Antipartum hemorrhage and its types placenta previa & abruptio placenta

Antipartum hemorrhage and its types placenta previa & abruptio placenta

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  ANTEPARTUM HEMORRHAGE [APH] GUIDEDBY DR.NEHA VERMA ASSOCIATE PROFESSOR PRASUTI TANTRA EVUM STREE ROGA PRESENTED BY SONAM BAGHEL PG SCHOLAR PRASUTI TANTRA EVUM STREE ROGA
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  DEFINITION • Any bleedingoccurring from the genital tract after the period of viability (28weeks) but before birth of the baby is defined as antepartum haemorrage (APH). • INCIDENCE- The incidence is about 3% amongst hospital deliveries. • EPIDEMIOLOGY- Affects 3-5% of all pregnancies 3 times more common in multiparous than primiparous women.
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  Causes of AntepartumHemorrhage Maternal Causes: • Placental bleeding (70%): Placenta praevia (35%) Abruptio placentae (35%) • Unexplained or indeterminate (25%): Bleeding is present, but the source and site are not determined. • Extra placental causes (5%): Cervical polyp Carcinoma cervix Varicose vein Local trauma Foetal-Vasa Praevia (<1%)
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  DEFINITION (PLACENTA PREVIA) •When the placenta is implanted partially or completely over the lower uterine segment (over and adjacent to the internal os) it is called placenta previa. • INCIDENCE: About one-third cases of antepartum hemorrhage belong to placenta previa. The incidence of placenta previa ranges from 0.5–1% amongst hospital deliveries. • In 80% cases, it is found to multiparous women.
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  ETIOLOGY The exact causeof implantation of the placenta in the lower segment is not known. The following risk factors are identified:-  Multiparity  Increased maternal age (> 35 years)  History of previous cesarean section or any other scar in the uterus (myomectomy or hysterotomy)  Placental size.  Placental abnormality (succenturiate lobes)  Smoking - causes placental hypertrophy to compensate carbon monoxide induced hypoxemia.  Prior curettage.  Previous history of placenta previa.
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  TYPES OR DEGREES: Thereare four types of placenta previa depending upon the degree of extension of placenta to the lower segment. Type—I (Low-lying): The major part of the placenta is attached to the upper segment and only the lower margin encroaches on the lower segment but not up to the os. Type—II (Marginal): The placenta reaches the margin of the internal os but does not cover it. It can be (a) anterior (b) posterior Type—III (Incomplete or partial central): The placenta covers the internal os partially (covers the internal os when closed but does not cover it fully when the os is completely dilated). Type—IV (Central or total): The placenta completely covers the internal os even when the os is fully dilated.  Clinically type- I & II Anterior- Minor degree III & IV, II Posterior- - Major degree
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  CLINICAL FEATURES SYMPTOMS: • Suddenonset of painless and apparently causeless and recurrent bleeding without onset of labour. • The first bleeding is often minor and is called warning bleed.subsequent bleeding may be life threatening because of poor contractility of lower segment. SIGNS General examination: • Pallor is proportionate to the visible blood loss. • The patient may or may not be in shock depending on the amount of bleeding. Per-Abdomen examination: • The size of the uterus is proportionate to the period of gestation. • The uterus is relaxed and non-tender,corresponding to the period of amenorrhoea • Malpresentation is often associated • Foetal parts are easily felt and FHS may be normal. • Stallworthy’s sign- Slowing of the fetal heart rate on pressing the head down into the pelvis which soon recovers promptly as the pressure is released is suggestive of the presence of low lying placenta especially of posterior type.
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  Vulval inspection • Onlyinspection is to be done to note whether the bleeding is still occurring or has ceased. • character of the blood—bright red or dark coloured. and the amount of blood loss—to be assessed from the blood stained clothings. • In placenta praevia, the blood is bright red as the bleeding occurs from the separated utero-placental sinuses close to the cervical opening and escapes out immediately. Per-Vaginum examination • A per vaginum examination is not to be done in case of APH , unless placenta previa is ruled out because it may provoke serious bleeding which may be life- threatening.
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  CONFIRMATION OF DIAGNOSIS: Painless and recurrent vaginal bleeding in the second half of pregnancy should be taken as placenta previa unless proved otherwise. Ultrasonography is the initial procedure either to confirm or to rule out the diagnosis.  Localization of placenta (placentography) • Sonography Transabdominal ultrasound (TAS) Transvaginal ultrasound (TVS) Transperineal ultrasound– Color Doppler flow study • Magnetic resonance imaging (MRI)  Clinical– By internal examination (double set up examination)– I. Direct visualization during cesarean section– II. Examination of the placenta following vaginal delivery
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  COMPLICATIONS OF PLACENTAPREVIA MATERNAL FETAL During pregnancy- • Shock • Malpresentation • Premature labor During labor – • Early rupture of the membranes • Cord prolapse • Intrapartum hemorrhage • Postpartum hemorrhage • Retained placenta • operative interference Puerperium: • Sepsis • Subinvolution • Embolism • Low birth weight • Asphyxia • Intrauterine death • Birth injuries • Congenital malformation
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  MANAGEMENT  PREVENTION: • Adequateantenatal • Antenatal diagnosis of low lying placenta at 20 weeks with routine ultrasound needs repeat ultrasound examination at 34 weeks to confirm the diagnosis. • Significance of “warning hemorrhage” should not be ignored. • Color flow Doppler USG in placenta previa is indicated to detect any placenta accreta.  AT HOME: (1) The patient is immediately put to bed (2) To assess the blood loss—(a) Inspection of the clothings soaked with blood. (b) To note the pulse, blood pressure and degree of anemia. (3) Quick but gentle abdominal examination. (4) Vaginal examination must not be done.
