Antepartum Hemorrhage 041731 pm_87e144-1.pptx

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1. ANTEPARTUM HEMORRHAGE BY: Nabimanya Conrad Super & Nanzige Falahan

2. OBJECTIVES Definition Epidemiology Etiology/Risk factors Complications Investigations History taking & Examination in APH Management

3. DEFINITIONS This is any bleeding from or into the birth canal which occurs at or after 26 weeks of gestation or 800 grams and before birth of the baby(Uganda Clinical Guidlines 2022) Vaginal bleeding between 24 weeks gestation and delivery.(Ten Teachers Obstetrics 20th edition)

4. EPIDEMIOLOGY Hemorrhage is the leading cause of maternal mortality globally, accounting for approximately 27% of deaths worldwide; this includes postpartum, intrapartum and antepartum hemorrhage In developed countries, hemorrhage prior to delivery accounts for only 16.3% of maternal deaths, while Sub-Saharan Africa remains high at 24.5%. APH complicates 3–5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide. Up to one-fifth of very preterm babies are born in association with APH, and the known association of APH with cerebral palsy can be explained by preterm delivery.

5. CLASSIFICATION . PV spotting. Minor APH <50 mL of blood and settled. Major APH 50-1000 mL of blood with no shock. Massive APH >1000 ML of blood and /or signs of shock.

6. ETIOLOGY/ RISK FACTORS Placental causes (70% of all cases) Placental abruption. Placental Praevia . Vasa Praevia . Marginal haemorrhage . Others;placenta accreta /uterine rupture. Local causes (extra-placental causes) Cervix; Cervical ectropion ,Cervical carcinoma. Vaginal trauma.

7. PLACENTA PREVIA Placenta previa is defined as the implantation of the placenta over or adjacent to the internal os of the cervix /location below the presenting part of fetus. INCIDENCE: About one-third cases of antepartum hemorrhage belong to placenta previa. The incidence of placenta previa ranges from 0.5% to 1% amongst hospital deliveries. In 80% cases, it is found in multiparous women. The incidence is increased beyond the age of 35 years, with high birth order pregnancies and in multiple pregnancy. Classification Total placenta previa (Grade IV) : occurs when the internal cervical os is completely covered by the placenta. Partially placenta previa (Grade III): occurs when the internal os is partially covered by the placenta. Marginal placenta previa (Grade II) : occurs when the placenta is at margin of internal os Lateral/ Low-lying placenta previa (Grade I) : occurs when the placenta is implanted in the lower uterine segment. The edge of the placenta is near the internal os but does not reach it.

8. continued . Placenta praevia may be associated with placenta accreta , placenta increta or percreta . Coagulopathy is rare with placenta previa . The most characteristic event in placenta previa is painless hemorrhage. This usually occurs near the end of or after the second trimester. The initial bleeding is rarely so profuse as to prove fatal. It usually ceases spontaneously, only to recur.

9. Mechanism of bleeding As the placental growth slows down in later months and the lower segment progressively dilates, the inelastic placenta is sheared off the wall of the lower segment. This leads to opening up of uteroplacental vessels and leads to an episode of bleeding. As it is a physiological phenomenon which leads to the separation of the placenta, the bleeding is said to be inevitable. However, the separation of the placenta may be provoked by trauma including vaginal examination, coital act, external version or during high rupture of the membranes. The blood is almost always maternal, although fetal blood may escape from the torn villi especially when the placenta is separated during trauma.

10. Risk factors Multiparity Increased maternal age Previous placental praevia Multiple gestation Previous c -section Uterine anomalies Maternal smoking

11. Complications During pregnancy; Premature labour Malpresentation(e.g breech presentaion, transverse lie) Death due to massive hemorrage During Labour Early rupture of membranes cord prolapse slow dilataion intrapartum hemorrhage retained placenta

12. FETAL COMPLICATIONS OF PLACENTA PREVIA Low birth weight Asphyxia intrauterine death birth injuries congenital malformation maternal and fetal morbidity/mortality

13. Clinical presenation Bright red bleeding(or dark if clotted in vagina). Usually preceded by small warning bleeds/spotting Painless unless in labour no uterine tenderness or abnormal fetal lie on Abdominal palpation fetal heart auscultaion: usually normal but can be distant,bradychardic, tachycardic or absent.

