Aph

lecture for medical students

1. Antepartum haemorrhage (APH) Dr.Tarig Mahmoud Ahmed MD SUDAN HAIL UNIVERSITY KSA

2. Antepartum haemorrhage (APH) is any bleeding occurring in the antenatal period after 20 weeks gestation. It complicates 2–5 per cent of pregnancie s.

3. CAUSES: placental abruption(one third) placenta praevia (one third) other causes (one third).

4. Placenta praevia Placenta praevia is defined as a placenta that has implanted into the lower segment of the uterus. It is now classified as either major, in which the placenta is covering the internal cervical os , or minor, when the placenta is sited within the lower segment of the uterus, but does not cover the cervical os .

5. The incidence in the UK is approximately 5 per 1000 and is increasing due to the rising Caesarean section rate and increasing maternal age. In women who have had a previous caesearean section, there is a risk of placenta implants into, and thus invades, into the previous scar ‘morbidly adherent placenta’.

6. morbidly adherent placenta are three types: 1. Placenta accreta . Placenta is abnormally adherent to the uterine wall. 2. Placenta increta . Placenta is abnormally invading into the uterine wall. 3. Placenta percreta . Placenta is invading through the uterine wall.

7. Diagnosis: recurrent painless bleeding in the 3 rd trimester. On abdominal palpation, the uterus will be soft and non-tender and the presenting part will be high. ultrasoundscans will demonstrate the abnormal location of the placenta. A digital examination is contraindicated as this can precipitate bleeding.

8. Management: resuscitated using approach of ABC. If the bleeding is minor and the fetus uncompromised, the patient should be admitted for observation for at least 24 hrs. Women with major placenta praevia who have had recurrent bleeding should be admitted as inpatients from 34 weeks till Caesarean section at 37–38 weeks .

9. Cases of minor placenta praevia can be considered for a vaginal delivery if the placenta is a minimum of 2 cm away from the cervical os . There is risk of serious maternal haemo - rrhage , either as APH or during Caesarean section when the placental bed may not contract, or due to morbid adherence.

10. Placental abruption A placental abruption is separation of a normally sited placenta from the uterine wall. Has tow Presentation : revealed with vaginal bleeding. concealed, which present as uterine pain and potentially maternal shock or fetal distress without obvious bleeding.

11. Risk factors for placental abruption: Hypertension Smoking Trauma to abdomen Cocaine use Anticoagulant therapy Polyhydramnios and multiple gestation FGR High parity sudden decompression of the uterus (e.g. after rupture of the membrane in polyhydramnios ).

12. Clinical presentation and diagnosis The classical presentation is that of abdominal pain, vaginal bleeding and uterine contractions, often close to term or in established labour. maternal shock and/or collapse. Abdominal palpation typically reveals a tender, tense uterus ‘woody hard’. The fetus is often difficult to palpate. fetus may be dead, in distress or unaffected. The diagnosis is usually made on clinical grounds.

13. Management: resuscitated using approach of ABC. 2 14-gauge intravenous lines . Full blood count and clotting studies. Test for renal function and liver function tests. Cross-match at least 6 units of blood. Fluid resuscitation intravenously. Foley catheter into the bladder and fluid balance chart.

14. In very severe cases, the fetus will be dead and vaginal delivery can be accelerated by artificial rupture of the membranes. If the fetus is alive, delivery without compromising the mother’s resuscitation is urgent and this will usually be by Caesarean section.

15. Placenta praevia Vs Placental abruption pain abruption - constant placenta praevia - painless obstetric shock abruption - the actual amount of bleeding may be far in excess of vaginal loss placenta praevia - obsetric shock in proportion to amount of vaginal loss

16. uterus abruption - uterus is tender and tense placenta praevia - uterus is non-tender fetus abruption - normal presentation and lie placenta praevia - may have abnormal presentation and/ or lie

17. fetal heart abruption - fetal heart distressed/absent placenta praevia - in general, fetal heart normal associated problems: abruption - may be a complication of pre- eclampsia , may cause DIC. placenta praevia - small antepartum haemorrhage may occur before larger bleed

18. vasa previa Vasa praevia is rupture of fetal vessels running within the membranes, often near to the cervical os and damaged when the membranes rupture. it is catastrophic for the fetus as it is fetal blood that is lost

19. Risk factors: placenta praevia. a velamentous placental insertion. multiple pregnancy.

20. Management: When vasa previa ruptured cardiotocograph will rapidly become abnormal with a fetal tachycardia,followed by deep deceleration. the best solution is a high index of suspicion and rapid Caesarean section.

21. Thank you