Bleeding In Late Pregnancy

BLEEDING IN LATE PREGNANCY (ANTEPARTUM HAEMORRHAGE)

The term "antepartum hemorrhage" refers to bleeding into or from the genital tract after the stage of viability, or 22 weeks of pregnancy, but prior to the delivery of the fetus.

• Continue the pregnancy, administer tocolytics, and take some time off if the bleeding is modest and the fetus is not advanced.
• Plan to terminate the pregnancy if the bleeding is significant, the gestational age exceeds 37 weeks, or the patient is in labor.
• Uterine scar disruption, previa, and regional reasons (for example bleeding from the vulva, vagina or cervix, cervical polyp, carcinoma of cervix, vulval varicosities, cervical erosion and trauma). Idiopathic bleeding and unexplained coagulopathies are the other explanations.

Causes of Antepartum hemorrhage:

• Placental Bleeding (70%)
  • Placenta praevia (35%)
  • Abruptio placenta (35%)
• Unexplained (25%)
• Extra placental causes (5%)
  • Local cervical vaginal lesions
  • Cervical polyp
  • Carcinoma cervix
  • Varicose vein
  • Cervicitis
  • Local trauma (vaginal trauma)
  • Uterine scar disruption

Effect of APH

• Effect on fetus:
  Severe vaginal bleeding during pregnancy increases fetal mortality and morbidity; stillbirth or neonatal death may occur. Hypoxia from premature placental separation and the ensuing birth of a child with developmental disabilities is possible.
• Effect on mother:

           When bleeding is excessive, shock and disseminated intravascular coagulation may also occur. The mother could pass away or suffer from chronic illness.

Investigation

• Abdominal palpation:
  Examining the woman for abdominal discomfort or symptoms of an acute abdomen is necessary. When the uterus is palpated in the abdomen, it has a tight or "woody" feeling, which implies a major abruption. Uterine contractions may also be detected by abdominal palpation. A soft, non-tender uterus may indicate bleeding from the placenta or vasa previa or a problem with the lower genital tract.
• Speculum examination:
  A speculum examination can be helpful to pinpoint a lower genital tract or cervical cause for the APH.
• Digital vaginal examination:

           Digital vaginal examination should not be done until placenta previa has been ruled out by an ultrasound if placenta previa is a likely diagnosis (for example, if a prior scan reveals a low placenta, there is a high presenting             region on abdominal examination, or the bleeding has been painless). If APH is accompanied by pain or uterine activity, a digital vaginal exam can reveal cervical dilation.

• Ultrasound:
  Although abruption is not always present, ultrasound can be used to diagnose placenta previa. Since there are no sensitive or trustworthy diagnostic techniques for placental abruption, it must be diagnosed clinically. The sensitivity of ultrasound to detect retroplacental hemorrhage is low.
• Blood count and coagulation screen, blood cross-matched, Urea, electrolytes and liver function tests, haemoglobin should be assessed.

General Management of Antepartum Haemorrhage:

• It is important that women be instructed to inform their antenatal care provider of any vaginal bleeding.
• Women with APH who present to a maternity unit should be evaluated, stabilised as needed, and transferred to a hospital maternity unit with resources for performing emergency operations and resuscitation (such as anaesthetic support and blood transfusion resources).
• Clinical evaluation should be done by a multidisciplinary team that includes obstetric and midwifery staff and has easy access to a lab, an operating room, neonatal care, and anaesthetic services.
• Determine whether a quick response is necessary to manage maternal or fetal compromise. A history is taken to determine any coinciding symptoms, such as discomfort, and the severity of vaginal bleeding, the mother's cardiovascular health, and the fetal state are all evaluated as part of the triage procedure.
• To determine the health of the mother and child, it is important to record the fetal heart rate along with the pulse of every woman who presents with APH.
• Continue the pregnancy, give tocolytic medications, rest, and use conservative management if the bleeding is mild and the fetus is not mature. APH can be brought on by vasa previa, placental site bleeding, placenta previa, and placental abruption.

