10-Bleeding_In late pregnancy-1[1]_APH[1].pptx

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1. BLEEDING IN LATE PREGNANCY LECTURER DR CONTEH

2. NAMES OF GROUP MEMBERS Mohamed Lamin Sesay 22074 Fatima Zainab Kamara 22044 Sewah Bangura 22008 Freda Kawie 22055

3. OUTLINE Overview Definition Classification Causes Placenta Previa Abruptio Placenta Vasa Previa Management Summary References

4. OVERVIEW Bleeding in late pregnancy, commonly known as Antepartum Hemorrhage{APH} or Prepartum Hemorrhage is one of the obstetrical bleeding emergencies contributing to a significant amount of perinatal & maternal morbidity and mortality. It is one of the leading causes of antepartum hospitalization and operative interventions. Any bleeding of virginal origin that occurs during the late period of pregnancy is termed as Antepartum Hemorrhage . It diagnosis are dependent on the cause{s}.

5. CLASSIFICATION The total amount of blood loss and signs of circulatory shock due to bleeding, determines the severity of the Antepartum Hemorrhage. There are four degrees of Antepartum Hemorrhage: 1. Spotting- Stains, Spotting of blood 2. Minor Hemorrhage Less than 500mL 3. Major Hemorrhage- 500-1000mL without signs of circulatory shock 4. Massive Hemorrhage- >1000mL with/without signs of shock

6. MEDICAL APPROACH A B C Pulse, blood pressure, temperature Assess fundal height {GA}, ANC book? Fetal lie {abnormal?} Ultrasound: vital?, position of placenta, estimate fetal weight NO digital vaginal exam unless placental location known

7. DEFINITION Any bleeding from the genital tract after 22 weeks Incidence is about 4% of all pregnancies All cases are to be admitted and should be handled as a MEDICAL EMERGENCY ! Bleedi n g i n l at e p r egnancy v e r su s a n t epar t um haemorrhage?. Bleeding f r o m g en i t al t r act durin g 3 r d trim e s t e r . ( or after gestational age of viability).

8. C a us e s Placental causes (commonest): Placenta previa. Accidental Hge. Vasa previa. Local gynecological causes. Heavy show??

9. P L A C E N T A P R E V I A

10. Pla c en t a p r e v i a Definition: Placenta located in the lower uterine segment after gestational age of viability. Incidence: 1:200

11. E t i olog y Unknown? Scarred uterus. High parity. Multiple pregnancy.

12. D eg r e e 1 st degree: The lower edge within 5 cm from internal os. 2 nd degree: The lower edge of the placenta is just reaching the internal os but not covering it. 3 rd degree: The placenta cover the closed internal os. 4 th degree: The placenta completely cover the internal os even when dilated.

13. M e ch an i s m o f b lee d i n g F orm a tion & e l on g a t i o n of l ow er u t er i ne st a g e whi l e the p l a c e n t a is se g me n t durin g 3 rd not stretchable . This lead to unavoidable separation & bleeding.

14. C l i n i c a l p i ctu r e Symptoms: Vaginal bleeding ( causeless, painless & recurrent) …………. Exception??? Signs: Vital signs Pallor No vaginal examination ( u/s first to exclude placenta previa)

15. Investigation U/S: ( Trans-abdominal versus Transvaginal ) Confirm diagnosis & degree of P.P. Viability, biometry …… etc. HB level & HCT value. MRI: When placenta accreta is suspected.

16. T r ea tm en t Resuscitation: I.V. line & fluid, cross matched blood. Indication of termination: Mature fetus (after 37 w). Dea d f e t u s or con g en i t al mal f orm a tion incompatible with extrauterine life. Active labour pain. Attack of severe bleeding.

17. M e th o d s o f t e rm i na t i o n The role by CS except: 1 st degree placenta previa. 2 nd degree placenta previa (anterior). ???? Cross matched blood should be available. Consent for hysterectomy.

18. C on s e r v a t i v e m anage m en t I n m i ld a tt ack or the a tt ack ha s s t o ppe d a n d Gestational age less than 37w with living fetus. Hospitalization. Cross matched blood. Antenatal corticosteriod. Tocolytics. ??? Anti D for Rh -ve mother.

19. E ffe c t o f P . P . o n p r e g n a n c y & l a b o u r Increase incidence of: Malpresentation. Preterm labour. CS. Placenta accreta. Postpartum hemorrhage.

20. A C CI D EN T A L H E M OR RH A G E ( A B R U P T I O PL A C E N T A )

21. A c c i d en t a l h e m o r r h ag e Definition: P r em a tu r e sep a r a ti o n of no r mally im p la nt ed placenta. Incidence: 1%

22. E t i olo g y Idiopathic. Pre-eclampsia. Trauma. Sudden drop of intrauterine pressure due to PROM. Smoking. Myoma in placental bed.

23. T y p e s Revealed: Marginal (peripheral) detachment of placenta. External hemorrhage. Concealed Central separation with adherence of edge. Retroplacental hematoma provoke more separation. Blood may dissect through the myometrium between pe ri t onea l c a vi t y muscle f i be r s t o r e a ch (couvelaire’s uterus) Mixed .

24. C l i n i c a l p i ctu r e A- concealed accidental Hge. Severe abdominal pain. Shock ( hemorrhage & pain). Abdominal examination. Tender & rigid abdomen. Fundal level higher than period of amenorhea. B- Revealed accidental Hge. Vaginal bleeding. Mild abdominal pain. Signs hypovolemic shock.

25. I n v e st i g at i on . U/S: Exclude placenta previa. Viability of fetus. Retroplacental hematoma. Urine analysis: Proteinurea.

26. D i ffe r en t i a l d i agno s i s Concealed type: Rupture uterus. Hypertonic inertia. Revealed & mixed type: Other causes of antepartum Hge.

27. C om p l ic a ti o n o f c o n c e al e d t y p e Fetal death. r enal Acu t e tu b ula r nec r osi s & ac u t e failure. DIC & consumptive coagulopathy. substances Escape of thromboplastin-like into the maternal circulation . Postpartum Hge.

28. Management A-Concealed & mixed types: Correction of shock. Termination usually by amniotomy & induction of labour. CS indicated only in: Living fetus. c ondit i o n in spi t e of D e t e r io r a tion o f m a t ernal resuscitative measures. Other obstetrics indication.

29. Management B- Revealed type: Severe hge: Correction of shock followed by CS. Mild Hge. Hospitalization. Careful monitoring of maternal & fetal condition. Anti D for Rh -ve mother. Tocolytics contraindicated.

30. V a s a p r e v i a Very rare. Bleeding of fetal origin. Occur due to velamentous insertion of the cord & some fetal vessels pass near the internal os. It leads to early fetal distress. Treatment by immediate CS.

31. S U MMA R Y O F MA N A G E M EN T

32. REFERENCES DR. Alfred S Gbenda Magdy Abdelrahman Mohamed Lecturer of OB/GYN DR. David Brewen Conteh