Antepartum Hemorrhage .ppt 0002415263673

ANTEPARTUM
HAEMORRHAGE
7/2/2024 1

CONTENTS
 Introduction
 Definitions
 Incidence
 Causes
 Placenta previa
 Abruptio placenta
 Uterine rupture
 Vasa prevea
7/2/2024 2

Introduction
 Vaginal bleeding is a common event at all stages of
pregnancy.
- Decidual hemorrhage from spiral arteries
- Discrete cervical
- Endometrial
- Vaginal pathological lesions
 Causes of second and third trimester bleeding
- Bloody show associated with
* Cervical insufficiency or preterm/term labor
- Placenta previa
- Abruptio placentae
- Uterine rupture
- Vasa previa
7/2/2024 3

APH
Definition:
APH refers to uterine bleeding after 20 weeks of
gestation unrelated to labor and delivery.
Prevalence:
4 – 5 %
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PLACENTA PREVIA
Definitions
Incidence
Pathogenesis
Risk factors
Clinical manifestations
Diagnosis
Management
7/2/2024 5

DEFINITIONS
Placenta previa refers to the presence of placental tissue
overlying or proximate to the internal cervical os.
 Four placental configurations have been defined.
Type I. Low lying placenta – to describe a placenta that
lies in the lower uterine segment, but does not reach
the internal os (2-3 cm from internal os )
Type II. Marginal placenta previa – the placenta is
adjacent to the internal os but does not cover it.
7/2/2024 6

Type III. Partial placenta previa – the placental
edge partially covers the internal cervical os.
Type IV. Complete placenta previa (central pp) -
The placenta completely covers the internal
os. (20 - 30%)
Incidence: 4/1000 pregnancies
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RISK FACTORS
1. Endometrial Scarring
- Increasing parity
- Increasing maternal age
- Increasing number of prior c. section
- Increasing number of curettages for abortions
2. The need for increased placental surface area.
- Maternal smoking
- Residence at higher altitudes
- Multiple gestation.
3. Early Gestational Age
4. Male Gender
7/2/2024 9

CLINICAL MANIFESTATIONS
 Painless vaginal bleeding (70 – 80%)
 Uterine contractions associated with bleeding (10 –
20%)
 Asymptomatic, accidentally discovered by U/S
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WARNING
Digital examination of the cervix should be avoided
in women presenting with bleeding in the second
half of pregnancy until placenta previa has been
excluded because digital examination of placenta
previa can cause immediate, a severe hemorrhage.
7/2/2024 11

ASSOCIATED CONDITIONS
 Placenta accreta: complicates 5 – 10%
 Mal presentation
 Preterm premature rupture of the membranes
(PPROM) .
 Intrauterine growth restriction (16%)
 Vasa previa, velamentous umbilical cord insertion.
 Congenital anomalies.
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DIAGNOSIS
 Suspicion: painless vaginal bleeding beyond 20
weeks gestation.
 Sonographic examination
- Trans abdominal U/S
- Trans vaginal U/S
7/2/2024 13

DIFFERENTIAL DIAGNOSIS
 Abruptio placentae
 Placenta previa
 Decidual or cervical bleeding
 Unknown
7/2/2024 14

MANAGEMENT
A. Asymptomatic Placenta Previa
- Serial U/S evaluation at 4 week intervals.
- Avoidance of coitus and digital examination
- Counseling to seek immediate medical attention if
contractions or vaginal bleeding occur
B. Acute Care of Symptomatic PP
- Admission
- Establish intravenous access and administer
crystalloid
7/2/2024 15

MANAGEMENT
- Laboratory Monitoring
* Blood type and Rh antibody screen
* Cross match 2 – 4 units of PRBC
* Maternal coagulation profiles
- Fetal Monitoring
* Continuous fetal HR monitoring
- Maternal Monitoring
- HR
- Blood pressure
* Assessment of vaginal blood loss
7/2/2024 16

INDICATIONS FOR DELIVERY
 A non reassuring fHR tracing
 Life threatening refractory maternal hemorrhage
 Significant vaginal bleeding after 34 weeks
gestation.
Mode of delivery
C/Section for p.praevia type IIb-IV
EUA in a double set-up in theatre (EUA set and C/S set)
for type I and IIa, for ARM and induction of labour
at 38wks.
7/2/2024 17