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  ADMISSION TO HOSPITAL: Allcases of APH, even if the bleeding is slight or absent by the time the patient reaches the hospital, should be admitted. TREATMENT ON ADMISSION 1) Immediate attention- General and abdominal examination Clinical assessment of blood loss Hemoglobin %, Hematocrit ABO and Rh grouping Ultrasound (USG) to confirm placenta position 2) Formulation of the line of treatment- Expectant vs Active Management TRANSFER TO HOSPITAL: Arrangement is made to shift the patient to an equipped hospital having facilities of blood transfusion, emergency cesarean section and neonatal intensive care unit (NICU).
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  Criteria Management - Noactive bleeding - Pregnancy < 37 weeks - Hemodynamically stable - Fetal Heart Sound (FHS): Reassuring - CTG: Reactive Bed rest Investigations—Hb%,BG Periodic inspection etc. Criteria Management - Bleeding continues - Pregnancy > 37 weeks - Patient in labor - Exsanguinated - FHS non-reassuring or absent - Gross fetal malformation Immediate delivery based on USG findings and clinical condition EXPECTANT TREATMENT (If conditions are stable) ACTIVE INTERFERENCE (If bleeding continues or unstable)
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  Placental Position (USG)Management • Placental edge > 2–3 cm away from internal os (Type I or marginal previa) • Double set-up examination in OT → If favorable: ARM + Oxytocin → Satisfactory labor: Vaginal delivery • Placental edge ≤ 2 cm from internal os or major placenta previa • No internal examination → Proceed with Cesarean Section  PLACENTA POSITION (BY USG) AND DELIVERY PLAN
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  ABRUPTIO PLACENTAE (Syn :Accidental Hemorrhage, Premature Separation Of Placenta)
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  DEFINITION: It is thepremature separation of a normally implanted placenta, after viability, but before delivery of the foetus. It is also known as placental abruption. It causes perinatal mortality and may cause maternal mortality as well. INCIDENCE - It occurs in one in 100 to 250 deliveries and is more common in the developing world like India. TYPES-It has 3 types 1. Revealed haemorrhage 2. Concealed haemorrhage 3. Mixed haemorrhage
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  VARIETIES (1) Revealed :Following separation of the placenta, the blood insinuates downwards between the membranes and the decidua. Ultimately, the blood comes out of the cervical canal to be visible externally. This is the commonest type. (2) Concealed : The blood collects behind the separated placenta or collected in between the membranes and decidua. The collected blood is prevented from coming out of the cervix by the presenting part which presses on the lower segment. This type is rare. (3) Mixed : In this type, some part of the blood collects inside (concealed) and a part is expelled out (revealed). Usually one variety predominates over the other. This is quite common.
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  ETIOLOGY/ RISK FACTOR:- The primary cause of placental abruption is unknown,  There are several associated conditions and risk factor like:- 1. Hypertension in pregnancy 2. High level of maternal serum alpha foeto-protein and hCG. 3. Short cord. 4. Sudden uterine decompression 5. Uterine anomaly (Septate Uterus) 6. Abnormal placentation ( circumvallate placenta) 7. Malnutrition, Maternal anaemia 8. Smoking 9. High parity, elderly or with fibroids 10.Malformed foetus 11.Cocaine abuse is associated with increased risk of transient hypertension, vasospasm and placental abruption. 12. Prior abruption: Risk of recurrence for a woman with previous abruption varies between 5 to 17%
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  CLINICAL CLASSIFICATION: Depending uponthe degree of placental abruption and its clinical effects, the cases are graded as follows: • Grade—0: Clinical features may be absent. The diagnosis is made after inspection of placenta following delivery. • Grade—1 (40%): (i) Vaginal bleeding is slight (ii) Uterus: irritable, tenderness may be minimal or absent (iii) Maternal BP and fibrinogen levels unaffected (iv) FHS is good. • Grade—2 (45%): (i) Vaginal bleeding mild to moderate (ii) Uterine tenderness is always present (iii) Maternal pulse ↑, BP is maintained (iv) Fibrinogen level may be decreased (v) Shock is absent (vi) Fetal distress or even fetal death occurs. • Grade—3 (15%): (i) Bleeding is moderate to severe or may be concealed (ii) Uterine tenderness is marked (iii) Shock is pronounced (iv) Fetal death is the rule (v) Associated coagulation defect or anuria may complicate.
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  ABRUPTIO PLACENTAE –EMERGENCY MANAGEMENT 1. INITIALASSESSMENT •General and abdominal examination •Fetal status assessment •Determine Grade of abruption 2. INVESTIGATIONS & STABILIZATION •IV Infusion – Crystalloids •Blood tests: • Hemoglobin (Hb%) • Hematocrit • Coagulation profile • ABO and Rh grouping •Blood transfusion (as indicated) •Repeat/Periodic coagulation profiles •Monitor: • Urine output • Fetal heart rate (Electronic fetal monitoring) 3. TYPE OF ABRUPTION Revealed abruption → Proceed to delivery plan Concealed abruption → Expectant management is an exception 4. DELIVERY DECISION A. Patient in Labor ARM (Artificial Rupture of Membranes) Oxytocin infusion → Proceed to Vaginal Delivery B. Patient Not in Labor Assess maternal/fetal condition Decide based on clinical indications i. Vaginal Delivery (Selected Cases) ARM + Oxytocin Only if conditions favor safe vaginal birth ii. Cesarean Section If vaginal delivery is not feasible or contraindicated Follow clear clinical indications