Antepartum haemorrhage - an emergency in Obstetrics

Antepartum haemorrhage can due to placenta previa , abruption place, or due to rupture uterus

1. R.S.D.K.S GMC AMBIKAPUR, SURGUJA DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY ANTEPARTUM HEMORRHAGE PRESENTED BY:- GUIDED BY:- LEEYMAAN CHOUDHARY DR.AVINASHI KUJUR (MBBS 2020 BATCH) (H.O.D OBS & GYNE) ROLL NO- 37

2. DEFINITION IT IS DEFINED AS BLEEDING FROM OR INTO THE GENITAL TRACT AFTER THE 20 TH WEEK OF PREGNANCY BUT BEFORE THE BIRTH OF BABY.(INCLUDING THE FIRST AND SECOND STAGE OF LABOUR).

3. CAUSES OF ANTEPARTUM HEMORRHAGE

4. PLACENTA PREVIA DEFINITION - IT IS DEFINED AS WHEN THE PLACENTA IS IMPLANTED PARTIALLY OR COMPLETELY OVER THE LOWER UTERINE SEGMENT(OVER OR ADJACENT TO THE INTERNAL OS) . THE TERM PREVIA MEANS (LATIN:IN FRONT OF) DENOTES THE POSITION OF THE PLACENTA IN RELATION TO THE PRESENTING PART. THE INCIDENCE IS HIGHER IN AGE>35YEARS,SMOKERS,MULTIPARA,etc.

5. ETIOLOGY THE EXACT CAUSE IS STILL UNKNOWN,FOLLOWING THEORIES ARE:- 1)DROPPING DOWN THEORY- THE FERTILIZED OVUM DROPS DOWN AND GETS IMPLANTED IN THE LOWER SEGMENT,POOR DECIDUAL REACTION IN THE UPPWER SEGMENT MAY BE THE CAUSE . 2)DEFECTIVE DECIDUA- RESULTS IN SPREAD OF CHORIONIC VILI OVER A WIDE AREA IN UTERINE WALL TO GET NOURISHMENT. DURING THIS PROCESS PLACENTA ENROACHES THE LOWER SEGMENT.

6. 3) HYPERPLACENTOSIS-BIG SURFACE AREA OF PLACENTA AS IN TWINS MAY APPROACH THE LOWER SEGMENT OF UTERUS. THE RISE OF PLACENTA PREVIA INCREASES WITH PRIOR CESAREAN DELIVERY. THE RISK FACTORS AS FOLOWS:-

7. RISK FACTORS MULTIPARITY MATERNAL AGE>35 YEARS(4 FOLD INCREASE) PRIOR CESAREAN DELIVERY RACE – ASIAN WOMENS INFERTILITY TREATMENT PRESENCE OF UTERINE SCAR:CESAREAN SECTION,MYOMECTOMY,HYSTEROTOMY. PRIOR CURETTAGE,PRIOR PLACENTA PREVIA. MULTIPLE PREGNANCY,PLACENTA SIZE ABNORMALIKTY, SMOKING:CAUSES PLACENTAL HYPERTROPHY TO COMPENSATE CO INDUCED HYPOXEMIA.

8. TYPES OR DEGREES

9. CAUSE OF BLEEDING AS PLACENTAL GROWTH SLOWS DOWN IN LATER MONTHS AND LOWER SEGMENT PROGRESSIVELY ENLARGES,THE INELASTIC PLACENTA IS SHEARED OFF THE WALL OF LOWER SEGMENT. THIS LEADS TO OPENING OF UTEROPLACENTAL VESSELS AND LEAD TO EPISODE OF BLEEDING. IT IS PHYSIOLOGICAL PHENOMENON SO IT IS INEVITABLE. SPONTANEOUS CONTROL OF BLEEDING BY PRESSURE OF PRESENTING PART,THROMBOSIS OF OPEN SINUS.

10. PLACENTAL MIGRATION USG AT 17 WEEKS REVEALS PLACENTA COVERING INTERNAL OS IN 15% CASES,BUT REPEAT USG AT 34 WEEKS SHOWED NO PLACENTA COVERING IN 90% OF CASES, AS THE LOWER UTERINE SEGMENT EXPANDS FROM 0.5cm TO 5cm i.e10 FOLD INCREASE, THE TERM PLACENTAL MIGRATION (TOUGH MISNOMER), SO AS THE LENGTH INCREASES LOWER PLACENTAL EDGE RELOCATES FROM CERVICAL OS.

11. CLINICAL FEATURES SYMPTOMS:- VAGINAL BLEEDING AFTER 20 WEEKS OF PREGNANCY. SUDDEN ONSET,PAINLESS,CAUSELESS AND RECURRENT BLEED,BRIGHT RED IN COLOUR. NOT RELATED TO ACTIVITY,OFTEN OCCURS DURING SLEEP. NO FEATURES OF PRE ECLAMPSIA.

12. . SIGNS:- ANEMIA PROPORTIONATE TO BLOOD LOSS, ON ABDOMINAL EXAMINATION: - SIZE OF UTERUS PROPORTIONATE TO PERIOD OF GESTATION. THE UTERUS FEELS RELAXED,SOFT,ELASTIC,NO TENDERNESS, MALPRESENTATION- BREECH,TWINS,TRANVERSE,UNSTABLE LIE OFTEN SEEN, THE HEAD IS FLOATING, CAN’T BE PUSHED INTO PELVIS. FETAL HEART SOUND – SLOWING OF FETAL HEART RATE ON PRESSING THE HEAD DOWN INTO PELVIS IS SUGGESTIVE OF LOW LYING PLACENTA OF POSTERIOR TYPE,THIS SIGN IS STALLWORTHY’S SIGN .