14. Investigations Ultrasound scan to localize placenta as well as assess fetal wellbeing Blood for CBC/Hb Blood grouping and cross matching

15. Prevention Adequate antenatal care Antenatal diagnosis(e.g ultrasound scans) Significance of warning hemorrhage must not be ignored

16. ABRUPTIO PLACENTA This is separation of the placenta-either totally or partially-from its implantation site before delivery. TYPES Can be partial or total, revealed or concealed. Total: whole placenta separates from implantation site Partial: a part of placenta separates. Revealed: bleeding insinuates downward between membeanes and decidua.Ultimately, the blood comes out of the cervical canal to be visible externally. This is the most common type Concealed: The blood collects behind the separated placenta or collected in between the membranes and decidua. collected blood is prevented from coming out of the cervix by the presenting part which presses on the lower segment. At times, the blood may percolate into the amniotic sac after rupturing the membranes. In any of the circumstances blood is not visible outside. Mixed : In this type, some part of the blood collects inside (concealed) and a part is expelled out (revealed).

17. Risk factors High bith order, gravida>5+ Advancing age of mother Malnutrition smoking Pre-eclampsia(the most important predisposing factor). How ?: Spasm of vessels in utero-placental bed causes anoxic endothelial damage hence rupture of vessels or extravasation of vessels of decidual basalis. Trauma to placenta Short cord folate deficiency sudden uterine decompression ETC....

18. Etiopathogenesis Premature placental separation is initiated by hemorrhage into the decidua basalis. The collected blood (decidual hematoma) at the early phase, hardly produces any morbid pathological changes in the uterine wall or on the placenta. However, depending upon the extent of pathology, there may be degeneration and necrosis of the decidua basalis as well as the placenta adjacent to it. Rupture of the basal plate may also occur, thus communicating the hematoma with the intervillous space. The decidual hematoma may be small and self limited; the entity is evident only after the expulsion of the placenta (retroplacental hematoma).

19. Couvelaire uterus This is a pathological entity first described by Couvelaire and is met with in association with severe form of concealed abruptio placentae. There is massive extravastiom of blood into the uterine musculature upto the serous coat. Effusions may also be seen beneath tubal serosa.

20. Clinical presentation Constant abdominal pain which usuall precedes vaginal bleeding Passage of dark blood which may not clot. Sometimes there will be no bleeding externally. On abdominal palpation; woody hard and tender uterus.Fetal parts also difficult to feel depending on severity Fetal heart auscultation; bradycardia(FH<100/min) or Fetal tachcycardia>160/min or absent fetal heart beat.

21. Complications MATERNAL Revealed type —maternal risk is proportionate to the visible blood loss and maternal death is rare Concealed type- hemorrhage, shock,blood coagulation disorders, oliguria and anuria, post partum hemorrhage, peurperal sepsis FETAL Revealed type - the fetal death is to the extent of 25–30%. Concealed type - the fetal death is appreciably high, ranging from 50% to 100%. The deaths are due to prematurity and anoxia due to placental separation

22. Investigations Blood grouping and cross matching. Arrange blood products e.g whole blood,platelets. Blood for CBC/Hb, platelet count Ultrasound scan Urinalysis (for proteinuria to exculde pre-ecclampsia) Bedside clotting time,prothombin time,activated partial thromboplastin time.

23. UTERINE RUPTURE This is a partial or complete tear of the gravid uterus. Predisposing factors Previous operations on the uterus - Myomectomy - Caesarean section, wedge resection in previous cornual ectopic pregnancy. • Obstetric manoeuvres on the uterus - Breech extraction - Manual removal of the placenta - Poorly applied forceps • History of previous perforation of the uterus •Grand multiparity • Uterine hyper stimulation (inappropriate use of oxytocin, misoprostol or herbs) • Macrosomia • Malpresentation

24. continued Signs and symptoms In labour: Vaginal bleeding Oedema of the lower vagina and vulva (Kanula sign) Retained placenta Cessation of uterine contractions following hypertonic uterine contractions Continuous abdominal pain/tenderness Signs of shock - Restlessness - Sweating - Hypotension (low blood pressure) - Pulse rises (tachycardia) Hypovolaemia Deformity of uterine and abdominal outline

25. Signs and symptoms(uterine rupture) Displacement of the uterus to one side with tenderness after delivery Easily palpable foetal parts Dislodged presenting part Foetal heart sounds irregular or absent Uterine rupture may present before onset of labour and woman presents with: History of trauma to the abdomen Previous operations on the uterus, especially history of classical caesarean section. Usually difficult to palpate the abdomen Vaginal bleeding not proportional to profound signs of shock Other signs as when in labour

26. Differential diagnosis of ruptured uterus Placenta praevia Bowel obstruction Extrauterine pregnancy Ruptured spleen or liver, if it follows an accident Abruptio placenta Investigations Do blood grouping and cross matching Take off blood for haemoglobin level

27. Uterine rupture FOLLOW UP If hysterectomy performed, counsel the woman on consequences including future reproductive plans Review in postnatal clinic. Gynaecology clinic and do Pap smeae

28. VASA PREVIA Definition: Vasa praevia is the presence of unprotected fetal blood vessels running along the placenta and over the internal cervical opening. Epidemiology: Is very rare , presenting only 4:10,000 cases from largest study of the condition .