Placenta Previa

when the placenta is fully grown and reaches the cervical os when it is entirely or partially positioned in the lower uterine segment, either anteriorly or posteriorly. It's referred to as placenta previa.

Placenta previa affected 5.2 out of every 1000 pregnancies overall. There was evidence of regional variation, though. The prevalence was highest in Asia (12.2 per 1000 pregnancies), followed by Europe (3.6 per 1000), North America (2.9 per 1000), and Sub-Saharan Africa (2.7 per 1000). Major placenta previa affected 4.3 out of every 1000 pregnancies.

• About one-third case of antepartum hemorrhage belongs to placenta previa.
• Nullipara: 1/1000-1/1500 pregnancy.
• Grand multiparas: 1/20

  In hospital deliveries, the prevalence of placenta previa ranges from 0.5 to 1%. It is discovered to be multiparous women in 80% of cases. With repeated pregnancies and high birth orders, the frequency rises after the age of 35.

  In the third trimester, placenta previa may be a severe factor in antepartum hemorrhage.

Aetiology

With the following condition, it affects women more frequently:

• Multiparity
• Mothers who are older than 35
• previously existing placenta
• past uterine procedures, such as cesarean sections (risk increases with increased number of cesarean sections)
• Several pregnancies (larger placenta)
• Smoking (potential bigger placenta) (possible larger placenta)
• The chorionic villa spreads over a large portion of the uterine wall as a result of a defective decidua in order to obtain nutrients.
• Low implantation and improper presentation may be caused by uterine abnormalities.

Classification

• Type I (Low lying or low placental implantation)
  The placental edge will be close to the internal cervical os but not actually over it in a marginal previa. The risk of bleeding is lowest in low lying placenta previa.
• Type II (Incomplete or partial central)
  The cervical esophagus is completely or partially covered by the placental edge in a partial placenta previa.
• Type III (Central or complete or total)
  The lower uterine segment completely fills with the placenta's body, covering the cervical region in a complete or central placenta previa.

Placenta Previa

The following classification was suggested at a recent fetal imaging workshop sponsored by the National Institutes of Health:

• Placenta previa:
  The placenta partially or completely encases the internal os. The were previously further divided into total and partial previa.
• Low-lying placenta:
  A former term, marginal previa, described a placenta that was at the edge of the internal os but did not overlie it. Implantation in the lower uterine segment is such that the placental edge does not reach the internal os and remains outside a 2-cm wide perimeter around the organ.

Pathophysiology

• When the placenta is implanted in the lower uterine segment, placenta previa is present. Though it frequently isn't related to bleeding, this is frequent early in pregnancy.
• The placenta typically migrates as a result of the lower implanted placenta atrophying and the upper placenta hypertrophying. Only 0.5% of pregnancies at term are reported to have placenta previa.
• As the lower uterine segment stretches in the later stages of pregnancy, symptomatic placenta previa develops when painless vaginal bleeding results from the avulsion of the anchoring villi of an improperly placed placenta.

Clinical Features

• The typical scenario is painless late-pregnancy bleeding, which can happen unexpectedly and without warning during activity or rest. It could be preceded by coitus, trauma, or a pelvic exam.

Abdominal examination

• The uterus is neither painful or irritated.
• Uterine irritation may precede or accompany it, which happens throughout the third trimester.
• Malpresentations (breech, transverse lying, floating head) are a frequent finding because the placenta's presence in the lower uterine segment prevents the fetal head from entering the pelvis. Because it is floating, the fetal head is unable to penetrate the pelvis.
• Unless there is a significant placental separation, fetal heart sounds are typically present.
• Vaginal Examination
• On speculum examination, bright crimson blood might be visible. Vaginal examinations shouldn't be done outside of the operating room because they could cause more bleeding and be fatal for the mother and the unborn child. In this case, a vaginal examination should not be performed if the pregnant woman complains of bleeding without pain.
• Before any symptoms appear, ultrasonography can detect placenta previa. Before 28 weeks of pregnancy, if a sonogram shows a low-lying placenta, a second scan will be required to confirm the position of the placenta in relation to the cervix as the lower uterine segment develops in the final few weeks of pregnancy. When placenta previa is identified before any symptoms appear, no treatment is required.

