APH for class.pptx

antepartum haemorrhage
pregnancy and blood loss

1. ANTEPARTUM H AEMORRHAGE Dr Poonam Professor. Department of Obst .& Gynae

2. APH Its bleeding from genital tract after 28weeks of pregnancy but before the birth of the baby. After the Period of viability. (24/ 22weeks) Includes 1 st and 2 nd stage. 3% among hospital deliveries.

3. Causes of APH

4. Causes of APH

5. APH Extra placental causes : Cervical polyp Carcinoma cervix Varicose vein Local trauma. Unexplained

6. Placenta previa When placenta is implanted partially or completely over the lower uterine segment. Incidence: 0.5-1% Risk factor: elderly pt.( >35yrs) Multiparous Multiple pregnancies. Privious CS or any other scar in uterus. Placental abnormality –size or accenturiate lobe

7. Placenta previa

8. Placenta previa

9. Placental anomaly

10. Vasa previa

11. Lower uterine segment Anatomical definition : part developed from antomical and hystological internal os . thinner than upper segment. passive part. Stretching and thinning occur. (upper segment becomes thicker and smaller due to contraction and retraction. Radiological diagnosis . Part behind bladder .5cm above int os . Surgical :Behind loose peritoneum. Clinical : P/V 7.5 cm above ex os

12. Lower uterine segment

13. Lower uterine segment

14. Lower uterine segment

15. Lower uterine segment

16. Placenta previa Etiology :not known Theories Drop down theory- embryo grow in the lower part of uterus. Persistent chorionic activity ; in decedua capsularis . Defective decedua : membranous placenta Big surface area; multiple pregnancy

17. Type or degrees of placenta previa

18. Type or degrees of placenta prev Type 1 : low lying Type2: marginal Type3: incomplete central Type4: complete central. Clinical classification Mild : type 1 and Type 2 anterior. Severe : type 2 posterior. 3 and 4

19. Placenta previa Type 2 posterior is also called dangerous placenta previa Thickness of placenta 2.5 cm prevents engagement of head. Facilitate more bleeding. Placenta will be compressed if allowed to deliver vaginaly . More chance of cord prolapse or compression

20. Placenta previa Causes of bleeding in placenta previa As lower segment progressively dilates, in -elastic placenta is sheared off from the wall of the lower segments-opening of uteroplacental vessels. Mechanical injury to placenta – examination, ECV, rupture of membrane, coital act . Blood loss is mostly maternal.

21. Placenta previa

22. Placenta previa –clinical feature Symptoms Vaginal bleeding Sudden onset, painless, causeless, recurrent. 5% during onset of labour 50% have warning haemorrhage. Before 38weeks earlier bleeding in major degree. But in central placenta there may not be any bleeding till labour starts. Diagnosed by routine USG

23. Placenta previa –clinical feature Signs: anaemia proportional to amount of blood loss. (may be more in pre existing anaemia pt) Abdominal examination size of uterus: proportional to period of gestation soft, relaxed mal-presentation common. head free,not engaged. FSH: +/- ve . Stallworthy’s sign

24. Placenta previa –clinical feature NO VAGINAL EXAMINATION SHOULD BE DONE Inspection : bright red . Clothing/ body blood soaked.

25. Placenta previa –clinical feature DIAGNOSIS: Sonography - Abdominal USG . May be difficult in obese, posterior placenta. Overfull bladder . Myometrial contraction How to diagnose L.S ? Below the level of uterovesical fold of peritoneum. 5cm above internal os

26. Placenta previa –clinical feature TVS: superior resolution Color doppler flow study: prominant venous flow near int. Os. MRI: non invasive, no radiation. (excellent but costly)

27. USG findings

28. USG findings

29. USG-colour doppler

30. Placenta previa –clinical feature If USG not available /doubtful finding Examination in OT under GA --Double setup Boggy mass felt through fornices . placenta feels tough and firm contrast to blood clot feels soft and friable. Differential diagnosis : accidental Haemorrhage, local causes

31. Placenta previa Complications: Haemorrage leading to shock Malpresentation Premature labour. Increase operative delivery PPH due to –imperfect retraction of LUS, large surface area, atonic uterus for associated anaemia, placenta accreta Retained placenta. Sepsis

32. Placenta previa Fetal complication: Low birth wt. Prematurity. Birth asphyxia. IUD Associated with congenital malformation

33. Placenta previa –Management Antenatal;(diagnosed in routine checkup ) Adequate ANC Rpt USG at 34weeks Rule out accreta . Council pt for warning sign., hospital admission. Need for blood transfusion,Need for LSCS etc.

34. Placenta previa Plcental migration Lower segments expands from 0.5cm to 5cm by term. Placenta relatively grows away from os . Previa in early pregnancy may not be so at term

35. Placenta previa –Management If comes with bleeding Quick assessment Sent blood sample, arrange blood Two Large bore IV canula , infuse fluid. All examination should be gentle . Confirmation of diagnosis-USG Decide further management.

36. Management Management depends on amount of bleeding, condition of the pt, fetal condition and period of gestation Immediate resuscitation and termination beyond 37weeks IUD /with gross congenital anomaly shock/ continuous bleeding

37. Management Expectant management : ( Macafee Regimen) To continue pregnancy to achieve fetal maturity without compromising mothers health. Pre requisit : Availability of blood. Facility for CS

38. Expectant management : Pt selection Good health . Hb % >10gm%. HCT >30, <37weeks, assured fetal wellbeing

39. Expectant Management Bed rest, Blood investigation Close monitoring of bleeding, fetal survillence , haematinics. once bleeding stopped for 3-4days , gental vaginal inspection to rule out any local cause. Steroid injection for lung maturity if<34weeks Anti D injection, if Rh negetive .

40. Management-mode of delivery LSCS : Type 2 posterior./ type3 and Type 4 placenta. Pt in ex- sanguinated state, other obstetric indication like malpresentation Vaginal delivery: Minor degree PP. (Placenta 2-3cm away from os )

41. Management-mode of delivery Difficulty during CS Excessive bleeding due to incision over placenta. Open sinuses of lower segments bleeds as lower segment can not contract like upper segment.

42. Points to remember Definition. Causes of APH. Lower uterine segment Types of placenta previa Diagnosis Management.

43. Thank you