ante partum haemorrhage by dr wyo

House Surgeon WYO

ANTEPARTUM HEMORRHAGE

• Bleeding from female genital tract after the 24th week of pregnancy before the birth of the baby (some define from 20th week and some up to 28th week )

WHO • “ Bleeding from the female genital tract anytime after fetal viability but before delivery”

• Incidence : 3-5% of all pregnancies3 times more common in multiparous than nuliparous women .

Antepartum Hemorrhage: Types• Simple: • Local • Vagina – Trauma• Cervical – Infection or tumor

- Blood dyscrasias • Thrombocytopenia• Anticoagulants

• Complicated:• Abruptio Placentae• Placental praevia• Vasa Praevia

Placenta - Physiology and function

. Fetus entirely dependent on placenta until birth.

. Maternal and fetal blood kept separate by placental barrier.. Protects the infant from infection and

harmful substances.. Acts as endocrine organ - makes hormones to maintain pregnancy.. Made of 12-20 cotyledons.. Fetal blood transported to placenta via two umbilical arteries.

. Umbilical arteries get smaller and become arterioles then villi.

. Villi suspended in pools of maternal blood in the lacunae.. Fetal blood returns to fetus via umbilical vein.

NORMAL PLACENTA

ABRUPTIO PLACENTA

PLACENTA ACCRETA

PLACENTA PREVIA

Placenta praevia Abnormally implanted placenta placed totally

or partially in the lower segment of the uterus,

rather than in the fundus.

When the cervix begins to dilate and efface the

placenta separates, allowing

bleeding form the open vessels.

Placenta praevia: types• Complete placenta praevia• Partial placenta praevia• Marginal placenta praevia (placenta approaching

the border of os )

Grading of placenta praevia:• Grade I – The placenta is in the lower segment, but the lower edge does not reach the internal os.

• Grade II – The lower edge of the low-lying placenta reaches, but does not cover the internal os.

•  Grade III – The placenta covers the internal os but not cover when os is dilated

•  Grade IV – The placenta covers and entirely surrounds the internal os even though os is fully dilated.

LOW LYING MARGINAL

TOTALPARTIAL

TYPES OF PLACENTA PREVIA

Placenta praevia : Risk factors• Previous placenta praevia.• Multiple pregnancies- due to the placenta occupying a large surface area.• Mutiparity• Cigarette smoking• Increased maternal age• Endometritis• Previous caesarean section

Presentation Symptoms• Sudden, Painless ,Causeless recurrent vaginal bleeding (color Bright Red )• No history of trauma to abdomen • Triggering factors may be present (e.g. Bleeding post coitus )• Anemia symptoms which is proportionate visible blood loss (Tiredness, lassitude, weakness, dyspnoea, palpatation , pallor )• Fetal distress but more dangerous for mother • In excessive blood loss >>> symptoms of shock ( faintness , tachycardia , hypotension , sweating ,cold & clammy extremities, oliguria, syncope

Physical Exam

•Digital exam is contraindicated

• Breech presentation or unstable lie or high presenting part

• Soft and relaxed, non tender uterus which is proportionate to gestational age

• Concurrent contractions with bleeding are present

Investigations• Laboratory studies• CBC• PT & APTT• Imaging studies• Transvaginal ultrasonography• Transabdominal ultrasonography

A PLACENTA WHICH HAS IMPLANTED OVER THE OS

Placenta

Cervix

Uterus

Midwifery Actions-Woman presents with painless bleeding

• Calm attitude• Inform Obstetric staff• T, P, BP• CTG• Palpation• NO Vaginal Examination until location of placenta has been confirmed by ultrasound• Take history of amount of blood loss, explore possible causes.• Establish venous access• Take blood for Group & Matching, Full blood count, clotting IV fluids as prescribed

Midwifery Actions• Consider anxieties of woman in hospital with other children to care for• Possible visit to the neonatal unit• Include in discussions surrounding expectant birth date of the baby

Management• Assessing the airways, breathing, circulation• Cannula inserted for Drug administration ,Blood sampling ,IV fluid administration• In the absences of heavy vaginal bleeding , not in labour( B4 37 wk )

and bleeding stop spontaneously >>> Expectant Management • Ensure blood available• Monitor for anemia• Vitamins and Iron supplements should be taken• Anti D if Rh Neg• Steroids for fetal lung development

• If uncomplicated pregnancy no need of intervention• If needed tocolytics may be considered to administer antenatal steroids • Types of Tocolytics(anti-contraction medications or labour represents )

B2 agonist Calcium channel blockers Oxytocin antagonist – Atosiban NSAIDs Before the delivery the following should be consulted• Obstetric anesthesiologist• Interventional radiologist• General surgeon• Urologist

• Termination of Expectant Management when fetus is mature or dead or not compatible for life & mother is in danger ( heavy vaginal bleeding )

Normal spontaneous Vaginal delivery ????

OR

Elective LSCS????

