Aph

1. ANTEPARTUM HAEMORRHAGE (APH) FAHAD ZAKWAN

2. INTRODUCTION A ntepartum haemorrhage ( APH ), also called prepartum hemorrhage , is bleeding from the genital tract during pregnancy from 28 weeks gestational age to term

3. CLASSIFICATION

4. ( A) Placental site bleeding : (62 %) Placenta praevia (22 %): Bleeding from separation of a placenta wholly or partially implanted in the lower uterine segment . Abruptio placentae (30 %): Premature separation of a normally implanted placenta. Marginal separation ( 10 %): Bleeding from the edge of a normally implanted placenta .

5. (B) Non-placental site bleeding : (28 %) Vasa praevia : Bleeding from ruptured foetal vessels. Rupture uterus : 3-Bloody show. Cervical ectopy , polyp or cancer . Vaginal varicosity .

6. It should be considered as an obstetric emergency (regardless of whether there is pain or not) and medical attention should be sought immediately, because if it is left untreated it can lead to death of the mother and/or featus.

7. NOTE Avoid doing vaginal examination in patients with antepartum haemorrhage until placenta praevia has been excluded either clinically or by USS

8. EPIDEMIOLOGY It Affects 3-5% of all pregnancies. It is 3 times more common in multiparous than primiparous women

9. DIFFERENTIAL DIAGNOSIS OF APH Bloody show - most common benign cause of APH Uterine rupture Bleeding from the lower genital tract Cervical bleeding - cervicitis , cervical neoplasm , cervical polyp Bleeding from the vagina itself - trauma, neoplasm

10. PLACENTA PRAEVIA Abnormally implanted placenta in the lower segment of the uterus Although almost all the blood loss from placental site is maternal, some fetal loss is possible particularly if the substance of the placenta is traumatized. Bleeding from the vasa praevia is the only cause of pure fetal haemorrhage.

11. Bleeding is thought to occur in association with the development of the lower uterine segment in the third trimester. Placental attachment is disrupted as this area gradually thins in preparation for the onset of labor. When this occurs, bleeding occurs at the implantation site as the uterus is unable to contract adequately and stop the flow of blood from the open vessels.

12. RISK FACTORS Previous placenta praevia Multiple pregnancies Multiparity Previous c/s scar Advanced age History of threatened abortion in index pregnancy

13. Deficient endometrium due to pre-existent Uterine scar (previous CS) Endometritis Manual removal of placenta Curettage (especially for miscarriage or termination of pregnancy) Submucous fibroid

14. Typically: First episode of bleeding occurs: After 36th week: in 60% of cases 32-36th week: in 30% of cases Before 32nd week: in 10% of cases

15. CLINICAL PRESENTATION

16. ABDOMINAL EXAMINATION

17. Vaginal examination should be avoided , if done should, be in theatre under GA with preparation for emergency c/s in case profuse bleeding occurs. Explore the fornices first then the head. Passing the finger through the cx should be avoided.

18. GRADING PLACENTA PRAEVIA Placenta praevia is classified according to the placement of the placenta:

19. GRADE 1 – low lying Placenta encroaches lower segment but does not reach the cervical os.

20. GRADE 2 - marginal Placenta reaches cervical os but does not cover it

21. GRADE 3 - partial Placenta covers part of the cervical os . The placenta covers the internal os when it is closed or partially dilated but not when it is fully dilated

22. GRADE 4 - total Placenta completely covers the os, even when the cervix is dilated . The placenta covers the internal os completely whether the cervix is partially or fully dilated.

23. LOCALIZATION OF THE PLACENTA Ultrasound Transabdominal Transvaginal . Transperineal done if instrumentation of the vagina is likely to cause problems.

24. The transvaginal US is the most accurate route to locate the placenta but the probe should not touch the cx or the placental site .

25. Management Depends on -Gestation age -Severity of bleeding -Viability of fetus.

26. Immediate measures Call for help!!! Involve the senior staff on call put in 2 large bore (14 gauge) IV cannulas. Keep patient flat and worm. Send blood for group, cross matching diagnostic tests and ask for at least 2 units of blood Infuse rapidly 2 litres of normal saline (crystalloids) to re-expand the vascular bed. Give oxygen by mask 10 – 15L/min

27. Insert Foley catheter to empty the bladder and monitor urine output. Monitor the following: pulse BP RR urine output (continuous cathetarization) type and amount of fluid the patient received

28. The management includes Restore blood volume by giving IV fluids – normal saline or ringers lactate Assess blood loss: If bleeding is heavy or continuous , arrange or do caesarean section delivery irrespective of foetal maturity within 6 – 8 hrs. If bleeding is light and stopped and the foetus alive and premature consider expectant management until 37/38 wks .

