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4th yr LECTURE ANTEPARTUM HAEMORRHAGE (3).pdf
- 1. November 4, 2022APH 1 ANTEPARTUM HAEMORRHAGE Prepared by: TAHIRA SHAHEEN Principal CON Rajanpur
- 2. OBJECTIVES ⚫ At the endof this lecture the learners will be able to: ⚫ Define antepartum haemorrhage ⚫ Discuss its causes, types, and diagnosis methods ⚫ Explain the management and complications of APH. APH 2 November 4, 2022
- 3. APH (Antepartum Haemorrhage) ⚫ Antepartumhaemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby. APH 3 November 4, 2022
- 4. APH 4 November 4,2022 Antepartum Haemorrhage ⚫ vaginal blood loss >15 mL after 20 weeks’ gestation ⚫ 5% of all pregnancies ⚫ Accounts for 20 -25% of perinatal mortality
- 5. APH 5 November 4,2022 Causes ⚫ Placenta praevia 20% ⚫ Placental abruption 30% ⚫ Others/ unknown 45% ⚫ Vasa praevia ⚫ Marginal sinus bleeding ⚫ Rupture uterus ⚫ Local causes 5%
- 6. APH 6 November 4,2022 Local causes of APH ⚫ Only 5% of APH ⚫ Causes include: ⚫ Cervicitis ⚫ Cervical erosion, polyp ⚫ Cervical cancer ⚫ Vaginal/ vulval varicocities ⚫ Vaginal infections ⚫ Foreign bodies ⚫ Genital lacerations ⚫ Bloody show ⚫ Degenerating fibroids ⚫ non-genital tract bleeding
- 7. APH 7 November 4,2022 Severity of bleeding ⚫ Mild (<15% circulatory volume) ⚫ No change in vital signs ⚫ No postural hypotension ⚫ Normal urine output ⚫ Moderate (15 - 30%) ⚫ Postural changes in BP or pulse ⚫ Symptoms (thirst, dypsnoea etc.) ⚫ Severe (>30%) ⚫ Shock ⚫ Fetal distress ⚫ Oliguria
- 8. APH 8 November 4,2022 Initial management of APH ⚫ Admit ⚫ History ⚫ Examination ⚫ Observation ⚫ NO PV Exam ⚫ IV access/ resuscitate ⚫ Clotting screen ⚫ Cross match ⚫ Kleihauer test ⚫ CTG ⚫ Placental localization ⚫ Speculum examination when placenta praevia excluded, bleeding settled ⚫ Anti-D if Rh-negative
- 9. The Kleihauer Betketest ⚫ The Kleihauer Betke test is utilized to determine if there is fetal blood in maternal circulation, with a threshold of 5 mL. ⚫ The Rosette test is performed by incubating the Rh-negative maternal venous whole blood sample with anti-Rho (D) immune globulin. ⚫ The normal range is 0 to 0.1% as reported by the lab. APH 9 November 4, 2022
- 10. APH 10 November 4,2022 Placental abruption ⚫ Separation of placenta before delivery ⚫ Starts with bleeding into decidua basalis ⚫ Impairs placental function ⚫ About 1.5% of pregnancies ⚫ Perinatal mortality 10%
- 11. APH 11 November 4,2022 Complications ⚫ DIC (Disseminated intravascular coagulation) ⚫ Fetal death ⚫ Hypovolemic shock ⚫ Feto-maternal haemorrhage
- 12. DIC ⚫ Disseminated intravascular coagulation(DIC) is a rare but serious condition that causes abnormal blood clotting throughout the body's blood vessels. ⚫ You may develop DIC if you have an infection or injury that affects the body's normal blood clotting process. APH 12 November 4, 2022
- 13. APH 13 November 4,2022 Predisposing factors of abruption ⚫ Hypertension ⚫ External trauma – Motor Vehicle Accident (MVA), External Cephalic Version (ECV) ⚫ Acute decompression of polyhydramnios ⚫ PROM (Premature Rupture of Membranes) ⚫ Substance abuse -tobacco, cocaine, amphetamines ⚫ Past history of abruption ⚫ Antiphospholipid syndrome ⚫ Multiple pregnancies
- 14. External cephalic version ⚫ Externalcephalic version is a procedure that externally rotates the fetus from a breech presentation to a vertex presentation. APH 14 November 4, 2022
- 15. AMNIOTIC FLUID VALUES ⚫ Amnioticfluid volumes have been labeled as oligohydramnios if the actual volume of the amniotic fluid is <200 mL or <500 mL, ⚫ Normal amniotic fluid volume if 200 or 500−1500 or 2000 mL, and ⚫ Polyhydramnios if the volumes are >1500 or >2000 mL. APH 15 November 4, 2022
- 16. Antiphospholipid syndrome ⚫ Antiphospholipid syndromeis a condition in which the immune system mistakenly creates antibodies that attack tissues in the body. These antibodies can cause blood clots to form in arteries and veins. ⚫ Blood clots can form in the legs, lungs, and other organs, such as the kidneys and spleen. APH 16 November 4, 2022
- 17. APH 17 November 4,2022 Classification of abruption ⚫ Mild ⚫ Blood loss < 200 mL ⚫ No uterine tenderness or rigidity ⚫ Normal CTG ⚫ Moderate ⚫ Blood loss > 200 mL OR ⚫ Uterus tense and tender OR ⚫ Abnormal CTG ⚫ Severe ⚫ Fetal death - DIC in 30%
- 18. Types of placentalabruption ⚫ A partial placental abruption occurs when the placenta does not completely detach from the uterine wall. ⚫ A complete or total placental abruption occurs when the placenta completely detaches from the uterine wall. There is usually more vaginal bleeding associated with this type of abruption. ⚫ Revealed placental abruptions have moderate to severe vaginal bleeding that you can see. ⚫ Concealed placental abruptions have little or no visible vaginal bleeding. Blood is trapped between the placenta and uterine wall. APH 18 November 4, 2022
- 19.