Investigation

• Health History and Physical Examination:
  Painless late-pregnancy bleeding is the typical case, and it might occur suddenly and without warning when you're working out or relaxing. Coitus, trauma, or a pelvic exam could come first.
• Abdominal examination:
  The uterus is neither painful or irritated. Malpresentations (breech, transverse lying, floating head) are a frequent finding because the placenta's presence in the lower uterine segment prevents the fetal head from entering the pelvis. Unless there is a significant placental separation, fetal heart sounds are typically present.
•  Ultrasonography:
  When vaginal bleeding occurs or at a regular prenatal visit, placenta previa is identified via ultrasound. A combination of abdominal ultrasound and transvaginal ultrasound, which is performed with a wand-like equipment inserted inside your vagina, may be necessary for a conclusive diagnosis.
• Magnetic Resonance Imaging:
  When vaginal bleeding occurs or at a regular prenatal visit, placenta previa is detected using ultrasound technology.

Management

How a woman is managed if she has bleeding due to placenta previa depends on her gestational age, the intensity of the bleeding, and the fetal state.

Definitive management

• When the dating criteria are certain, the fetus is at least 37 weeks along, and a feeding-severe patient is in labor, there is evidence of maternal and fetal risk and intrauterine fetal death, and immediate delivery is the recommended course of action.
• A light vaginal examination is only carried out in the operating room if the surgical table is equipped with all the necessary settings and tools to determine the degree of placenta previa, with the exception of serious placenta previa.
• When there is slight bleeding and the patient is in labor and the placenta previa is of the type I or type II anterior implanted variety, an artificial rupture of the membranes is performed. Even if the baby is dead, a Caesarean section is performed in cases of centrally posterior placenta previa and lower degree placenta previa when bleeding is severe and control of bleeding is impossible.
• If the pregnancy is less than 34 weeks and the infant needs to be delivered, steroid injections to mature the fetal lungs will be needed. If the woman is rhesus negative and delivery is not immediately anticipated, anti-D immunoglobulin should be administered intramuscularly (11).
• The woman frequently experiences a bleeding episode before it subsides.
• Fetal reaction and maternal hemostasis need to be closely monitored. Delivery may be necessary if fetal distress persists.

Expectant Management

• When the gestational age is less than 37 weeks, the first bleeding is less than 600 ml, the patient is not in labor, the condition of the mother and the fetus is not in danger, and the bleeding has stopped for a week, expectant management is taken into consideration.
• If the patient is in shock, hospitalize them and give them IV fluids and blood transfusions to help them survive. Sonography should be used to confirm aberrant placental implantation, and as needed, crystalloid and blood products should be used to restore lost blood.
• If the woman and fetus are healthy and far from term, complete bed rest is recommended. Tocolytics may be given as needed until fetal maturity, at which point a cesarean section can be done. Rarely is the early bleeding serious.
• Blood grouping, Hb, and cross-matching should be done to get the patient ready for unforeseen circumstances. Checking hemoglobin should be done frequently.
• close observation of the patient's vital signs, blood pressure, and fetal heart sound, and recording as necessary.
• Gently perform a speculum examination for the local origin of bleeding three days after the bleeding has stopped.
• Catheterize the patient while keeping the output intake chart current.
• Keeping the patient in the hospital till delivery with little or no ambulation once the bleeding has ceased
• If the patient is in labor and above and meets the expectant management requirements described above, vaginal delivery may be attempted if the lower placental edge is more than 2 cm from the internal cervical os.
• Scheduled cesarean delivery: After fetal lung maturity has been determined by amniocentesis, often at 36 weeks of gestation, this is done if the mother has remained stable.
• Hysterectomy is required if these more conservative treatments fail and bleeding is severe.

