Obstetrics and Gynaecology for NEET-PG
Antepartum Haemorrhage for NEET-PG
Antepartum haemorrhage is bleeding from the genital tract after 20 weeks of gestation and before delivery of the baby. The two major causes are placenta praevia and abruptio placentae, which together account for most cases, with local lesions and unexplained bleeding making up the rest. For NEET-PG, the classic discriminator is that placenta praevia causes painless, causeless, recurrent bright red bleeding with a soft non-tender uterus, while abruptio placentae causes painful bleeding with a tense tender uterus and often fetal distress. Placenta praevia is an abnormally implanted placenta in the lower uterine segment and is graded by its relationship to the internal os, with transabdominal or transvaginal ultrasound being the diagnostic tool of choice. Digital vaginal examination is contraindicated until praevia is excluded because it can precipitate torrential bleeding. Abruptio placentae is premature separation of a normally situated placenta, often linked to hypertension, trauma, and sudden uterine decompression, and it may present with concealed haemorrhage where revealed bleeding underestimates blood loss. Complications include hypovolaemic shock, disseminated intravascular coagulation, Couvelaire uterus, and acute kidney injury. Management depends on maternal and fetal status, gestational age, and bleeding severity. Recognising the clinical contrast, avoiding vaginal examination in praevia, and knowing the complications of abruption are consistent exam anchors.
MedNext Academy | 3 min read
Antepartum Haemorrhage for NEET-PG
Antepartum haemorrhage is bleeding from the genital tract after 20 weeks of gestation and before delivery of the baby. The two major causes are placenta praevia and abruptio placentae, which together account for most cases, with local lesions and unexplained bleeding making up the rest. For NEET-PG, the classic discriminator is that placenta praevia causes painless, causeless, recurrent bright red bleeding with a soft non-tender uterus, while abruptio placentae causes painful bleeding with a tense tender uterus and often fetal distress. Placenta praevia is an abnormally implanted placenta in the lower uterine segment and is graded by its relationship to the internal os, with transabdominal or transvaginal ultrasound being the diagnostic tool of choice. Digital vaginal examination is contraindicated until praevia is excluded because it can precipitate torrential bleeding. Abruptio placentae is premature separation of a normally situated placenta, often linked to hypertension, trauma, and sudden uterine decompression, and it may present with concealed haemorrhage where revealed bleeding underestimates blood loss. Complications include hypovolaemic shock, disseminated intravascular coagulation, Couvelaire uterus, and acute kidney injury. Management depends on maternal and fetal status, gestational age, and bleeding severity. Recognising the clinical contrast, avoiding vaginal examination in praevia, and knowing the complications of abruption are consistent exam anchors.
Antepartum haemorrhage is bleeding from the genital tract after 20 weeks of gestation and before delivery of the baby. The two major causes are placenta praevia and abruptio placentae, which together account for most cases, with local lesions and unexplained bleeding making up the rest. For NEET-PG, the classic discriminator is that placenta praevia causes painless, causeless, recurrent bright red bleeding with a soft non-tender uterus, while abruptio placentae causes painful bleeding with a tense tender uterus and often fetal distress. Placenta praevia is an abnormally implanted placenta in the lower uterine segment and is graded by its relationship to the internal os, with transabdominal or transvaginal ultrasound being the diagnostic tool of choice. Digital vaginal examination is contraindicated until praevia is excluded because it can precipitate torrential bleeding. Abruptio placentae is premature separation of a normally situated placenta, often linked to hypertension, trauma, and sudden uterine decompression, and it may present with concealed haemorrhage where revealed bleeding underestimates blood loss. Complications include hypovolaemic shock, disseminated intravascular coagulation, Couvelaire uterus, and acute kidney injury. Management depends on maternal and fetal status, gestational age, and bleeding severity. Recognising the clinical contrast, avoiding vaginal examination in praevia, and knowing the complications of abruption are consistent exam anchors.
Key points
- **Definition:** Bleeding from the genital tract after 20 weeks of gestation and before the birth of the baby. Before 20 weeks it is called abortion.
- **Two major causes:** Placenta praevia and abruptio placentae account for the majority. Others include vasa praevia, local cervical lesions, and unexplained bleeding.
- **Praevia presentation:** Painless, causeless, recurrent bright red bleeding with a soft, relaxed, non-tender uterus and a high presenting part.
- **Abruption presentation:** Painful bleeding with a tense, tender, woody-hard uterus, fetal distress, and shock out of proportion to visible blood loss.
- **Praevia diagnosis:** Transvaginal or transabdominal ultrasound localises the placenta. Vaginal examination is contraindicated until praevia is excluded.
- **Concealed abruption:** Blood accumulates behind the placenta, so revealed bleeding underestimates the true loss and clinical shock is disproportionate.
- **Risk factors:** Abruption links to hypertension, trauma, sudden uterine decompression, and cocaine. Praevia links to prior caesarean and multiparity.
- **Couvelaire uterus:** Blood infiltrates the myometrium in severe abruption, giving a bluish bruised uterus, though it is not itself an indication for hysterectomy.
- **Coagulopathy:** Abruptio placentae is the commonest obstetric cause of disseminated intravascular coagulation due to thromboplastin release.
- **Placenta accreta link:** Placenta praevia over a previous caesarean scar raises the risk of morbidly adherent placenta such as accreta or percreta.
- **Management principle:** Resuscitate first, then decide expectant versus active management based on gestational age, bleeding, and maternal-fetal condition.
Frequently Asked Questions
How do you clinically distinguish placenta praevia from abruption?
Praevia gives painless bright red bleeding with a soft non-tender uterus, while abruption gives painful bleeding with a tense tender uterus and fetal distress.
Why is vaginal examination contraindicated in placenta praevia?
Digital examination can dislodge the low-lying placenta and provoke torrential haemorrhage, so ultrasound must exclude praevia first.
What is concealed abruption?
It is abruptio placentae where blood is trapped behind the placenta. The visible bleeding is minimal, but the patient may be in shock and coagulopathy.
What is a Couvelaire uterus?
It is uteroplacental apoplexy in severe abruption where blood extravasates into the myometrium, giving a bruised bluish appearance.
Which condition most commonly causes obstetric DIC?
Abruptio placentae is the commonest obstetric cause of disseminated intravascular coagulation because separation releases thromboplastins into circulation.
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