Antepartum
& Postpartum
Hemorrhage
PLAN
CASE
PRESENTATION
CORE PRESENTATION
Clinical features
Risk factors
Investigations
Management
Case
37
years old pregnant female of 32
weeks GA presents to the emergency
room because of significant vaginal
bleeding over the past hour. The
patient also reports some contractions,
but denies any continuing abdominal
pain and any recent trauma.
Current Gestational
History
-G3 P2
-Date of Last Menstruation: 4/11/11
-Estimated Date of Delivery: 11/8/12
-No prior antenatal care
Past Obsetrical History:
-G3 P2
-2 previous SVDs (spontaneous vaginal
delivery)
-Both boys and weighed 3.5kg and 3.8kg
respectively
-No previous obstetrical complications or
morbidity
Past Medical History:
-None
Family History:
-Unremarkable, no history of twins or
multiple gestations
Social History
Lives
with her husband in the Santiago
Denies any smoking, alcohol drugs.
Denies any spousal abuse.
Completed elementary school. A
housewife with low economic status.
Physical Examination
Vital
Signs: Stable (BP 110/70, P
72)
General Appearance: No apparent
distress, appeared clinically stable
Capillary reflex < 2 seconds
Uterine Height: 30 cm
Fetal Lie:Longitudinal
Contractions: Present
Fetal Heart Tones: 144 x minute
Differential
diagnosis?
Placental
abruption
Placenta praevia
Uterine rupture
Haemorrhoids
Miscarriage
Vasa praevia
Neoplasia
CORE PRESENTATION
ANTEPARTUM
HEMORRHAGE
Per
vagina blood loss after 20 weeks
gestation.
Complicates
close to 4% of all pregnancies
and is a MEDICAL EMERGENCY!
Is
one of the leading causes of antepartum
hospitalization, maternal morbidity, and
operative intervention.
What are the most common
causes of Antepartum Hemorrhage ?
COMMON CAUSES
Placenta
Previa
Placental Abruption
Uterine Rupture
Vasa Previa
Bloody Show
Coagulation Disorder
Hemorrhoids
UTI
Vaginal Lesion/Injury
Cervical Lesion/Injury
Neoplasia
PLACENTA PRAEVIA
Placenta Previa
Defined as a placenta implanted in the lower
segment of the uterus.
Incidence about 5 in 1000 in UK
Classifies into;
Major cervical os completely covered
Minor placenta at lower segment of uterus but
does not covered uterus
Previously classified as I to IV
1. Low-lying placenta. The placenta is implanted in the
lower uterine segment such that the placenta edge
actually does not reach the internal os but is in close
proximity to it
2. Marginal placenta previa. The edge of the placenta is
at the margin of the internal os.
3. Partial placenta previa. The internal os is partially
covered by placenta.
4. Total placenta previa. The internal cervical os is
covered completely by placenta.
Placenta Previa
Etiology:
Advancing maternal age
Multiparity
Multifetal gestations
Prior cesarean delivery
Smoking
Prior placenta previa
Clinical features
The
most characteristic event in placenta
previa is painless hemorrhage.
This
usually occurs near the end of or after
the second trimester.
Often
Soft
recurrent in third trimester
uterus and non-tender, and free
presenting part due to obstruction
Placenta Previa
Placenta
previa may be associated with
placenta accreta, placenta increta or
percreta.
Coagulopathy
previa.
is rare with placenta
Placenta Previa
Diagnosis.
Placenta previa or abruption should always be suspected
in women with uterine bleeding during the latter half of
pregnancy.
The possibility of placenta previa should not be dismissed
until appropriate evaluation, including sonography, has
clearly proved its absence.
The diagnosis of placenta previa can seldom be
established firmly by clinical examination. Such
examination of the cervix is never permissible
unless the woman is in an operating room with all
the preparations for immediate cesarean delivery,
because even the gentlest examination of this sort
can cause torrential hemorrhage.
Placenta Previa
The
simplest and safest method of
placental localization is provided by
transabdominal sonography.
Transvaginal
ultrasonography has
substantively improved diagnostic
accuracy of placenta previa.
MRI
Placenta Previa
Management
Admit to hospital ABC
NO
VAGINAL EXAMINATION
IV access
Delivery by C-section
Placental localization if minor PP, placenta minimum
2cm away from cervical os may considered vaginal
delivery.
Placenta Previa
Management
Severe
bleeding
Moderate
bleeding
Resuscitate
>34/52
Gestation
<34/52
Resuscitate
Steroids
Mild
bleeding
Caesarean
section
Gestation
<36/52
Unstable
Stable
Conservative
care
>36/52
PLACENTAL ABRUPTION
Placental Abruption
Defined
as the separation of the
normally implanted placenta from
uterine wall
Occurs
in 1-2% of all pregnancies
Perinatal
mortality rate associated
with placental abruption was 119
per 1000 births compared with 8.2
per 1000 for all others.
Placental Abruption
external
hemorrhage
concealed hemorrhage
Total
Partial
What are the risk factors for
placental abruption?
The primary cause of placental abruption is
unknown, but there are several associated
conditions.
Increased
age and
parity
Cigarette
smoking
Thrombophilias
Preeclampsia
Cocaine
Chronic
Prior
hypertension
Preterm
ruptured
membranes
Multifetal
gestation
Hydramnios
use
abruption
Uterine
leiomyoma
External
trauma
The
hallmark symptom of placental
abruption is pain which can vary from
mild cramping to severe pain.