13. DIAGNOSIS PAINLESS AND RECURRENT VAGINAL BLEEDING IN 2 ND HALF OF PREGNANCY SHOULD BE TAKEN AS PLACENTA PREVIA UNLESS PROVEN OTHERWISE . TRANSABDOMINAL SCAN(TAS):- 100% ACCURACY AFTER 30 TH WEEK,POOR IMAGING IN POSTERIORLY SITUATED PLACENTA. TRANSVAGINAL(TVS) SCAN -PROBE IN THE VAGINA WITHOUT TOUCHING CERVIX,BETTER THAN (TAS).

14. COLOUR DOPPLER- HYPERVASCULARITY AT THE UTERINE SEROSA-BLADDER JUNCTION IS DIAGNOSTIC. MAGNETIC RESONANCE IMAGING(MRI ) - BETTER THAN USG TO DIAGNOSE THE POSTERIOR PLACENTA PREVIA,PLACENTA ACCRETA,PERCRETA WITH BLADDER INVASION.

15. DIFFRENTIAL DIAGNOSIS MUST BE DIFFRENTIATED FROM OTHER CAUSES LIKE, ABRUPTIO PLACENTA,CAN BE DIFFRENTIATED ON THE BASIS OF CLINICAL FEATURES AND ABDOMINAL EXAMINATION. LOCAL CERVICAL LESIONS LIKE POLYPS,CARCINOMA,BOTH CAN BE EASILY DIFFRENTIATED BY PER SPECULUM EXAMINATION.

16. COMLICATIONS

17. FETAL COMPLICATIONS LOW BIRTH WEIGHT/FETAL GROWTH RESTRICTION ASPHYXIA DUE TO EARLY SEPERATION,COMPRESSION OF PLACENTA OR CORD. INTRAUTERINE DEATH DUE TO MATERNAL HYPOVOLEMIA AND SHOCK. BIRTH INJURIES CONGENITAL MALFORMATION.

18. MANAGEMENT PREVENTION:- REGULAR ANTENATAL CARE,CORRECTION OF ANEMIA. ANTENATAL DIAGNOSIS AT 20WEEKS THEN AT 34 WEEKS TO CONFIRM, SIGNIFICANCE OF WARNING HEMORRHAGE. COLOR FLOW DOPPLER USG INDICATED TO DETECT ANY PLACENTA ACCRETA,

19. TREATMENT ON ADMISSION IMMEDIATE ATTENTION:- ASSESS AMOUNT OF BLOOD LOSS,PALLOR,BLOOD PRESSURE,PULSE RATE. BLOOD SAMPLES FOR ABO,CROSS MATCHING,HEMATOCRIT AND COAGULATION PARAMETER. A LARGE BORE IV CANNULA,INFUSION OF NORMAL SALINE AND BLOOD MUST BE ARRANGED. GENTLE ABDOMINAL PALPATION FOR TENDERNESS AND FHS ON AUSCULTATION. INSPECTION OF VULVA.

20. FORMULATION OF LINE OF TREATMENT 1)EXPECTANT MANAGEMENT- FIRST GIVEN BY McAfee & Johnson, THE AIM IS TO CONTINUE PREGNANCY FOR FETAl MATURITY WITHOUT COMPROMISING MATERNAL HEALTH. VITAL PREREQUISITES:- A)BLOOD TRANFUSION B)24Hr CESAREAN SECTION SUITABLE CASES ARE :- A) MOTHER IS HEMODYNAMICALLY STABLE WITH Hb>10Gm%.,HEMATOCRIT>30% B) DURATION OF PREGNANCY <37 WEEKS C) NO ACTIVE VAGINAL BLEEDING. D)FETAL WELLBEING(CTG AND USG)

21. TERMINATION OF EXPECTANT TREATMENT IS DONE AT 37 WEEKS,BY THIS TIME BABY BECOMES MATURE, PRE TERM DELIVERY MAY BE CONDUCTED IN CASES OF CONTINOUS HEMORRHAGE, NONREASSURING FETAL STATUS,OR FETUS IS DEAFD STERIOD THERAPY INDICATED WHEN PREGNANCY <34Wks,BETAMETHASONE REDUCES RISK OF RESPIRATORY DISTRESS OF NEW BORN WHEN PRE TERM DELIVERY IS CONSIDERED.

22. ACTIVE MANAGEMENT INDICATIONS:- BLEEDING AT OR AFTER 37WEEKS, PATIENT IS IN LABOUR,OR IN EXANGUINATED STATE ON ADMISSION. CONTINOUS BLEEDING, BABY WITH NONREASSURING CARDIAC STATUS. CESAREAN DELIVERY FOR ALL WOMEN WHERE PLACENTAL EDGE IS WITHIN 2CM FROM INTERNAL OS,OR PLACENTA IS LOW LYING. VAGINAL DELIVERY MAY BE CONDUCTED IN PATIENTS WHO HAVE PLACENTA LYING AWAY 2-3CM FROM INTERNAL OS,BASED ON SONOGRAPHY.

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