Antepartum hemorra١١١١١١١١١١١١١١١١١١.pdf

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1. byHamzat

2. •Deathfromhemorrhagestillremainsaleadingcauseofmaternal
•APHisdefinedasbleedingfromthegenitaltractinpregnancyfromtheage
viability(24 –WHObut28wksinNigeria)andtheonsetof
•It 4%ofall Itisamedical
•Itisassociatedwith risksoffetal maternalmorbidityand

4. •Isdefinedasthe of partiallyorwhollyinthelower

•Aboutone-thirdcasesof hemorrhagebelongto
incidenceof previa from0.5–1%amongsthospitaldeliveries.
80%cases,itisfoundinmultiparous

5. •Theexactcauseof oftheplacentainthelowersegmentis

•Thefollowingrisk are
Advancingmaternal

/multiple
Priorcaesarean

Priorplacenta
Uterine

6. TYPESOR
• I lying):the edgeisintheloweruterinesegmentbut
notreachtheinternal
• II(Marginal):The reachesthemarginoftheinternalosbut
notcoverit.Dividedintoanteriorand
• III orpartial Theplacenta theinternal
partially theinternaloswhenclosedbutdoesnotentirelydoso
fully
• IV(Centralortotal):Theplacenta theinternalos
afteritisfully

7. Degreesofplacentapreviawithfindingson

8. CAUSEOF
•Bleedingresultsfromsmalldisruptionsintheplacentalattachment
normal andthinningoftheloweruterine
•Astheplacentalgrowthslowsdowninlatermonthsandthelower
progressivelydilates,theinelasticplacentaisshearedoffthewallof
lowersegment.Thisleadstoopeningupofuteroplacentalvessels
leadstoanepisodeof

9. CLINICAL
•Bleeding:usuallymildbutitcouldbesevere; painless

•Softandtender
•Normalheartrate(unlessthereisseverebleedingor

•Highpresenting
•Fetal
•Generalconditionandanemiaare tothevisible

10. Abdominal
•Thesizeoftheuterusis totheperiodof
•Theuterusfeels softandelasticwithoutany areaof
•

•Theheadisfloatingincontrasttotheperiodofgestation.Theheadcannot
pusheddownintothe
•Fetalheartsoundisusually
•Vulvalinspection:thebloodisbrightredasthebleedingoccursfrom
separated placentalsinusesclosetothecervicalopeningandescapes

• is

11. DIAGNOSIS:Painlessand vaginalbleedinginthesecondhalfof
shouldbe as previaunless otherwise. is
initial eithertoconfirmortoruleoutthe
I. of

––

–– ultrasound
––
––ColorDopplerflow
•Magneticresonance

II.
––Byinternal
setup
––Direct
caesarean
–– ofthe
followingvaginal

12. •
—Adequate
diagnosisat20th
—Significanceof“warninghemorrhage”shouldnotbe
ON
• Overallassessmentofthecaseis
madeas
(1)Amountofthebloodloss—by notingthegeneralcondition,
pulserateandblood
(2)Bloodsamplesaretakenforgroup,crossmatchingand
of

13. (3)A boreIVcannulaissitedandaninfusionofnormalsaline
startedandcompatiblecrossmatchedblood should

(4)Gentleabdominalpalpationtoascertainanyuterinetenderness
tonotethefetalheart
(5)Inspectionofthevulvatonotethepresenceofanyactive
• OFTHELINEOF
•Thedefinitivetreatmentdependsuponthedurationof
andmaternalstatusandextentofthe

14. •Theaimistocontinuepregnancyforfetalmaturitywithoutcompromisingthe

Conductof
•StrictBed
• likehemoglobinestimation,bloodgroupingandurineforprotein

•PeriodicinspectionofthevulvalpadsandfetalsurveillancewithUSGatintervalof

15. •Supplementaryhematinicsshouldbegivenandthebloodloss
replacedbyadequatecrossmatchedblood ifthe
is
•Steroidforlung if ageislessthan34
•Useoftocolysis(magnesium canbedoneifvaginalbleeding
associatedwithuterine
•RhimmunoglobinshouldbegiventoallRh

16. Active
1.Bleedingoccursatorafter37weeksof
2.Patientisin
3.Fetal

5.Congenitalanomalynotcompatiblewith

Cesareandeliveryisdoneforallwomenwithsonographicevidence
placentapreviawhereplacentaledgeiswithin2cmfromthe
os.Itisespeciallyindicatedifitisposterioror

