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Antepartumhaemorrhage 121128013531-phpapp02
This document defines antepartum haemorrhage (APH) as bleeding from or into the genital tract occurring after 22 weeks of pregnancy but before birth. APH complicates 3-5% of pregnancies and is a leading cause of perinatal and maternal mortality. The main causes of APH are placenta praevia, abruptio placenta, and vasa praevia. Placenta praevia is when the placenta implants over or near the cervical opening and is diagnosed using ultrasound. Abruptio placenta occurs when the placenta separates from the uterus prematurely. Vasa praevia occurs when fetal blood vessels in the membranes are not supported by
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Introduces Ahmed Farrasyah B Mohd Kutubudin, Batch 24 Group A2, discussing Antepartum Haemorrhage (APH) with references to RCOG guidelines and Obstetrics today.
Defines APH as bleeding from 22 weeks of pregnancy, affecting 3-5% of pregnancies, a leading cause of perinatal and maternal mortality, unpredictable with significant preterm births.
Explains different grades of haemorrhage: Spotting, Minor (less than 50 ml), Major (50-1000 ml), Massive (greater than 1000 ml) and recurrent APH episodes.
Lists etiology of APH including placenta praevia, abruptio placenta, and vasa praevia among others.
Describes placenta praevia, its definition, and its role as a major cause of vaginal bleeding in the second and third trimesters.
Classifies placenta praevia into four types: Low lying, Marginal, Partial, and Total.
Identifies risk factors for placenta praevia including previous treatments, maternal age, and smoking.
Outlines patients' management strategies based on the type of placenta previa and associated risks for fetal distress.
Defines abruptio placenta as the separation of a normally located placenta post 22 weeks gestation.
Lists risk factors for abruptio placenta, including maternal hypertension, trauma, and substance use.
Identifies symptoms indicating abruptio placenta, emphasizing the need for clinical diagnosis over ultrasound.
Describes vasa praevia, its definition, and the implications of fetal vessels rupture during birth.
Emphasizes prenatal diagnosis to reduce perinatal risks and the importance of fetal heart monitoring post-membrane rupture.
Outlines maternal and fetal complications related to APH, including anaemia, fetal hypoxia, and infection.
Focuses on the assessment of mother and fetus during APH, emphasizing stabilization and bleeding evaluation.
Details importance of full history taking post-stabilization, considering pain patterns and risk factors.
Describes general and specific examination steps to assess maternal condition, including cervix examination.
Lists necessary investigations including FBC, ultrasound, and D-dimer for diagnosis of potential conditions.
Outlines criteria for admitting women with APH, emphasizing assessment and observation of symptoms.
Highlights managing preterm deliveries with corticosteroids, monitoring strategies in an emergency.
Discusses both conservative and definitive management strategies for placenta praevia based on bleeding and risks.
Explains emergency care protocols including ICU admission, monitoring, and deciding on delivery mode.
Describes anti-D Ig administration for Rh negative mothers after APH presentation and additional follow-up.
Final slide thanking the audience.
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Antepartumhaemorrhage 121128013531-phpapp02
- 1. AHMED FARRASYAH BMOHD KUTUBUDIN 071303511 BATCH 24 GROUP A2 ANTEPARTUM HAEMORRHAGE
- 2. reference • RCOG Guidelines •Obstetrics today
- 3. Definition • Antepartum haemorrhage(APH) is defined as bleeding from or in to the genital tract, occurring from 22 weeks (>500g) of pregnancy and prior to the birth of the baby. • complicates 3–5% of pregnancies • leading cause of perinatal and maternal mortality worldwide. • Up to one-fifth of very preterm babies are born in association with APH • Most of the time unpredictable.
- 4. Different terminologies used: •Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection • Minor haemorrhage – blood loss less than 50 ml that has settled • Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock • Massive haemorrhage – blood loss greater than 1000 ml and/or signs of clinical shock. • Recurrent APH - > one episode
- 5. Etiology • Placenta praevia •Abruptio placenta • Vasa praevia • Excessive show • Local causes ( bleeding from cervix, vagina and vulva ) • Inderterminate APH
- 6. Placenta Praevia (PP) •Implantation of placenta over or near the internal os of cervix. • Confirm diagnosis of PP can be done at 28 weeks when LUS forming. Leading cause of vaginal bleeding in the 2nd and 3rd trimester.