Nursing Management

• Ensure the physiologioc well being of the client and fetus.
  • Record your vital signs.
  • Analyze the color and volume of bleeding (maintain a perineal pad count, weight perineal pads before and after use to estimate blood loss).
  • Keep an eye out for signs of shock, which include a rapid heartbeat, pallor, cold, moist skin, and a drop in blood pressure.
  • Keep an eye on the fetal heart rate.
  • Strictly enforce bed rest to limit the fetus's rest.
  • Keep an eye out for new bleeding incidents.
• Provide client and family teaching
  • Describe the disease and available treatment options. Placing the lady at bed rest in a side-lying position will ensure that the mother and fetus have an appropriate blood flow. Prepare the patient for discharge and ambulation (maybe within 48 hours of last bleeding episode).
  • Discuss the necessity of having access to hospital transportation at all times.
  • Inform the client to refrain from sexual activity and to go back to the hospital if bleeding occurs again.
  • Teach the client how to properly wash their hands and use the restroom to avoid illness.
• Provide emotional and psychological support.
  Complications
  • Preterm delivery
  • Preterm premature rupture of membrane
  • Intra uterine growth retardation
  • Malpresentation
  • Antepartum hemorrhage with varying degree of shock
  • Fetal abnormalities
  • Intrauterine death
  • Increase number of caesarean section
  • Adherent placenta
  • Postpartum haemorrhage Trauma to cervix and lower segment.
  • sepsis
  • Sub-involution Embolism
  • The decidua basalis and myometrium may be invaded by the villi if placenta previa develops over a preexisting uterine scar. This may cause uncontrollable bleeding that necessitates a cesarean hysterectomy.

PREMATURE SEPARATION OF THE PLACENTA (ABRUPTIO PLACENTAE)

The Latin phrase abruptio placentae refers to the separation of the placenta from its implantation site either partially or completely prior to delivery. The most common cause of perinatal death, premature placenta separation occurs in around 10% of pregnancies. The separation typically happens toward the end of pregnancy, though it could also happen in the first or second stage of labor.

Predisposing Factors

Although there is no known primary cause for premature separation, there are some risk factors that have been identified, such as:

• high parity
• Advanced maternal age
• A short umbilical cord
• Chronic hypertensive disease
• Pregnancy-induced hypertension
• Direct injury (as from an automobile accident or intimate partner abuse)
• Cocaine use or smoking causes vasoconstriction, and
• Thrombophilic diseases, such as autoimmune antibodies and protein, that cause thrombosis
• It could be brought on by chorioamnionitis, an infection of the fluid and membranes surrounding the fetus.

Etiology/Pathophysiology

Although the cause of this illness is uncertain, it has been suggested that abruption begins with degenerative alterations in the small maternal arterioles, which cause thrombosis, decidua degeneration, and possibly vascular rupture. A retroplacental clot occurs when the vessel bleeds. The placenta separates as a result of the bleeding's increased pressure behind it. The fetal blood supply is hampered, and the degree of placental separation determines how distressed the fetus becomes.

Clinical Types and Presentation

Three types of abruption have been described

• Revealed
• Concealed
• Mixed, or concealed and revealed.

Placental abruption, in contrast to placenta previa, manifests as pain, vaginal bleeding, and increased uterine activity.

Revealed Haemorrhage

Because blood leaks out of the cervical os and the lower section of the placenta, the massive hemorrhage is visible from the outside. These conditions result in less severe clinical symptoms.

Abruption usually happens after 36 weeks of pregnancy, when the fetal position is longitudinal and the part that is present is firmly seated in the pelvic brim. Uterine activity may increase in disclosed placental abruption, however this conclusion is inconsistent.