18. •
•Duringpregnancy:Antepartumhaemorrhage,
Preterm
•Duringlabour:PROM,Cordprolapse,
Increasedincidenceofoperative
hemorrhage, placenta,
•Puerperium:Sepsis,Subinvolution,
• Lowbirthweight,Asphyxia, death,Birth

19. ABRUPTIO
•Itisoneformofantepartumhemorrhagewherethebleeding
dueto ofnormallysituatedplacentaafter
ageof
•Occursin2%ofall
• mortalityrateassociatedwithplacentalabruptionwas
per1000 birthscomparedwith8.2per1000forall

20. :Followingseparationoftheplacenta,theblood
outofthecervicalcanaltobevisible
(2)Concealed:Thebloodcollectsbehindthe placenta
collectedinbetweenthemembranesand
(3)Mixed:Inthistype,somepartofthebloodcollects
(concealed)andapartisexpelledout
(A)Concealed;(B) (C)Marginal(subchorionic)and;(D)

21. CLINICAL
0:Clinical maybeabsent.Thediagnosisismade
inspectionofplacenta
1(40%):(i) bleedingisslight(ii)Uterus:irritable,
maybeminimalorabsent(iii)MaternalBPandfibrinogenlevels
(iv)FHSis
2(45%):(i) bleedingmildto (ii)Uterine
is present(iii)Maternalpulse↑,BPismaintained(iv)Fibrinogen
maybedecreased(v)Shockisabsent(vi)Fetaldistressorevenfetal

3(15%):(i)Bleedingis tosevereormaybeconcealed
Uterinetendernessismarked(iii)Shockis (iv)Fetaldeathis
rule(v)Associated defectoranuriamay

22. Risk
•Theprimarycauseof
abruptionisunknown,but
•Increasedageand
•
•Chronic
•Pretermruptured
•
•
•
•Folicacid
areseveralassociatedconditions.•
•Cocaine
•Prior
•Uterine
•External

23. Clinical
•Bleeding: soclinicalpictureis
•Painontheuterusandthisincreasesin
•Signsofshock faintingand
• hardtenderuterus(uterine
•Couvelaireuterus(Bluish
•Difficulttopalpatethefetalpartsandtohearthefetal
•Normallieand
• isdonetoconfirmfetal assess
growth& measure

24. • forplacentalabruptionvariesdependingon
ageandthestatusofthemotherand
•
•History&
•Assessblood
•Nearly morethan
•IVaccess,Xmatch,DIC
•Assessfetal
•Placental

25. Principleof
Earlydelivery(50%ofabruptionpresentin
Adequateblood
Adequate
Detailedmaternaland
Coagulationprofile(30%develop
C/S:distressed severebleeding,alivebaby&notin
mortalityrateis
delivery:verylow dead cervixisfully

Conservative:smallabruption,wellmotherandfetus,if
age<34,give

27. • Shock,Bloodcoagulationdisorders,Oliguriaand
haemorrhage,Puerperalsepsis,Acuterenal
tubularorcortical
• IUGR,Anaemia,Premature Fetaldistressand

29. •Rarely reportedconditioninwhichthe fetal vesselsfromthe
crosstheentrancetothebirth
•Incidencevariesoccurrencein1:3000
•Associatedwithahighfetalmortalityrate95%)whichcan
attributedtorapidfetalexsanguinationresultingfromthe
tearingduring

30. •Therearethreecausestypicallynotedforvasa
•lobed
• insertionoftheumbilical
• (Accessory)

31. Risk
•Bilobedand
• insertionofthe
•Low-lying
•Multiple
•Pregnanciesresultingfrominvitro
•Palpablevesselonvaginal

32. •Usually
•Suddenonsetofpainlessbleedinginsecondorthirdtrimesteror
ruptureof
•Nosignorsymptomofplacentapraeviaor
•
•Congenital
•Abnormalheart

33. •Detectionofnucleatedredbloodcells(Singer’salkali
test)orhemoglobinis
•Managementdependsonfetal age,
or ofbleeding,andthepresumedcauseof
•Pregnancy>37weeksandbleedingrecurrent—delivery
recommended.Themodeofdeliverydependsonthe of
fetus,andotherassociated
•Expectantmanagementcanbedoneinselectedcasesfor
maturitysimilartoplacentaprevia.Fetalmonitoringmustbe
done.Intrapartumdiagnosisofvasaprevia,needs
Neonatalblood maybe