29. Causes There are three causes typically noted for vasa previa : Bi-lobed placenta Velamentous insertion of the umbilical cord Succenturiate (Accessory) lobe

30. DIFFERENTIAL DIAGNOSIS FOR APH Abruptio Placenta Placenta previa Ruptured Uterus Differentials for concealed abruptio include: Degenerative fibroids Twisted ovarian cyst Acute appendicitis

31. INVESTIGATIONS IN APH Blood for CBC/Hb, platelet count Blood grouping and cross-matching Ultrasound scan Bedside clotting time, prothrombin time (PT), activated partial thromboplastin time (aPTT) Urinalysis (for proteinuria to exclude Pre-eclampsia commonly associated with abruptio)

32. HISTORY TAKING IN APH Characterize per-vaginal bleed: Onset, duration, number of episodes, amount Any precipitating factor(s) - Blunt abdominal trauma >> abruptio - Rupture of membranes >>abruptio or vasa praevia Associated symptoms : Pain vs painless - Abruptio usually painful - Placenta praevia & vasa praevia usually painless Uterine contractions - Abruptio placentae usually associated with strong uterine contractions - Placenta praevia & vasa praevia usually not associated with uterine contractions - Regular uterine contractions may indicate onset of preterm labour. Fetal movements

33. HISTORY CONTINUED Antenatal history: Results of investigations & scans done so far - Placental &/or umbilical cord abnormalities noted (e.g. low-lying placenta, aberrant cord insertion) - Any preeclampsia (increases risk of abruptio) Use of assisted reproductive technologies - Increased risk of placenta praevia - Increased risk of vasa praevia (multiple gestations) Obstetric history : Any previous antepartum hemorrhage & diagnosis Any previous caesarian section or uterine surgery - Increased risk of placenta praevia

34. continued Past medical, surgical, social history Any known lower genital tract pathology - Cervicitis, cervical polyps, cervical cancer etc - Last Pap smear & results Any pre-existing hypertension or thrombophilia - Increased risk of abruptio Any known coagulopathy Smoking & drug use - Increased risk of placenta praevia & abruptio

35. PHYSICAL EXAMINATION FOR APH General examination: Maternal vitals (BP, HR, RR, SpO2) Assess for pallor & signs of coagulopathy Obstetric examination: Palpate for tenderness (abdominal &/or uterine), uterine consistency (woody hard uterus in abruption) & fetal lie + presentation ƒ DopTone to look for fetal heartbeat Pelvic examination: (done only after ultrasound is performed to rule out placenta praevia in which case a pelvic examination is contraindicated) Rule out lower genital tract pathology Assess for cervical dilatation/effacement (indicates preterm delivery which can occur as a result of other causes of antepartum hemorrhage as well)

36. MANAGEMENT OF APH • Pre-referral care(if at facility that cant manage APH) - Do not perform a digital V/E but inspect the vulva - Establish an IV line and give IV fluid normal saline or ringers lactate - Refer the woman urgently • The management of APH depends on the cause, gestation age, maternal/foetal condition and severity of the bleeding •For abruptio placenta follow the management protocol(indicated earlier). For placenta praevia refer to management protocol (also indicated earlier) •Preparedness for complications Grouping and cross-matched blood Keep emergency tray replenished with supplies at all times Counsel client and companion about her condition.

37. PRECAUTIONS IN APH MANAGEMENT 1. 4 DON’TS - Digital vaginal exam - Bladder catheterization - Rectal examination - Rectal enema 2. WHEN NOT TO DELIVER - Preterm - Alive foetus - Stable mother - Not in labour 3. WHEN TO DELIVER - Term - Dead foetus - Labour - Mother unstable

38. REFERENCES Ten Teachers Obstetrics (20th edition) Williams Obstetrics(24th edition) Uganda's MoH: Essential Maternal Newborn Care Guidlines 2022 Hwee's Obstetrics Gynecology Dutta Textbook of Obstetrics (8th edition) ncbi.nlm.nih.gov (Epidemiology)