- 20. APH 20 November 4,2022 Clinical features ⚫ Vaginal bleeding in 80% (Revealed) ⚫ Abruption is ‘Concealed in 20% ⚫ Initial bleeding ⚫ Pain, uterine tenderness, rigidity ⚫ Sudden increase in fundal height ⚫ Fetal distress or death ⚫ DIC
- 21. APH 21 November 4,2022 Diagnosis ⚫ Clinical diagnosis, confirmed retrospectively by examination of placenta ⚫ Clinical features important in concealed abruption ⚫ Ultrasound unreliable ⚫ Only shows 25% of abruptions
- 22. APH 22 November 4,2022 Management ⚫ Admit ⚫ History, examination ⚫ Assess blood loss ⚫ Nearly always more than revealed ⚫ IV access, X match, DIC screen (PT, APTT) ⚫ Assess fetal well-being ⚫ Placental localization
- 23. NORMAL RESULTS ⚫ PT (Prothrombintime) results: 11 to 13.5 seconds. ⚫ INR (International normalized ratio) of 0.8 to 1.1 ⚫ APTT (Activated partial throboplastin clotting time) : A normal range is around 21 to 35 seconds. APH 23 November 4, 2022
- 24. APH 24 November 4,2022 Placenta praevia ⚫ Placenta implanted on lower uterine segment ⚫ 1% of all pregnancies ⚫ Perinatal mortality rate ~ 3% ⚫ Major problem is preterm delivery ⚫ At 18 weeks, ~5% of placentas are ‘low lying’
- 25. APH 25 November 4,2022 Classification of Placenta Praevia FOUR grades or degrees of placenta praevia: 1. Low-lying: edge not near internal os, but could be palpated by finger through cervix. 2. Marginal: edge of placenta reaches but does not cover os. 3. Partial: placenta partially covers internal os. 4. Total: placenta completely covers internal OS.
- 26.
- 27. APH 27 November 4,2022 Aetiology/ associations of Placenta Praevia ⚫ Uterine surgery or instrumentation ⚫ Previous CS, D&C, myomectomy ⚫ 1 previous CS + anterior placenta praevia = 25% risk placenta accreta (Placenta accreta is a serious pregnancy condition that occurs when the placenta grows too deeply into the uterine wall. ) ⚫ Increasing parity and age ⚫ Multiple pregnancy
- 28. APH 28 November 4,2022 Clinical presentation of Placenta Praevia ⚫ Painless Recurrent Vaginal bleeding ⚫ 1/3 < 30 weeks ⚫ 1/3 30-35 weeks ⚫ 1/3 > 36 weeks ⚫ Usually first episode mild ⚫ Earlier is worse ⚫ Often gets worse ⚫ Abnormal presentation or lie
- 29. APH 29 November 4,2022 Diagnosis ⚫ Placental localization is by ultrasound examination ⚫ Transvaginal ultrasound better ⚫ Not always right ⚫ At 18 weeks, 5-10% of placenta low lying. ⚫ Repeat scan at 32 - 34 weeks
- 30.
- 31. APH 31 November 4,2022 Vasa Praevia ⚫ Vasa Praevia is defined when unprotected umbilical vessels run through the amniotic membranes, and pass over the cervix. ⚫ Velamentous insertion of cord, succenturiate placenta ⚫ Fetal vessels in membranes over the cervix ⚫ May rupture at or before ROM ⚫ Suspect in small APH with abnormal CTG ⚫ Confirm with Apt test (used to differentiate fetal or neonatal blood from maternal blood).
- 32. Velamentous insertion ofcord ⚫ Velamentous cord insertion (VCI) is an umbilical cord attachment to the membranes surrounding the placenta instead of the central mass. APH 32 November 4, 2022
- 33. Succenturiate placenta ⚫ The succenturiateplacenta is a condition in which one or more accessory lobes develop in the membranes apart from the main placental body to which vessels of fetal origin usually connect them. APH 33 November 4, 2022
- 34. APH 34 November 4,2022 Management ⚫ Admit to hospital ⚫ NO VAGINAL EXAMINATION ⚫ IV access ⚫ Placental localization ⚫ Conservative treatment until fetal maturity if possible
- 35. APH 35 November 4,2022 Management Severe bleeding Caesarean section Moderate bleeding Gestation >34 wks <34 wks Resuscitate Steroids Unstable Stable Resuscitate Mild bleeding Gestation <36 wks Conservative care >36 wks
- 36. APH 36 November 4,2022 Delivery ⚫ Delivery is by Caesarean section ⚫ Usually LSCS, go around placenta ⚫ Beware morbidly adherent placenta ⚫ Occasionally Caesarean hysterectomy necessary
- 37. APH 37 November 4,2022 Outpatient management ⚫ Inpatient observation for 72 hours without bleeding ⚫ Stable haematocrit > 35% ⚫ Reactive CTG ⚫ Can call ambulance 24 hours/day ⚫ Rest at home, no intercourse ⚫ Patient understands complications ⚫ Weekly follow-up until delivery
- 38. APH 38 November 4,2022 Asymptomatic patients ⚫ Placenta praevia now diagnosed prior to bleeding ⚫ If no bleeding, no need to admit before 34 weeks ⚫ Admit if bleeds ⚫ Delivery still by CS at 37-38 weeks ⚫ Uncertainty about admission between 34 and 37 weeks - admit grades 3 and 4
- 39.