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1. Antepartum Hemorrhage

2. It is defined as bleeding from or in to the genital tract, occurring from 22 weeks (>500g) of pregnancy and prior to the birth of the baby. Complicates 3–5% of pregnancies leading cause of perinatal and maternal mortality worldwide. Up to one-fifth of very preterm babies are born in association with APH Most of the time unpredictable.

3. NO consistent definitions of the severity of APH. It is recognised that the amount of blood lost is often underestimated. The amount of blood coming from the introitus represent the total blood lost (for example in a concealed placental abruption),It is important to assess for signs of clinical shock. fetal compromise or fetal demise is an important indicator of volume depletion

4. Terminologies used Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection Minor haemorrhage – blood loss less than 50 ml that has settled Major haemorrhage – blood loss of 50–1000 ml , with no signs of clinical shock Massive haemorrhage – blood loss greater than 1000ml and/or signs of clinicalshock . Recurrent APH - > one episode

5. Etiology Placenta praevia Abruptio placenta Vasapraevia Excessive show Local causes ( bleeding from cervix, vagina and vulva ) Inderterminate APH

6. CLASSIFICATION PLACENTA PRAEVIA Implantation of placenta over or near the internal os of cervix. Confirm diagnosis of PP can be done at 28 weeks when LUS forming Leading cause of vaginal bleeding in the 2 nd and 3rd trimester

7. Risk Factors for Placenta Previa Previous placenta praevia(4-8%) Previous caesarean sections (risk with numbers of c-section). Previous termination of pregnancy Multiparity Advanced maternal age (>40years) Multiple pregnancy Smoking Deficient endometrium due to presence or history of: Uterine scar endometritis Manual removal of placenta curettage submucous fibroid Assisted conception

8. Clinical Classification

9. ABRUPTIO PLACENTA Separation of normally located placenta after 22weeks of gestation(>500g) and prior to delivery of fetus .

10. Risk Factors Previous history of AP Maternal hypertension Advanced maternal age Trauma(domestic violence, accident , fall) Smoking/alcohol/cocaine Short umbilical cord Sudden decompression of uterus (PROM/deliveryof1sttwins) Retroplacental fibroids Idiopathic

11. Obstetrics Emergency Diagnosed CLINICALLY: Painful vaginal bleeding-80% Tense and tender abdomen/backpain(70%) Fetal distress(60%) Abnormal uterine contractions(hypertonic and high frequency) Preterm labour(25%) Fetal death(15%) Ultrasound is NOT USEFULto diagnose AP. Retroplacental clots (hyperechoic) easily missed .

12. VASA PREAVIA Rupture of fetal vessels that run in membrane below fetal presenting part which is unsupported by placenta/ umbilical cord. PredisposingFactors : Velamentous insertion of the umbilical cord Accesory placental lobes Multiple gestations The term velamentous insertion is used to describe the condition in which the umbilical cord inserts on the chorioamniotic membranes rather than on the placental mass .

13. Diagnosis of VP Antenatal diagnosis–reduced perinata l mortality and morbidity. Painless vaginal bleeding at the time of spontaneous rupture of membrane or post amniotomy Fetal bradycardia Fetal shock or death can occur rapidly at the time of diagnosis due to blood loss constitutes a major bulk of blood volume is fetus (3kg fetus-300ml) Hence, ALWAYS check th e fetal heart after rupture of membrane or amniotomy. Definitive diagnosis by inspecting the placenta and fetal membrane after delivery.

14. Complications of APH

15. Clinical Assessment in APH First and foremost Mother and fetal well being (mother is thepriority ) E stablish whether urgent intervention is required to manage maternal or fetal compromise. Assess the extent of vaginal bleeding, cardiovascular condition of the mother Assess fetal well being. Full history must be taken after the mother is stable. A ssociated pain with the haemorrhage? Continuous pain:Placental abruption. Intermittent pain:Labour . Risk factors for abruption and placenta praevia should be identified. Reduced fetal movements? If theAPH is associated with spontaneous or iatrogenic rupture of the fetal membranes:ruptured vasapraevia Previous cervical smear history possibility of Cacervix . Symptomatic pregnant women usually present with APH (mostly postcoital)o rvaginal discharge

16. Examination General : PULSE & BP(a MUST!) Abdomen : -The tense, tenderor‘woody ’ feel to the uterus indicates a significant abruption. -Pain less bleeding, high fetal presenting part–Placenta praevia -soft, non-tender uterus may suggest a lower genital tract cause or bleeding from placenta or vasapraevia . Speculum : -identify cervical dilatation or visualise a lower genital tract cause.  Digital vaginal examination -Should NOT be done until Placenta Praevia has been excluded by USG.

