antepartumhaemorhage-140426030544-phpapp02.pptx

Antepartum hemorrhage clinical features and management

1. Antepartum Haemorrhage (APH) Prepared by Abdulghani Jaafar

2. Contents Definition Importance Causes Management of APH Prognosis

3. Bleeding In Pregnancy Bleeding in early Pregnancy Antepartum haemorrhage (APH) Post partum Haemorrhage (PPH)

4. Antepartum Haemorrhage Antepartum haemorrhage (APH, prepartum hemorrhage) is bleeding from the vagina during pregnancy from twenty four weeks of gestational age to term. Epidemiology Affects 3-5% of all pregnancies 3 times more common in multiparous than primiparous women

5. Importance Obstetric emergency Attention should be sought immediately If left untreated can lead to death of the mother and/or foetus Can leads to DVT Management reduce the risk of premature delivery and maternal/perinatal morbidity/mortality

6. Causes 1: Placental causes: A. Placental abruption B. Placenta previa C. Vasa previa 2: Causes in genital tract: A. Labour B: rupture of uterus C. Trauma D. Infection ( cervicitis & vulvovginitis ) E. Tumours

7. 3: Bleeding disorders A. Congenital (von willebrand’s disease) B. Acquired ( DIC)

8. Placenta praevia Definition Insertion of the placenta, partially or fully, in the lower segment of the uterus

9. Etiology No definitive cause Endometrial factors: A scarred endometrium Curettage for several times Abnormal uterus Placental factors Large plcenta Abnormal formation of the placenta

10. Risk factors for Placenta praevia Multiparity Advanced maternal age Prior LSCS or other uterine surgery Prior placenta praevia Uterine structural anomaly

11. Degrees of Placenta praevia

12. Classification of degrees of Placenta praevia Four grades: Type I ( Low lying): Placenta encroaches lower segment but does not reach the internal os Type II (Marginal placenta previa): Reaches internal os but does not cover it Type III (Partial Placenta previa): Covers part of the internal os Type IV (Complete): Completely covers the os, even when the cervix is dilated

13. Placenta praevia - Clinical Features Recurrent painless vaginal bleeding (not always) Abdominal findings Uterus is soft, relaxed and non tender Contraction may be palpated Presenting part is usually high Abnormal presentations Maternal cardiovascular compromise Foetal condition satisfactory until severe maternal compromise Vaginal examination- should not be done

14. Investigation 1: For Localization of placenta: Ultrasound: Abdominal ultrasound can easily diagnose placenta previa with an accuracy of 93-97%. Transvaginal ultrasound is safe and is more accurate than transabdominal ultrasound in locating the placenta 2: Haematological Investigations: A. Complete blood picture. B. Blood grouping. C:Renal profile

15. Placenta praevia -Complications Maternal Major hemorrhage, shock, and death Renal tubular necrosis and acute renal failure Post partum haemorrhage Morbid adherence of Placenta : placenta accreta complicates approximately 10% of placenta praevia cases Anaemia in chronic haemorrhage Disseminated intravascular coagulopathy (DIC)

16. Placenta praevia -Complications cont…. Foetal IUD Hypoxic ischemic encephalopathy Cerebral paulsy Placental abruption Premature labour

17. Placental abruption Definition Premature separation of a normally situated placenta in a viable foetus Placental abruption should be considered in any pregnant woman with abdominal pain with or without PV bleeding, as mild cases may not be clinically obvious

18. Etiology Risk factors Increased age and parity Vascular diseases: preeclampsia, maternal hypertension, renal disease,SLE Mechanical factors: Trauma, intercourse Sudden decompression of uterus Polyhydroamnios Multiple pregnancy 4. Smoking, cocaine use, 5. Premature rupture of membranes

19. Pathology Main changes Hemorrhage into the decidua basalis → decidua splits → decidural hematoma → separation, compression, destruction of the placenta adjacent to it Types of abruption 1. Revealed abruption 2. Concealed abruption 3. Mixed type

20. Revealed abruption Concealed abruption

21. Diagnosis-Clinical Features Vaginal bleeding associate with persistent abdominal pain Tenderness on the uterus “Woody” hard uterus Change of foetal heart rate Features of hypovolemic shock

22. Complication of Placental abruption Maternal Disseminated intravascular coagulopathy Hypovolemic shock Amnionic fluid embolism Renal tubular necrosis and acute renal failure Post partum haemorrhage Maternal death