29. Keep the woman in hospital for bed rest until delivery Correct anaemia Give iron/ folic acid, vit . B12 Blood transfusion Packed cells Whole blood

30. NOTE Decide management after weighing benefits and risks to the woman and fetus. PRIORITY IS SAVING THE MOTHER!! ALL GRADES OF PLACENTA PRAEVIA ARE DELIVERED BY C/S EXCEPT GRADE IA WHERE THE PLACENTA JUST DIPS IN THE LOWER SEGMENT AND ITS ANTERIORLY LOCATED

31. Bloods Tests Complete blood picture and D- Dimer Group and cross match 4 units Consider need for Anti-D if Rh negative. Ultrasound Confirm diagnosis. Corticosteroids Consider corticosteroid prophylaxis if < 34 weeks

32. ABRUPTIO PLACENTA Refers to bleeding due to the premature separation of a normally sited placenta from its attachment to the uterus . May be described as Concealed ( if no external bleeding is seen) Revealed (if there is obvious external bleeding)

33. RISK FACTORS Hypertension Maternal thrombophilias Increasing maternal age, parity Cigarette smoking Abdominal trauma e.g. motor vehicle accident Substance abuse (crack, cocaine, amphetamines) Sudden decrease in uterine volume (e.g. SROM in the presence of polyhydramnios, or after delivery of a first twin) External cephalic version (ECV) or instrumental delivery .

34. CLASSIFICATION Classification of placental abruption is based on: extent of separation ( ie , partial vs complete) and location of separation ( ie , marginal vs central). Clinical characteristics include the following:

35. Class 0 is asymptomatic . Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.

36. Class 1 is mild represents approximately 48% of all cases. Characteristics include the following: No vaginal bleeding to mild vaginal bleeding Slightly tender uterus Normal maternal BP and heart rate No coagulopathy No fetal distress

37. Class 2 is moderate represents approximately 27% of all cases. Characteristics include the following: No vaginal bleeding to moderate vaginal bleeding Moderate-to-severe uterine tenderness with possible tetanic contractions Maternal tachycardia with orthostatic changes in BP and heart rate Fetal distress Hypofibrinogenaemia (i.e. 50-250 mg/ dL )

38. Class 3 is severe represents approximately 24% of all cases. Characteristics include the following: No vaginal bleeding to heavy vaginal bleeding Very painful tetanic uterus Maternal shock Hypofibrinogenemia ( ie , <150 mg/ dL ) Coagulopathy Fetal death

39. Clinical features Vaginal bleeding is usually associated with abdominal pain , uterine contractions , tenderness and / or irritability May be faint and / or collapse Signs of haemorrhagic shock Consider concealed abruption if abdominal or back pain is present Fetal moments are usually absent unless it is an early abruption or partial

40. Contractions/uterine tenderness Uterine contractions are a common finding with placental abruption. Contractions progress as the abruption expands, and uterine hypertonus may be noted. Contractions are painful and palpable.

41. Principles of early management Intravenous (IV) access (2 large bore iv lines must be put in place) Indwelling catheter Start intensive care list (fluid balance, blood pressure, pulse rate etc) The cornerstone of appropriate management is adequate resuscitation with intravenous fluids (plasma volume expanders, blood) Consider need for early delivery dependent on maternal and fetal condition

42. Achieving adequate perfusion is essential to allow the reticulo -endothelial system ( Kupfer cells, spleen) to clear fibrinogen / fibrin degradation products (FDPs). Acceptable perfusion is signalled by urine output of > 30 mL per hour Cross match blood Urgent complete blood picture , D- dimer , thrombin time, fibrinogen levels, creatinine Bed side clotting time (NORMAL – 7mins) Consider giving FFP if there is prolonged bed side clotting time or abnormal bleeding indices.

43. Later on Monitor in-put and output Monitor maternal vital signs. Continuous CTG to assess for signs of fetal compromise if the fetus was alive at the time of diagnosis. Anti D prophylaxis for Rh negative women

44. Active management: Consultation with anaesthetist as indicated Consider central venous pressure monitoring Ensure adequate blood, blood products (6-8 packed cells to start with in case of total abruption), and fresh frozen plasma (FFP) guided by fibrinogen levels and mostly also 1 FFP unit required for each 4-6 units of blood transfused. Specific replacement of coagulation factors is very rarely required - only in consultation with laboratory / haematologist If fetal death is confirmed Aim for vaginal delivery with ARM and Syntocinon ® if condition allow.

45. Delivery Consider vaginal delivery with continuous electronic fetal monitoring if fetus is alive and rapid recourse to caesarean section depending on fetal/maternal condition. Caesarean section if acute fetal compromise occurs (if it was alive at diagnosis) or if other obstetric indications dictate so. Following delivery: Recognize increased risk of PPH After delivery do placental examination for: Completeness Any area of abruption Associated pathological features e.g. abnormal degree of calcification Send for histopathology