Antepartam haemorrhage

1. ANTEPARTAM ANTEPARTAM
HAEMORRHAGEHAEMORRHAGE
 IMMEDIATE DELIVERYIMMEDIATE DELIVERY

2. Significant bleeding from Significant bleeding from
birth canal after 24birth canal after 24
thth
week week
of gestation till de.of gestation till de.

3. CAUSESCAUSES
PLACENTALPLACENTAL
 Placenta PraeviaPlacenta Praevia
 Placental AbruptionPlacental Abruption
 Vasa PraeviaVasa Praevia
NON PLACENTALNON PLACENTAL
 Labour (Heavy show )Labour (Heavy show )
 Uterine ruptureUterine rupture
 Local / Non obstetricalLocal / Non obstetrical
Cervicitis Cervicitis
Polyp Polyp
LacerationsLacerations
 Bleeding DisordersBleeding Disorders
ConginitalConginital
acquiredacquired

4. PLACENTA PRAEVIAPLACENTA PRAEVIA
Implantation ofImplantation of
placenta in lowerplacenta in lower
uterine segmentuterine segment

Partial Partial
Complete Complete

5. DEGREESDEGREES

MINOR MINOR
MAJORMAJOR
MM
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6. ETIOLOGYETIOLOGY
Scarred or poorly vascularized endometriumScarred or poorly vascularized endometrium
Advancing ageAdvancing age
MultiparityMultiparity
Previous uterine surgeriesPrevious uterine surgeries
caeserian, myomectomy, D&C, caeserian, myomectomy, D&C,
ERPCERPC

7. BleedingBleeding

Mechanical SeperationMechanical Seperation
Rupture of Cervical dilalatation intravaginal Rupture of Cervical dilalatation intravaginal
Venous lakes effacement manipulationVenous lakes effacement manipulation

8. DIAGNOSISDIAGNOSIS
Presenting complaintsPresenting complaints
Painless vaginal bleedingPainless vaginal bleeding

Mild Moderate ProfuseMild Moderate Profuse

SHOCKSHOCK

9. CLINICAL FINDINGSCLINICAL FINDINGS
PallorPallor
Vital SignsVital Signs HemorrhageHemorrhage
StableStable
UnstableUnstable
AbdomenAbdomen
Soft , relaxed , non tenderSoft , relaxed , non tender
LieLie transverse/oblique transverse/oblique
Presenting partPresenting part high high
Fetal heartsFetal hearts present present

10. DIAGNOSISDIAGNOSIS
HistoryHistory
Clinical examinationClinical examination
UltrasonographyUltrasonography
Colour DopplerColour Doppler
C T scanC T scan
MRIMRI

11. MRI USGMRI USG

12. MANAGEMENTMANAGEMENT
Depends Depends
Amount of hemorrhage Gestational ageAmount of hemorrhage Gestational age

13. MANAGEMENTMANAGEMENT
AirwayAirway
I/V Line I/V Line 16 / 18 Gauge cannula16 / 18 Gauge cannula
Fluids Fluids crystalloids / colloids crystalloids / colloids
Blood transfusion /FFPBlood transfusion /FFP
Indwelling urinary catheterIndwelling urinary catheter
Inform Senior ObstetricianInform Senior Obstetrician
Avoid pelvic examinationAvoid pelvic examination

14. MANAGEMENTMANAGEMENT
InvestigationsInvestigations
Blood grouping & cross matchBlood grouping & cross match
Complete blood countsComplete blood counts
Coagulation profile (Platelet count, Coagulation profile (Platelet count,
APTT,PT,FDPs)APTT,PT,FDPs)
Ultrasound scanUltrasound scan ( full bladder ) ( full bladder )

15. EXPECTANT MANAGEMENT EXPECTANT MANAGEMENT
(Preterm fetus)(Preterm fetus)
AIM AIM To prolong pregnancy till Term To prolong pregnancy till Term
Haemodynamically stableHaemodynamically stable with mild bleeding and with mild bleeding and
no uterine contractionsno uterine contractions
Close observationClose observation vital signs & vaginal bleeding vital signs & vaginal bleeding
Correction of anaemiaCorrection of anaemia
Steroids for fetal lung maturationSteroids for fetal lung maturation
Counseled and prepared for Caeserian sectionCounseled and prepared for Caeserian section

16. IMMEDIATE DELIVERYIMMEDIATE DELIVERY
Caeserian Section / HysterotomyCaeserian Section / Hysterotomy
Haemodynamically unstable.Haemodynamically unstable.
Profuse vaginal bleeding.Profuse vaginal bleeding.
After 37 completed weeks of gestation.After 37 completed weeks of gestation.
If patients has palpable uterine contractions.If patients has palpable uterine contractions.
SURGEON / ANAESTHETIST SENIORSURGEON / ANAESTHETIST SENIOR
GENERAL ANAESTHESIAGENERAL ANAESTHESIA

17. COMPLICATIONSCOMPLICATIONS
MaternalMaternal
Anaemia Anaemia
ShockShock
Complications of surgery & AnaesthesiaComplications of surgery & Anaesthesia
Post Partam hemorrhagePost Partam hemorrhage
Maternal mortaliy Maternal mortaliy
FetalFetal
Morbidity / MortalityMorbidity / Mortality

18. PLACENTAL ABRUPTIONPLACENTAL ABRUPTION
 Bleeding following Bleeding following
premature premature
separation of a separation of a
normally situated normally situated
placenta. placenta.