23. Complication of Placental abruption Feotal Premature labour IUGR in chronic abruption Hypoxic ischemic encepalopathy and cerebral paulsy Foetal death

24. Investigations 1: Diagnostic investigations: Ultrasonography Mainly to exclude placenta praevia Can detect Retroplacental hematoma Feotal viability Most of the time findings will be negative Negative findings do not exclude placental abruption 2: Laboratory investigations Investigation for Consumptive coagulopathy – Platelet count/BT/CT/PT/INR & APTT Liver and Renal function tests

25. Vasa praevia Foetal blood vessels from the placenta or umbilical cord cross the internal os beneath the baby Rupture of membranes leads to damage of the foetal vesseles leading to exsanguination and death High foetal mortality (50-75%)

26. Vasa praevia

27. Risk factors Eccentric (velamentous) cord insertion Bilobed or succenturiate lobe of placenta Multiple gestation Placenta praevia In vitro fertilization (IVF) pregnancies History of uterine surgery or D & C

28. Eccentric (velamentous) cord insertion

29. Diagnosis - Vasa praevia 1.Moderate vaginal bleeding + feotal distress 2.Vessels may be palpable through dilated cervix 3.Vessels may be visible on ultrasound ( Transvaginal colour Doppler ultrasound) Difficult to distinguish from abruption Can look for feotal Hb (Kleihauer-Betke test) or nucleated RBC’s in shed blood Tachycardia or bradycardia in CTG

30. Management of APH

31. Management of APH Admit to hospital for assessment and management May need resuscitation measures if shocked or severe bleeding Airway, breathing and circulation Senior staff must be involved –Consultant obstetrician and consultant anaesthetist, neonatalogist Two wide bore canula Take blood for Grouping & FBC , coagulation profile,Liver & renal function Severe bleeding or fetal distress : urgent delivery of baby irrespective of gestational age

32. Management of APH Volume should be replaced by Crystalloid / colloid until blood is available Severe bleeding or feotal distress: Urgent delivery of baby irrespective of gestational age

33. Management of APH cont… History Obtain a history if patient’s condition allow including: Colour and consistency of bleeding Quantity and rate of blood loss Precipitating factors i.e. Sexual intercourse, Vaginal examination Degree of pain, site and type Placental location-review ultrasound report if available Ascertain foetal movements Ascertain blood group

34. Management of APH cont… Examination Assess maternal and foetal well-being Pallor, record temperature, pulse and BP Perform abdominal examination Note areas of tenderness and hypertonicity Determine gestational age of foetus, presentation and position, auscultate foetal heart No vaginal examination should be attempted at least until a placenta praevia is excluded Do speculum examination to assess cervix / bleeding and exclude local lesions  

35. Management of APH cont… Investigations Arrange urgent ultrasound scan Foetal monitoring Continuos electronic foetal monitoring is indicated

36. Further management of APH Further management will depend on Cause of the APH Extent of bleeding Presence of feotal distress Gestational age and feotal maturity

37. Placenta praevia - Management 1.Near term / Term Delivery is considered Types I and II - May be able to deliver vaginally Types III and IV - Will require caesarean section by senior obstetrician

38. Placenta praevia – Management cont… 2.Early in pregnancy Continuation of pregnancy better if possible Need bed rest Educate patient regarding condition and risk 3 pint of crossed matched blood should be available till delivery Foetal well being and growth should be monitored Medications may be given to prevent premature labour- Nifidipine, Atosiban

39. Placental abruption – Management ctd Small abruption Conservative management depending on gestational age Careful monitoring of feotal condition

40. Placental abruption - management Moderate or severe placental abruption: Restore blood loss Ideally measure central venous pressure (CVP) and adjust transfusion accordingly Prevent coagulopathy Monitor urinary output Delivery 1.Caesarean section 2.Vaginal If coagulopathy present If feotus is not compromised If feotus is dead

41. Vasa Previa management Urgent delivery Most of the time urgent LSCS Neonatologist involvement Aggressive resuscitation of the baby with blood transfusion following delivery

42. Prognosis of APH Feotus may die from hypoxia during heavy bleeding Perinatal mortality more than 50 per 1000 even with tertiary care facilities High rates of maternal mortality

43. Thank You