ante partum haemorrhage by dr wyo

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  • ANTEPARTUMHEMORRHAGE House Surgeon WYO
  • 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 pregnancies 3 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.
  • ABRUPTIO PLACENTANORMAL 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.
  • TYPES OF PLACENTA PREVIALOW LYING MARGINAL TOTALPARTIAL
  • 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
  • Cervix PlacentaUterus A PLACENTA WHICH HAS IMPLANTED OVER THE OS
  • 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 Sheehans 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 delivery B. 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 1 st 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