Concealed Haemorrhage

The placenta and the uterine wall are where the hemorrhage in this instance happens. The fundal size appears larger than would be consistent with the anticipated date of confinement, and the volume of the uterine content increases. Increased uterine tone, discomfort, and shock are common symptoms. The uterus could stiffen and swell.

The uterus will be hard and tense during a clinical examination, and the uterine fundus will be higher than usual for the gestational age.

In about 30% of cases, the fetal heart tones are absent and the fetus is stillborn while the patient is frequently in labor. The prognosis for the fetus is inversely correlated with the time between conception and delivery and is based on the degree of placental separation.

Mixed, or Concealed and Revealed Haemorrhage

Most of the time, the hemorrhage is both hidden and obvious. Blood loss quickly appears vaginally after a period of time during which the hemorrhage is hidden. Haemorrhage occurs close to the placental edge.

Investigation

• Based on the presence of uncomfortable late-trimester vaginal bleeding and normal placental implantation in the fundus or on the lateral uterine wall, not over the lower uterine segment. Patient may be in shock, with less or no fetal movement, a sign of fetal distress, and a tender uterus.
• Ultrasound
• Hemoglobin level
• Urine for protein
• Because placental abruption can be detected by magnetic resonance imaging (MR), management should change if this information is known.
• Coagulation profile

Complications

The complications of placental abruption:

• Postpartum bleeding
• Shock with hypovolemia.
• Afibrinogenaemia
• Severe placental abruption in afibrinogenaemia causes significant placental damage and releases thromboplastin into the mother's bloodstream. The development of hypo- and afibrinogenemia may then result from intravascular coagulation and defibrination.
• Disseminated Intravascular Coagulation:
  The pathological condition known as disseminated intravascular coagulation (DIC), also known as disseminated intravascular coagulopathy or less frequently as consumptive coagulopathy, is characterized by the widespread activation of the clotting cascade that causes blood clots to form in the body's small blood vessels. As a result, tissue blood flow is compromised, which can eventually harm several organs. Furthermore, because the coagulation process depletes platelets and clotting factors, normal clotting is interrupted, and significant bleeding can happen from a variety of places.
• Renal tubular or cortical necrosis:
  This is a complication that must always be taken into account as a potential, thus it's crucial to maintain meticulous fluid balance charts and pay close attention to urinary output. Haemodialysis or peritoneal dialysis may be required on rare occasions due to this problem, however these procedures are becoming less common.
• Perinatal mortality..

Management

• In both mild and severe cases, surgery may be necessary and is risky.
• Restart the pregnant woman immediately, and if she arrives at a primary care facility, stabilize, speak with a physician, and transfer her as soon as possible to a tertiary care facility for initial management.
• The hazards of prematurity and maternal illness must be weighed against the benefits of continuing the pregnancy when deciding when to give birth.

Consider:

• Gestational age
• Fetal condition
• Severity of abruption - blood loss, clinical signs and symptoms of haemorrhagic shock along with features of concealed blood loss such as abdominal pain and tenderness
• Co-existent conditions such as pre-eclampsia, placental insufficiency or IUGR
• In some severe cases, bleeding breaks through the uterine wall, giving the uterus a bruised appearance. A Couvelaire uterus is what this is referred to as.

If abruption is confirmed:

