 Ectopic Pregnancy Management
• The HCG will need to be rechecked on a
regular basis until it reaches zero if the
entire fallopian tube is not removed.
• An HCG level that remains high could
indicate that the ectopic tissue was not
entirely removed, which would require
another surgery or medical management.
60