Out come
 Maternal risks
- Hemorrhage
.Ante partum hemorrhage
. Intra partum hemorrhage
. Post partum hemorrhage
-Maternal mortality and morbidity
1%
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Fetal risks
- Neonatal morbidity and mortality
. Prematurity
Recurrence rate:
4-8 %
7/2/2024 19

ABRUPTIO PLACENTAE
Definition:
AP refers to premature separation of a normally
implanted placenta prior to delivery of infant.
Incidence: 0.4 – 1.3%
Pathogenesis:
- Acute events e.g. trauma
- Long standing disorder
7/2/2024 20

RISK FACTORS
 Previous abruption (10 fold)
 Trauma (MVA) – mechanical factors
 Sudden internal decompression of the uterus
- Polyhydramnios
- PMROM
- Twin Pregnancies
 Hypertension (5 fold)
 Cigarette Smoking (2.5 fold)
 Maternal parity and age
7/2/2024 21

RISK FACTORS
 Cocaine
 PPROM (2 – 5%)
 Inherited thrombophilia
 Multiple gestation
 Polyhydramnios (3%)
7/2/2024 22

CLINICAL MANIFESTATIONS
Classical symptoms of acute abruption placenta:
 Vaginal bleeding (80%)
 Abdominal pain (50%)
 Uterine contractions
 Uterine tenderness
 Non reassuring fHR tracing
7/2/2024 23

DIAGNOSIS
A. Clinical
 Vaginal bleeding
 Abdominal pain
 Preterm labor
 Trauma
B. Sonography
 Sensitivity (25%)
7/2/2024 24

C. Laboratory
 Coagulation failure
-Coagulation profile
-Fibrinogen level < 200 mg/dl
-Thrombocytopenia (100,000/microL)
-Kleihauer-Betke test: Test to check for presence of
fetal rbcs in maternal circulation.
7/2/2024 25

PATHOLOGY
 Retro placental clot
 Intradecidual hemorrhage
 Fibrin deposits
7/2/2024 26

Abruptio Placentae Grading
Grade O Retrospective diagnosis
Grade 1 Vaginal bleeding may be mild.<15%
placental separation.
Grade 2 Vaginal bleeding, concealed
hemorrhage, uterine tenderness,
non reassuring FHR, 15-45%
placental separation.
Grade 3 Vaginal bleeding ,shock, concealed
hemorrhage, uterine tenderness,
fetal death, >45% separation.
7/2/2024 27

D DIAGNOSIS
 Placenta previa
 Abruptio placentae
 Local causes: Cervicitis, cervical varicosities,
vaginitis, malignancy
 Vasa previa
 Rupture uterus
7/2/2024 29

MANAGEMENT
Stabilize maternal cardiopulmonary status:
 Start iv line using two large bore (16 – 18 gauge
cannula)
 Assessment of maternal haemodynamic status
 Fetal monitoring
7/2/2024 30

LABORATORY TESTS
 Hb, ht, platelet count
 Fibrinogen concentration
 PTT
 Bl. Group
 Cross mach 2-4 u prbc
7/2/2024 31

MODERATE TO SEVERE ABRUPTION
 Rapidly correct the intravascular fluid loss
- Crystalloid solution
- PRBC, whole blood
- Platelets transfusion – FFP or cryoprecipitate
 Maintain haematocrit above 30%
7/2/2024 32

 Live Fetus
- Emergency C/section
- Dilated cervix, allow vaginal delivery
 Death Fetus
Depends upon maternal condition
- Induction
- C. section
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Mild abruption
 Term fetus
- Delivery
 Premature fetus
- Conservative management
- Ante partum corticosteroid therapy to
pregnancies less than 34 weeks of
gestation
- Fetal & maternal monitoring
* Fetal well being
* Fetal growth
7/2/2024 34

OUTCOME
 Fetal risks
- Perinatal Mortality and morbidity
- IUGR
- Prematurity (4 fold)
- Still birth (9 fold)
 Maternal risks
- Hemorrhage, shock
- DIC
- Blood transfusion
- Renal failure
- postpartum hemorrhage
- Hysterectomy
- Maternal Death
7/2/2024 35

Recurrence Risk
- 5 – 10 % after one abruption
- 25% after two consecutive abruptions
Management in subsequent pregnancy
- Reversible risk factors
- Avoid cigarette smoking
7/2/2024 36

Antepartum Hemorrhage .ppt 0002415263673

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