Associated
Reduced
with vaginal bleed
fetal movement
Importantly,
negative findings with
ultrasound examination do not
exclude placental abruption.
Ultrasound only shows 25% of
abruptions.
Placental Abruption
Shock
Consumptive
Fetal
Coagulopathy
Death
Couvelaire
Uterus -
Constant pain + hard uterus on palpation
Due to large volume of blood within
myometrium
Management:
Treatment for placental abruption
varies depending on gestational age and the
status of the mother and fetus.
Admit
History
& examination
Assess
blood loss
Nearly
IV
always more than revealed
access, X match
Dead
fetus vaginal delivery accelerated with
artificial membrane rupture
Alive
fetus C-section
UTERINE RUPTURE
Uterine Rupture
Classic
presentation includes vaginal
bleeding, pain, cessation of
contractions, absence/ deterioration of
fetal heart rate, easily palpable fetal
parts, and profound maternal
tachycardia and hypotension.
Patients
with a prior uterine scar should
be advised to come to the hospital for
evaluation of new onset contractions,
abdominal pain, or vaginal bleeding.
What are the risk factors associated
with uterine rupture?
Uterine Rupture
Excessive
uterine
stimulation
Multiparity
Non-vertex
Hx
of previous C/S
fetal
presentation
Trauma
Shoulder
Prior
Forceps
rupture
Previous
surgery
uterine
dystocia
delivery
Uterine Rupture
Management:
Emergent laparotomy with C-section
Uterus may be repaired or removed
Initial management of APH
Admit
Kleihauer-Betke
History
Apt
Examination
NO
PV
Nurse on side
IV access/ resuscitate
Clotting screen
Cross match
test
test
CTG
Observation
Placental localization
Speculum examination
when placenta previa
excluded
Anti-D if Rh-negative
Kleihauer-Betke Test
Is
a blood test used to measure the
amount of fetal hemoglobin transferred
from a fetus to the mother's
bloodstream.
Used
to determine the required dose of
Rh immune globulin.
Used
for quantifying fetal-maternal
hemorrhage.
Apt test
The
test allows the clinician to determine
whether the blood originates from the infant or
from the mother.
Place 5 mL water in each of 2 test tubes
To 1 test tube add 5 drops of vaginal blood
To other add 5 drops of maternal (adult) blood
Add 6 drops 10% NaOH to each tube
Observe for 2 minutes
Maternal (adult) blood turns yellow-green-brown; fetal
blood stays pink.
If fetal blood, deliver STAT.
POSTPARTUM
HAEMORRHAGE
Postpartum Hemorrhage
In
spite of marked improvements in management,
PPH remains a significant contributor to maternal
morbidity and mortality both in developing and
developed countries.
One
of the most challenging complications a
clinician will face.
Prevention,
early recognition and prompt
appropriate intervention are the keys to minimizing
its impact.
PRIMARY
Loss of greater or equal of 500ml within
24 hours
SECONDARY
Loss of greater or equal of 500ml between 24
hours and 12 weeks post delivery
PPH
PPH Risk Factors
Many
factors affect a womans risk of
PPH.
Each
of these risk factors can be
understood as predisposing her to one
or more of the four T processes.
The Four T
Tone
Tissue
Trauma
Thrombin
PPH Risk Factors
PPH Risk Factors
PPH Risk Factors
PPH Risk Factors
PREVENTION OF PPH
Although
any woman can experience a PPH,
the presence of risk factors makes it more
likely.
For
women with such risk factors,
consideration should be given to extra
precautions such as:
IV
access
Coagulation studies
Crossmatching of blood
Anaesthesia backup
Referral to a tertiary centre
PREVENTION OF PPH
UTEROTONIC
DRUGS
Routine
oxytocic administration in the third stage of
labour can reduce the risk of PPH by more than 40%
The
routine prophylaxis with oxytocics results in a
reduced need to use these drugs therapeutically
Management
of the third stage of labour should
therefore include the administration of oxytocin
after the delivery of the anterior shoulder.
MANAGEMENT OF PPH
Early
recognition of PPH is a very
important factor in management.
An
established plan of action for the
management of PPH is of great value
when the preventative measures have
failed.
MANAGEMENT OF PPH
MANAGEMENT OF PPH
DRUG THERAPY FOR PPH
MANAGEMENT OF PPH
MANAGEMENT OF PPH
MANAGEMENT OF PPH
Summary: Remember 4 Ts
Tone
Tissue
Trauma
Thrombin
Summary: remember 4 Ts
TONE
Rule
out Uterine Atony
Palpate
fundus.
Massage uterus.
Oxytocin
Methergine
Hemabate
Summary: remember 4 Ts
Tissue
R/O
retained placenta
Inspect
placenta for
missing cotyledons.
Explore uterus.
Treat abnormal
implantation.
Summary: remember 4 Ts
TRAUMA
R/O
cervical or vaginal
lacerations.
Obtain
good exposure.
Inspect cervix and
vagina.
Worry about slow
bleeders.
Treat hematomas.
Summary: remember 4 Ts
THROMBIN
Check
labs if
suspicious.
THANK YOU