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- 9. Risk Factors ofPlacenta Praevia • Previous placenta praevia (4-8%) • Previous caesarean sections ( risk with numbers of c-section) • Previous termination of pregnancy • Multiparity • Advanced maternal age (>40 years) • Multiple pregnancy • Smoking • Deficient endometrium due to presence or history of: - uterine scar -endometritis -manual removal of placenta - curettage -submucous fibroid • Assisted conception
- 10. Clinical classification • Minor: • Type 1 (anterior/posterior) • Type 2 anterior • Major: • Type 2 posterior (dangerous type) • Type 3 • Type 4 Deliver vaginally Type 1 Posterior > likelihood of fetal distress Caesarean section Type 2 posterior > chance of fetal distress Type 3 & 4 anterior –cut through placenta to deliver. Hence need to be fast and efficient.
- 11. Abruptio Placenta (AP) •Separation of normally located placenta after 22 weeks of gestation ( > 500g) and prior to delivery of fetus.
- 12. Risk factors - Previoushistory of AP Maternal hypertension Advanced maternal age Trauma ( domestic violence, accident, fall) Smoking/alcohol/cocaine Short umbilical cord Sudden decompression of uterus ( PROM/delivery of 1st twins) Retroplacental fibroids Idiopathic
- 13. Obstetrics Emergency Diagnosed CLINICALLY: • Painful vaginal bleeding -80% • Tense and tender abdomen/back pain (70%) • Fetal distress( 60%) • Abnormal uterine contractions (hypertonic and high frequency) • Preterm labour ( 25%) • Fetal death ( 15%) Ultrasound is NOT USEFUL to diagnose AP. Retroplacental clots (hyperechoic) easily missed.
- 14. Vasa Praevia (VP) •Rupture of fetal vessels that run in membrane below fetal presenting part which is unsupported by placenta/ umbilical cord. • Predisposing Factors: -Velamentous insertion of the umbilical cord -Accesory placental lobes -Multiple gestations
- 15. The term velamentous insertionis used to describe the condition in which the umbilical cord inserts on the chorioamniotic membranes rather than on the placental mass.
- 17. Diagnosis of VP •Antenatal diagnosis –reduced perinatal mortality and morbidity. • Painless vaginal bleeding at the time of spontaneous rupture of membrane or post amniotomy • Fetal bradycardia • Fetal shock or death can occur rapidly at the time of diagnosis due to blood loss constitutes a major bulk of blood volume is fetus ( 3kg fetus-300ml) • Hence, ALWAYS check the fetal heart after rupture of membrane or amniotomy. • Definitive diagnosis by inspecting the placenta and fetal membrane after delivery.
- 18. Complications of APH Maternalcomplications Fetal complications Anaemia Fetal hypoxia Infection Small for gestational age and fetal growth restriction Maternal shock Prematurity (iatrogenic and spontaneous) Renal tubular necrosis Fetal death Consumptive coagulopathy Postpartum haemorrhage Prolonged hospital stay Psychological sequelae Complications of blood transfusion
- 19. Clinical assessment inAPH • First and foremost Mother and fetal well being (mother is the priority) • establish whether urgent intervention is required to manage maternal or fetal compromise. • Assess the extent of vaginal bleeding, cardiovascular condition of the mother • Assess fetal wellbeing.
- 20. Full History Should betaken after the mother is stable. • associated pain with the haemorrhage? Continuous pain : Placental abruption. Intermittent pain : Labour. • Risk factors for abruption and placenta praevia should be identified. • reduced fetal movements? • If the APH is associated with spontaneous or iatrogenic rupture of the fetal membranes : ruptured vasa praevia • Previous cervical smear history possibility of Ca cervix. Symptomatic pregnant women usually present with APH (mostly postcoital) or vaginal discharge.