17. Investigations FBC  Coagulation profile  Blood Grouping and CXM(Complete dependent lympho cytotoxic crossmatch) ,GSH-glutathione.  Ultrasound  D-dimer :AP  Colour dopplerTVS –VP  In all women who are RhD -negative, a Kleihauer test should be performed to quantify FMH to gauge the dose of anti-D Ig required. Fetal monitoring:  CTG monitoring

18. Management WHEN to admit?  Based on individual assessment - Discharge after reassurance and counselling Women presenting with spotting who are no longer bleeding and where placenta praevia has been Excluded. However, a woman withs potting+previous IUD due to placenta abruption,an admission would be appropriate. -All women with APH heavier than spotting and women with ongoing bleeding should remain in hospital atleast until the bleeding has stopped If preterm delivery is anticipated, a single course of antenatal corticosteroids ( dexamethasone 12mg 12hourly,2 doses) to women between 24 and 34 weeks 6 days of gestation.  Tocolytics should NOT be given unless for VERY preterm women who need time to transfer to hospital with NICU.  For very preterm ( 24-26 weeks) , -conservative management if mother is stable. -Delivery of fetus –life threatening At these gestations, experienced neonatologists should be involved in the counselling of the woman and her partner

19. For Placenta Praevia Conservative – MaCafee’sregime ( premature < 37 weeks ; mother hemodynamically stable, no active bleeding, fetus stable) A dvise bed rest, keep pad chart, vital signs monitoring , Ultrasound, steroids, GSH , Daily CTG and biophysical profile, fetal movement count. Plan for delivery ( >37weeks) Crossmatch 4 units of blood.

20. For Abruptio Placenta Obs Emeregency ICU admission : Close monitoring and resuscitation! -ABC ( high flow O2, aggressive fluid resuscitation) -Continuous Vital signs monitoring and urine output -Monitor vaginal bleeding –strict pad chart -Continuous CTG for fetal heartrate -Crossmatch 4 units of blood -FFP –coagulopathy -Dexamethasone –preterm

21. Abruptio placenta Decide Mode ofdelivery Vaginal delivery –when fetal death Caesarean section –if maternal/ fetal health compromised Indicated when early DIC sets in. Consent should be taken for hysterectomy in case bleeding could not be controlled. For Rh negative mothers, Anti-Dig should be given to all after any presentation with APH, independent of whether routine antenatal prophylactic anti-D has been administered. In the non- sensitised RhD -negative woman for all events after 20 weeks of gestation, at least 500iu Anti-D Ig should be given followed by a test to identify FMH, if greater than 4 ml red blood cells; additional A nti-D Ig should be given as required.

22. Summary Discuss about the causes, complications and their expectant and active management of APH. Any bleeding from or into the genital tract , occurring from 22weeks(>500g) of pregnancy and prior to the birth of the baby is called antepartum hemorrhage.Incidence3-5% of all pregnancies. Maternal causes are placenta previa and placenta abruption and fetal causes vasaprevia

23. Conclusion All patients of APH, irrespective of the amount of blood loss, should be admitted. The blood loss should be considered as due to placenta previa unless proved otherwise .The bleeding may occur any time and is unpredictable

24. Bibliography J.BSharma,"TextbookofMidwiferyandgynecologicalNursing”,1 st edition-2015,publishedbyAvichalpublishingcompany,pageno.265-274 2.NimaBhaskar,”TextbookofMidwiferyObstetricalNursing”1stedition2012,publishedbyEMMESS.pageno.319-326