19. AETIOLOGYAETIOLOGY
 Advance ageAdvance age
 Multiparity Multiparity
Poor nutritional status Poor nutritional status
Past History ( Past History ( recurrence 15 –20% )recurrence 15 –20% )
HypertentionHypertention
Abdominal Trauma Abdominal Trauma
Smoking Smoking
Uterine Decompression Uterine Decompression ( polyhydramniose , Twins )( polyhydramniose , Twins )
Chorio amnionitis Chorio amnionitis
 Fibroid, Folic Acid deficiencyFibroid, Folic Acid deficiency

20. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Local Vascular injuryLocal Vascular injury ((Pre eclampsiaPre eclampsia))
Haematoma Formation in Haematoma Formation in
Decidua BasalisDecidua Basalis

Separation of PlacentaSeparation of Placenta
Venous Venous EngorgementEngorgement
Abrupt uterine venous Abrupt uterine venous
pressurepressure

21. Revealed Concealed Revealed Concealed

22. SIGNS & SYMPTOMSSIGNS & SYMPTOMS
Small separation of Small separation of
the placentathe placenta::
Vaginal bleeding Vaginal bleeding ±±
Mild pain or discomfort.Mild pain or discomfort.
Abdominal pain. Abdominal pain.
Back pain Back pain
Vital signs StableVital signs Stable
Abdomen Abdomen
Soft/ Tenderness ±Soft/ Tenderness ±

FoetusFoetus uncompromiseduncompromised

23. Large separation of the placenta:Large separation of the placenta:
Heavy vaginal bleeding.Heavy vaginal bleeding.
Severe pain in the lower abdomen or back.Severe pain in the lower abdomen or back.
Hard, tender abdomen.Hard, tender abdomen.
Shock (tachycardia, fall in BP rapid breathing, and dizziness).Shock (tachycardia, fall in BP rapid breathing, and dizziness).
Fetal distress; fetal heart sounds inaudible.Fetal distress; fetal heart sounds inaudible.
Coagulopathy Coagulopathy [DIC]) – Thromboplastine from placenta is [DIC]) – Thromboplastine from placenta is
released into the mother's circulation causing blood clotting released into the mother's circulation causing blood clotting
defects. defects.
Renal cortical necrosis ---- AnureaRenal cortical necrosis ---- Anurea

24. EXAMINATIOBNEXAMINATIOBN
GPEGPE depends upon Hemorrhagedepends upon Hemorrhage..
 PallorPallor
Pulse Pulse
B.PB.P
ABDOMINAL EXAMINATIONABDOMINAL EXAMINATION
Fundal height larger than datesFundal height larger than dates
Hard and tender Hard and tender
Fetal Part and FHSFetal Part and FHS
PELVIC EXAMINATIONPELVIC EXAMINATION
Exclude placenta praevia by USG Exclude placenta praevia by USG
P/S examinationP/S examination
P/V examinationP/V examination

25. INVESTIGATIONSINVESTIGATIONS
 Blood grouping. Blood grouping.
 Blood Complete picture.Blood Complete picture.
 Coagulation Profile,Coagulation Profile,
Platelet counts, PT, APTT, FDPs Platelet counts, PT, APTT, FDPs
Serum FibrinogenSerum Fibrinogen
 Renal ProfileRenal Profile
 Viral SerologyViral Serology

26. INVESTIGATIONINVESTIGATION
: : Ultrasonography (Useful but not reliable )Ultrasonography (Useful but not reliable )

27. MANAGEMENTMANAGEMENT
I/V access I/V access Two large bore cannulas.Two large bore cannulas.
Save blood for cross match/ investigation(20 ml)Save blood for cross match/ investigation(20 ml)
I/V fluids Crystelloids /colloidsI/V fluids Crystelloids /colloids
Indwelling urinary catheterIndwelling urinary catheter
AnalgesiaAnalgesia
Blood transfusions / Fresh frozen plasmaBlood transfusions / Fresh frozen plasma
( Screened & Cross matched )( Screened & Cross matched )
Vital Signs monitoringVital Signs monitoring

28. MANAGEMENTMANAGEMENT
Expectant Expectant : :
Mild marginal Abruption with stable mother & fetusMild marginal Abruption with stable mother & fetus . .
Strict maternal & fetal monitoring.Strict maternal & fetal monitoring.
Vaginal Delivery:Vaginal Delivery:
If degree of separation is limited ,If degree of separation is limited ,
revealed hemorrhage revealed hemorrhage
After amniotomy & oxytocin infusion short labour is After amniotomy & oxytocin infusion short labour is
expected.expected.
Dead fetusDead fetus
No complicationsNo complications

29. MANAGEMENTMANAGEMENT
Caeserian Section:Caeserian Section:
Maternal IndicationsMaternal Indications
Uncontrollable revealed hemorrhageUncontrollable revealed hemorrhage
Rapidly expanding concealed hemorrhageRapidly expanding concealed hemorrhage
Vaginal delivery is not imminentVaginal delivery is not imminent
Fetal IndicationsFetal Indications
Alive fetus with reasonable chances of survivalAlive fetus with reasonable chances of survival

30. COMPLICATIONSCOMPLICATIONS
MATERNAL MATERNAL
Shock (Shock (Hypovolemic, / Neurogenic )Hypovolemic, / Neurogenic )
DICDIC
Renal failure Renal failure
PPH PPH ( Couvelier uterus ,uterine atony , DIC )( Couvelier uterus ,uterine atony , DIC )
Maternal mortality ( 0.5% --- 5 % )Maternal mortality ( 0.5% --- 5 % )
FETALFETAL
Perinatal mortality ( 50 % --- 80 % )Perinatal mortality ( 50 % --- 80 % )

31. FOLLOW UPFOLLOW UP
Follow up visitsFollow up visits
ContraceptionContraception
Counsel for chances of recurrence in next Counsel for chances of recurrence in next
pregnancy , pregnancy ,
 early antenatal bookingearly antenatal booking