- 21. Examination • General: PULSE& BP ( a MUST!) • Abdomen: The tense, tender or ‘woody’ feel to the uterus indicates a significant abruption. Painless bleeding, high fetal presenting part – Placenta praevia - soft, non-tender uterus may suggest a lower genital tract cause or bleeding from placenta or vasa praevia.
- 22. Examination • Speculum : -identifycervical dilatation or visualise a lower genital tract cause. • Digital vaginal examination Should NOT be done until Placenta Praevia has been excluded by USG.
- 23. Investigations • FBC • Coagulationprofile • Blood Grouping and CXM, GSH. • Ultrasound- TRO PP/ IUD • D-dimer : AP • colour doppler TVS – VP • In all women who are RhD-negative, a Kleihauer test should be performed to quantify FMH to gauge the dose of anti-D Ig required. Fetal monitoring: • CTG monitoring
- 24. Management • WHEN toadmit? • Based on individual assessment -Discharge after reassurance and counselling Women presenting with spotting who are no longer bleeding and where placenta praevia has been Excluded. However, a woman with spotting + previous IUD due to placenta abruption, an admission would be appropriate. - All women with APH heavier than spotting and women with ongoing bleeding should remain in hospital at least until the bleeding has stopped.
- 25. Management • If pretermdelivery is anticipated, a single course of antenatal corticosteroids ( dexamethasone 12mg 12 hourly ,2 doses) to women between 24 and 34 weeks 6 days of gestation. • Tocolytics should NOT be given unless for VERY preterm women who need time to transfer to hospital with NICU. • For very preterm ( 24-26 weeks) , -conservative management if mother is stable . -Delivery of fetus – life threatening At these gestations, experienced neonatologists should be involved in the counselling of the woman and her partner
- 26. Management For Placenta Praevia •Conservative – MaCafee’s regime ( premature < 37 weeks;mother haemodynamically stable,no active bleeding, fetus stable) -advise bed rest, keep pad chart, vital signs monitoring , Ultrasound, steroids, GSH, Daily CTG and biophysical profile, fetal movement count. • Plan for delivery ( >37 weeks) Crossmatch 4 units of blood.
- 27. Definitive treatment Type I,II(ant)Type II( post), III,IV ARM +/- oxytocin Satisfactory progress without bleeding Vaginal delivery Bleeding continues Caesarean section Caesarean section
- 28. Management Conservative (McCafee’s regime)Method of delivery Preterm & hemorrhage not present: 1. Bed rest along with pad chart 2. Vital signs monitoring 3. USG every two weeks 4. Fetal monitoring: CTG, USG, daily fetal movement count chart 5. Dexamathasone (if baby is <34 weeks gestation) 2 doses, 12mg I.M. 12 hours apart Vaginal delivery: Type I anterior Type I posterior Type II anterior Caesarean section: Type II posterior Type III (anterior & posterior) Type IV
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- 30. For Abruptio placenta,(obsemergency) • ICU admission : Close monitoring and resuscitation! ABC ( high flow O2, aggressive fluid resuscitation) Continuous Vital signs monitoring and urine output Monitor vaginal bleeding – strict pad chart Continuous CTG for fetal heart rate Crossmatch 4 units of blood FFP – coagulopathy Dexamethasone – preterm
- 31. Abruptio Placenta Decide Modeof delivery • Vaginal delivery – when fetal death • Caesarean section –if maternal/ fetal health compromised Indicated when early DIC sets in Consent should be taken for hysterectomy in case bleeding could not be controlled.
- 32. Management • For Rhnegative mothers, Anti-D Ig should be given to all after any presentation with APH, independent of whether routine antenatal prophylactic anti-D has been administered. In the non-sensitised RhD-negative woman for all events after 20 weeks of gestation, at least 500 iu anti-D Ig should be given followed by a test to identify FMH, if greater than 4 ml red blood cells; additional anti-D Ig should be given as required.
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