• Greater than 36 weeks gestation, Despite the appearance of minimal bleeding, delivery is advised due to the possibility of further, potentially fatal abruption.
• Between 32 35 weeks gestation, When there is no sign of fetal jeopardy and there are just small placental abruptions, conservative care may be an option.
• Below 32 weeks gestation,Unless there is evidence of maternal or fetal compromise, conservative management may be considered even in the presence of significant revealed bleeding or significant uterine tenderness.
• Birth should be hastened if there is indication of fetal compromise or coagulopathy.
• Emergency cesarean delivery: As soon as the mother is stabilized, this is done if there is a risk to the mother or the fetus.
• Vaginal delivery:This is done if the pregnancy is more than 36 weeks along if the bleeding is strong but under control. Make an amniotomy and start labor. Observe the fetal heart rate pattern and contractions using external monitors. If the fetus is already dead, avoid a cesarean delivery.
• Vaginal birth can be attempted if the abruption is substantial but the woman is stable.
• Both continuous electronic fetal heart rate monitoring and having blood products on hand in case of catastrophic bleeding are recommended. Active management of the third stage of labor, including the use of an oxytocin infusion, is recommended due to the significant risk of postpartum hemorrhage.
• If there is a risk to the mother or the fetus, delivery should begin right away, followed by immediate stabilization by caesarean section, unless a vaginal birth is imminent and medically possible.
• Blood should be transfused quickly enough to maintain circulation and prevent hypotension.
• Examine the placenta for any pathological characteristics and send it for histological evaluation. cautious hospital observation
• If the mother and fetus are stable and far from term, bleeding is minor or decreasing, and contractions are ceasing, this procedure is carried out. Use a sonogram to confirm a healthy placenta and, as necessary, replace lost blood with crystalloid and blood products.

Nursing Management

Continuous evaluation of maternal and fetal physiologic status, particularly;

• As required, vital signs every 1-2 hours.
• Examine the volume, consistency, and color of the blood loss.
• Watch your urine output.
• Keep an eye out for any changes in your vital signs that could indicate hypovolemic shock, and report any symptoms very away (fast, weak, pulse 110 per minute or more, low blood pressure: systolic less than 90 mm Hg, pallor, sweatiness, cold clammy skin, rapid breathing).
• Continually check the fetal heart
• A blood sample is obtained by inserting a large gauge intravenous catheter into a big vein for fluid replacement in order to perform tests on coagulation, full blood count, and cross-matching. The blood urea and electrolytes will also be assessed if pre-eclampsia is suspected.
• If necessary, give the mother oxygen via a mask.
• Check for changes in the fundal height. Since a growth in size would suggest bleeding. Watch out for DIC signs and symptoms like tachycardia, bleeding gums, and oozing from the IV site. If DIC occurs, administer blood products as directed.
• Depending on the patient's condition, additional general care is given.
• Analyze whether an immediate delivery is necessary. Vaginal birth is an option if the client is actively laboring and the bleeding is minimal. If there are no visible signs of fetal distress or a dilated cervix, a caesarean section must be done. Therefore, follow the doctor's instructions and get ready for an emergency cesarean section. As the primary uterogenic agent postpartum, administer an intravenous oxytocin infusion.
• To make sure that bleeding has been controlled and that coagulopathy (if present) is resolving, as well as to direct replacement of fluids and blood products, as needed, maternal vital signs, blood loss, urine output, uterine size and consistency, and laboratory results (hemoglobin/hematocrit, coagulation studies) are closely monitored.

Vasa Previa

The plural form of the Latin word "Vas," which denotes a dish or a vessel, is "Vasa" (thus the word "vase"). Combining the terms "pre" (or "prae"), which means before, and "via," which means way, creates the term "previa." In medicine, "previa" typically refers to anything blocking the route during childbirth. Vasa previa, thus, literally translates as "vessels in the path, before the infant."

Fetal blood arteries crossing or passing near the inner cervical os. Unsupported by the umbilical cord or placental tissue, these vessels run within the membranes and are vulnerable to rupture if the supporting membranes fail.

Pathophysilogy

There are three theories postulated with respect to velamentous insertion of the cord and vasa previa:

• The implantation of the umbilical cord vessels on the decidua basalis is initially successful, but as the fetus and placenta grow and expand, it becomes insufficient. As a result, the chorionfrondosum around the insertion regresses to become the chorionlaeve, leading to velamentous insertion.
• During velamentous insertion, the decidua basalis, the location of the future placenta, gains the richest vascularization, resulting in arteries that extend to the placenta's edge.
• The aberrant morphology of the fetus and placenta is caused by restricted intrauterine space or restrictions on fetal motion. For vasa previa to occur, the cord must be inserted velamentously.

