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antepartal hemorrhage
This document provides information on antepartum hemorrhage (APH) including definitions, causes, risk factors, clinical presentations, diagnoses, and management strategies. It covers two main causes of APH - placental abruption and placenta previa. Placental abruption is defined as premature separation of the placenta and can cause both concealed and revealed bleeding. It accounts for 40% of APH cases. Placenta previa refers to placenta implanted over the cervical os and is a risk factor for painless third trimester bleeding. Sonography and history are used to diagnose the cause of bleeding and determine management, whether expectant, medical, or termination of pregnancy.
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antepartal hemorrhage
- 1. Antepartal hemorrhage (APH) 5/21/2018 1 Foryr 2 anesthesia student by Dr Abebe Chanie
- 2. Objectives 5/21/2018 2 At theend of this session students will able to; define APH List differential diagnosis of APH Define AP &PP List risk factors for AP&PP Describe principle of mgt of APH
- 3. 5/21/2018 3 Obstetric hrrge alongwith HTN and infection as one of the infamous triads maternal death . o Leading cause of ICU admission o 12% maternal death o Most important cause of maternal death world wide and responsible for half of all postpartal death
- 4. APH 5/21/2018 4 • Definition; Vaginalbleeding after 28 wks of pregnancy but before delivery of the fetus • The 1st and 2nd stage of labor included Incidence is 3-4%
- 5. Causes of APH 5/21/2018 5 oAbruptio placenta 40% of APH (1:80 pregnancies) o placenta pravia 20% (1:200 pregnancies) o Indeterminate APH or APH of UK origin (uncertain, unclassified) 35-50% of APH o Local causes • Cervicitis • Cervical polyp or Ca • Vulvar or vaginal varices • Hematuria & rectal bleeding • Heavy show • Vasa praevia • Marginal sinus rupture • Circumvallate placenta • Abnormal clotting mechanism
- 6. ■ Placental Abruption 5/21/2018 6 Separation of the placenta—either partially or totally—from its implantation site before delivery is described by the Latin term abruptio placentae premature separation of the normally implanted placenta is most descriptive because it excludes separation of a placenta previa implanted over the internal cervical os.
- 7. Etiopathogenesis 5/21/2018 7 1. Rupture ofdecidual spiral arterioles 2. initiated by hemorrhage into the decidua basalis 3. The decidua then splits 4. Decidual hematoma expands and cause compression of adjacent placenta and further split
- 8. Can be 5/21/2018 8 1. Revealedor external ; bleeding typically insinuates itself between the membranes and uterus, ultimately escaping through the cervix to vagina 2.Concealed ; the blood is retained between the detached placenta and the uterus
- 9. Risk factors 5/21/2018 9 Priorabruption Increased age and parity Preeclampsia Chronic hypertension Chorioamnionitis Preterm ruptured membranes Multi fetal gestation Low birth weight Hydramnios Cigarette smoking Thrombophilias Cocaine use Uterine leiomyoma
- 10. Clinical Findings andDiagnosis 5/21/2018 10 • Most women present ;with sudden-onset abdominal pain, vaginal bleeding, and uterine tenderness • Vaginal bleeding (>80 percent of patients) • Abdominal pain (>50 percent) • Uterine contractions • Uterine tenderness • Non reassuring FHR tracing Fetal death DIC (concealed) • The amount of vaginal bleeding does not correlate well with the extent of maternal hemorrhage and cannot be used to gauge the severity of abruption
- 11. Grading of placentalabruption 5/21/2018 11 Grade 1: A mild abruption characterized by; slight vaginal bleeding and minimal uterine irritability Maternal blood pressure and fibrinogen levels are unaffected,and the fetal heart rate pattern is normal 40 percent of placental abruptions are grade 1.
- 12. 5/21/2018 12 Grade 2: Apartial abruption mild to moderate vaginal bleeding signifi cant uterine irritability or contractions Maternal blood pressure is maintained, but the pulse is often elevated and postural blood volume deficits may be present The fibrinogen level may be decreased the fetal heart rate often shows signs of fetal compromise account for 45 percent of all placental abruptions.
- 13. 5/21/2018 13 Grade 3: Alarge or complete abruption moderate to severe vaginal bleeding or occult uterine bleeding with painful, uterine contractions Maternal hypotension and coagulopathy are frequently present along with fetal death Accounts 15 percent of placental abruptions Grade 0 ;a retrospective diagnosis of abruptio placentae
- 14. Complications 5/21/2018 14 Hypovolemic ShockPlacental abruption is one of several notable obstetrical entities that may be complicated by massive and sometimes torrential hemorrhage Consumptive Coagulopathy placental abruption and amnionic-fluid embolism—led to the defibrination syndrome, which is referred to as consumptive coagulopathy or disseminated intravascular coagulation
- 15. complication 5/21/2018 15 • FM hemorrhage •uteroplacental apoplexy (couvelaire Ux) extravasation of blood into the ux myometrium red to purple discoloration of the serosal surface • Fibrin deposits to small vessels, hypoxic damage to organs - - corpulmonale • sheehan’s syndrome • acute renal & tubular necrosis • Fetal hypoxia &IUFD, IUGR, prematurity, • PPH-ux atony
- 16. Investigations 5/21/2018 16 Sonography sensitive forabout 25% -used to rule out placental abruption Laboratory is not useful in making the diagnosis but supports a diagnosis of severe abruption Hypofibrinogenemia and evidence of DIC are supportive of the diagnosis; however, clinical correlation is necessary.