Induction of labour • Is possible in:

Possible complications• Uncontrollable bleeding• Anaemia• Infection• Renal failure due to severe shock• Hysterectomy• Sheehan’s syndrome as a result of severe shock(Damage to the pituitary gland – hypopituitarism)• Fetal hypoxia• Premature birth• Fetal death• Psychological effects

Abruptio Placentae

Separation of the normally situated placenta from its uterine site of implantation after 20 weeks gestation, but before delivery of the placenta.( Premature separation of the placenta )

Placental abruption: types•Placental abruption can be broadly classified into two types:• Revealed• Concealed• Mixed

Classification• Placental Grades :A . Grade 0 - Patient asymptomatic. Small retroperitoneal clot seen after deliveryB. Grade 1 - Vaginal bleeding, may have abdominal tenderness or slight uterine tetany ,mom and baby not in distress.C. Grade 2 - Uterine tenderness, tetany with or without evidence of bleeding, baby shows signs of distress.D. Grade 3 - Uterine tetany , severe bleeding may not be visible. Baby is dead.

Mom often has coagulopathy.

Placental Abruption

Risk factors of Abruptio Placentae• Trauma (Fall, accident, ECV ) •Grandmutipra , Multiparity , Maternal hypertension• Sudden decompression of uterus – release of hydramnios

( after delivery of 1st twin ) • -Polyhydramnios with rapid decompression on membrane rupture

• -cocaine use, tobacco use• -PPROM• -short umbilical cord , IUGR• Anti-coagulant threapy

Presentation •Symptoms•Vaginal bleeding - 80% ( Red or brown loss PV)•Abdominal or back pain and uterine tenderness - 70%•Abnormal uterine contractions (eg hypertonic, high frequency) - 35%• Idiopathic premature labor - 25%•Tense, firm uterus tender to palpate•Signs of shock•Reduced or excessive fetal movements• Fetal distress - 60% or no fetal heart• Fetal death – 15%

•Physical Examination• Should be done after stabilizing the patient• Ultrasound should be done first to assess the location of placenta. Only then should a digital pelvic exam be conducted• Profuse bleeding in waves• Uterine contraction / Uterine hypertonic• Shock• Absence of fetal heart sounds• Increased fundal height (due to hematoma)

Investigations• Laboratory studies• CBC• PT & APTT• Fibrinogen levels• BUN / creatinine• Imaging studies• Transvaginal ultrasonography• Transabdominal ultrasonography

Management• Stabilize the woman• T, P, BP• Full history• IV access• Blood for group & hold, Full blood count, Coag & Kleihauer if rh negCaesarean Section Expectant Management• If unstoppable labour• If fetal distress• If life threatening

Haemorrhage

• If preterm • No profuse haemorrhage• Not life threatening• No fetal distress

Management • Vitamins and Iron supplements should be taken• Initial management• Transfusion, correction of coagulopathy and Rh immune globulin if needed• Cesarian section preferable mode of delivery• Vertical incision• Hysterectomy might be needed if severe blood loss• Tocolytics may be used in case of preterm delivery only if• Hemodynamically stable• No fetal distress• Preterm fetus may benefit from corticosteroid therapy• In case of fetal death mode of delivery is SVD

Complications of Abruptio placentae - Maternal

Can lead

to DIC

•Fetal complications include•Hypoxia or hypoxic-ischemic encephalopathy (HIE)•growth retardation•CNS abnormalities• Intra uterine death.

Complications of Abruptio placentae – Fetal

Abruptio Placentae Placenta Previa

Pain Abdominal pain, low back pain Painless unless in labour

Uterus Tender, irritable Nontender, soft (unless contracting)

Presentation Not associated with abnormal presentation Breech or high presenting part

Fetus Fetal heart tracing abnormal, atypical Fetal tracing not affected since blood is maternal

Shock Shock/anemia out of proportion to amount of blood seen

Shock/anemia proportionate to blood seen

Imaging U/S cannot rule out U/S sensitive

Non Placental causes of APH

Non Placental causes of APH

Uterine rupture-management• It is an emergency •Laparotomy is urgently done•Uterine rupture can be an antepartum or postpartum event

Vasa praevia•When vasa praevia is diagnosed antenatally, an elective Caesarean section should be offered prior to the onset of labour. • In cases of vasa praevia, premature delivery is most likely, therefore, consideration should be given to administration of corticosteroids at 28 to 32 weeks

Antepartum hemorrhage

History and Physical Examination

Fetal monitoring

Massive bleeding

Normal Bloody show

Routine Evaluation

Severely distressed fetus

Suspect Vasa Previa

Urgent Cesarean delivery

Inflamed cervix or mucopurulent

dischargeProbable cervical infection

Culture and treat as

appropriate

Uterine pain ??

No pain or pain only with

contractions. Non tender fundus

Pain between contractions and

tender fundus

Cesarean delivery if in

labour

Suspect Placenta previa

Immediate ultrasound

examination if available

Consider abruptio

placentaeConsider uterine

rupture

Consider urgent lapartomy

Monitor fetus. Supportive

mother care

Cesarean if fetal distress

SVD if fetal death

Call for helpEvaluate ABCsAdminister IV

fluidsConsider

transfusionConsider CS

THANK U XO MUCH