Risk Factors

Conditions connected to the vessels near the cervix include:

• Low-lying placenta, placenta previa,
• Multiple pregnancie
• Multilobate placentas
• Another risk factor is placenta membranacea and velamentous insertion.
• The risk of vasa previa is increased by in vitro fertilization (about 1:300 pregnancies).

Sign and Symptoms

• Before the widespread use of transvaginal ultrasound, there was vessel compression, amniotomy-induced vessel rupture, vessel rupture before to membrane rupture, vessel rupture following membrane rupture, and vessel palpability.
• Unfortunately, vaginal bleeding at the moment of membrane rupture continues to be the most common presentation rather than identification during prenatal ultrasonography. The bleeding is typically attributed to a placenta previa, placental abruption, or "heavy show."
• Fetal heart rate slows down as a result of velamentous insertion-related extrinsic cord compression.
• Could cause fetal asphyxia and death if left untreated.

Diagnosis

• Transvaginal ultrasonography is frequently used to confirm the diagnosis. Fetal vessels within the membranes crossing the internal cervical os directly or close by.
• Doppler ultrasound to rule out vasa previa in the female subject with a known succenturiate lobe or velamentous cord insertion.
• An examination of the body On digital examination, pulsating vessels in the membranes covering the cervical os are infrequently palpable.

Effect

The main issue with vasa previa is that the blood vessels carrying the fetal blood can rupture. If the condition is not discovered, this happens during or shortly after delivery. This leads to:

• Fetal hypoxia
• Hypovolemia
• Fetal exsanguination
• Fetal death

Management

• if a typical second trimester ultrasound reveals that the placenta is low lying. It is necessary to conduct additional testing for placental cord insertion.
• In order to assess the internal cervical os, transvaginal ultrasound may be a possibility for all women who are at a high risk for vasa previa, including those who have a low or velamentous cord insertion, a bilobate or succenturiate placenta, or who are bleeding vaginally. Even 100 ml of bleeding is enough to result in fetal shock and death.
• Transvaginal ultrasound with color Doppler can help with the diagnosis of vasa previa if it is suspected. Vasa previa may go undetected even when transvaginal ultrasonography with color Doppler is used. When prenatal vasa previa is identified, an elective caesarean section should be made available before the start of labor.
• Vasa previa patients are more prone to birth prematurely, hence hospitalization at around 30 to 32 weeks and the use of corticosteroids at 28 to 32 weeks to encourage fetal lung maturation should both be taken into consideration.
• If there has been bleeding or an early rupture of the membranes, a woman with an antenatal diagnosis of vasa previa should be offered delivery in a birthing unit with continuous electronic fetal heart rate monitoring and, if time allows, a rapid biochemical test for fetal hemoglobin. If any of the aforementioned tests are abnormal, an urgent caesarean section should be done.
• Women who have been diagnosed with vasa previa and who need to give birth should ideally be transferred to a tertiary facility with a pediatrician on staff who can start aggressive neonatal resuscitation right away.
• Vasa previa should be clearly noted on the chart for all women admitted to a tertiary care facility, and all medical staff members should be informed that if vaginal bleeding occurs, an immediate delivery by caesarean section may be necessary.

Complications of APH

• Maternal complications
  • Anaemia
  • Maternal shock
  • Coagulopathy
  • Prolonged hospital stay
  • Complications of blood transfusion
  • Infection
  • Renal tubular necrosis
  • Postpartum haemorrhage
  • Psychological sequelae
• Fetal complications
  • Fetal hypoxia
  • Small for gestational age and fetal growth restriction
  • Prematurity (iatrogenic and spontaneous)
  • Fetal death