- 17. PLACENTAL PREVIA 5/21/2018 17 TheLatin previa means going before the placenta goes before the fetus into the birth canal.
- 18. PP 5/21/2018 18 Definition; Inobstetrics, placenta previa describes a placenta that is implanted somewhere in the lower uterine segment, either over or very near the internal cervical os Classification Placenta previa—the internal os is covered partially or completely by placenta In the past, these were either total or partial previa Low-lying placenta—implantation in the lower segment of uterus is such that the placental edge does not reach the internal os and remains outside a 2-cm wide perimeter around the os
- 19. Risk factors 5/21/2018 19 Increasingparity Increasing maternal age Cigarette smoking (2x >non smoker) Residence in higher altitude Multiple gestations Previous placenta previa Prior curettage Prior cesarean delivery
- 20. Clinical presentation 5/21/2018 20 Painlessthird-trimester bleeding was a common presentation for placenta previa in the past, whereas most cases of placenta previa are now detected antenatally with ultrasound before the onset of significant bleeding • Sudden, painless, causeless, recurrent V.bleeding & bright red
- 21. causes of bleeding 5/21/2018 21 formationof LUS and cervical dilatation separation of placenta by trauma -VE ,coitus ,ECVV/S proportional to blood loss • High presenting part or abnormal lie • Non tender abdomen & normal uterine tone
- 22. Diagnosis 5/21/2018 22 Previa shouldnot be excluded until sonographic evaluation has clearly proved its absence Diagnosis by clinical examination is done using the double set-up technique but digital examination should not be performed unless delivery is planned A cervical digital examination is done with the woman in an operating room and with preparations for immediate cesarean delivery. Even the gentlest examination cancause torrential hemorrhage
- 23. 5/21/2018 23 Sonography Transabdominal sonographyis confirmatory an average accuracy of 96 percent has been reported Transvaginal sonography is safe, and the results are superior Magnetic Resonance Imaging not for routine use but for placenta accreta syndrome
- 24. Laboratory 5/21/2018 24 • CBC, Bloodgroup & Rh • Coagulation profile –PT, PTT, fibrinogen • Peripheral blood smear
- 25. Complications 5/21/2018 25 • Adherent placenta •IUGR • Rh sensitization • Prematurity • Maternal mortality • Perinatal mortality • Infection • PPH
- 26. Complications 5/21/2018 26 Abnormally ImplantedPlacenta A frequent and serious associated with placenta previa arises from its abnormally firm placental attachment because of poorly developed decidua that lines the lower uterine segment Placenta accrete syndromes arise from abnormal placental implantation and adherence and are classified according to the depth of placental ingrowth into the uterine wall. These include placenta accreta, increta, and percreta
- 27. Management 5/21/2018 27 Depends on • Fetalcondition • Maternal condition • GA • Extent of bleeding • labour Management Options • Expectant (conservative) • Termination (definitive )
- 28. Basic principles 5/21/2018 28 • Secureiv line resuscitate with crystalloids • Admit to the labor and delivery area for maternal and fetal monitoring • Monitor maternal v/s, urine output, amount of bleeding • Identify underlying cause & Rx causes • Monitor fetal condition • Don’t do pelvic examination • Prepare at least 2 unit of x- mathed blood
- 29. Termination 5/21/2018 29 • At orafter 37 weeks • Patient in labor • Pt in exsanguinated state on admission • Bleeding is continuing and of moderate degree • Baby is dead or congenitally deformed
- 30. Modes of delivery 5/21/2018 30 placentapraevia Vaginal –type1 & anterior type2 (marginal) - If no sever bleeding or fetal distress CS – type II posterior, III & IV even if no sever bleeding
- 31. 5/21/2018 31 Abruptio placenta • Vaginal *Induction by amniotomy • CS – Unsatisfactory progress of labor – Worsening complication – Fetal distress – Life threatening hemorrhage – when delay in delivery is likely to seriously endanger the mother or fetus because of severe hypertonus, life-threatening hemorrhage, or disseminated intravascular coagulation.
- 32. Expectant management 5/21/2018 32 • Motherin good health status • GA <37 weeks • no active vaginal bleeding • Good fetal well being component of expectant management Bed rest with bathroom privilege Periodic inspection of vulvar pads Fetal surveillance Speculum examination 2-3 day after bleeding stops to exclude local causes follow with APH follow up sheet
- 33. Vasa previa 5/21/2018 33 • Def-the velamentous insertion of fetal vessels over the cervical os. • Fetal vessels lack protection from Wharton's jelly and are prone to rupture. • When the vessels rupture, the fetus is at high risk for exsanguination. • The overall perinatal mortality is 58 to 73 percent
- 34. 5/21/2018 34 • usually presentsafter rupture of membranes with the acute onset of vaginal bleeding from a lacerated fetal vessel. • If immediate intervention is not provided, fetal bradycardia and subsequent death occur. Diagnosis • By palpation of the fetal vessels within the membranes during labor • Acute onset of vaginal bleeding and fetal bradycardia or death after membrane rupture. • Sonography and Doppler imaging, antenatally.
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