APH lecture.ppt ad it's surgical management

Diagnosis

1. ANTEPARTUM
HAEMORRHAGE
BY
COL O NDOLA

2. 2
Definition of APH
This is defined as bleeding from the
genital tract between the 28th week of
pregnancy and the onset of labour.

3. 3
Causes of APH
Placenta praevia
Placental abruption
Local causes
Undetermined origin
Vasa praevia

4. 4
Placenta Praevia
A placenta that is implanted entirely or
in part, in the lower uterine segment.

5. 5
Grades of Placenta
Praevia
Type I-placenta encroaches on the
lower uterine segment but does not
reach the internal cervical os.
Type II-placenta reaches the edge of
the cervix, but does not cover it.
Type III-placenta covers the cervix but
not at full cervical dilatation.

6. 6
Grades of Placenta
Praevia
Type IV-placenta is symmetrically
implanted in the lower uterine
segment and covers internal os at full
dilatation
Types I & II are minor praevias -as
the lower segment develops, may
become normally situated.
Types III & IV are major praevias

7. 7
Placenta Praevia
Causes are frequently unclear and the
low site of implantation may merely
represent an accident of nature
Associations include: older multiparous
women, multiple pregnancy and
previous uterine damage such as C/S

8. 8
Clinical presentation of
Placenta Praevia
Two classical presentation are of APH
or as fetal malpresentation in late
pregnancy. Can be asymptomatic and
routinely picked up on U/S.
Recurrent painless bleeding is the
typical history
Patient is usually stable unless there
has been a major bleed

9. 9
Clinical presentation of
Placenta Praevia
The uterus is soft and non tender
High head on presentation or
malpresentation-breech, transverse or
oblique lie
FHHR

10. 10
Diagnosis of Placenta
Praevia
History
Clinical examination
U/S
EIT-examination in theatre -full
preparation for C/S

11. 11
Management of Placenta
Praevia
Depends on stage of pregnancy and
extent of haemorrhage
Minor praeviawith minimal or no
bleeding -conservative management.
Aim to deliver at 38 weeks gestation.
Mode of delivery will depend on EIT
findings. If minor, then vaginal
delivery can be attempted unless it’s a
posterior placenta praevia.

12. 12
Management of Placenta
Praevia
Major placenta praevia, if
asymptomatic or minimal bleeding -
then aim to deliver at 38 weeks
gestation. EIT? Delivery is by C/S.
Any type of praeviaassociated with
severe haemorrhage should be
delivered by the quickest mode -C/S-
regardless of gestation age.

13. 13
Placental Abruption
The premature separation of a
normally situated placenta
The basic cause is unknown
Is a self extending process with the
accumulating blood clot causing more
separation and thus more
haemorrhage, until the edge of the
placenta is reached

14. 14
Placenta Abruption cont’d
Blood then escapes through the
potential space between the chorion
and decidua until it reaches the cervix
Blood can also reach the amniotic
cavity (by disrupting the placenta,
producing blood-stained liquor) and
the myometrium (causing a couvelaire
uterus)

15. 15
Complications of
Abruption
Fetal hypoxia or death -because of
the extent of placental separation
Haemorrhagic shock
Renal damage -acute tubular or
cortical necrosis
DIC
PPH

16. 16
Associations of Abruption
Hypertension-cause or consequence?
Sick placenta-excessive fetomaternal
transfer of AFP in mid pregnancy &
diminished ‘adhesiveness”
Previous history of abruption-risk of
recurrence ten fold
Trauma-RTA, assault, ECV,
cordocentesis

17. 17
Associations of Abruption
cont’d
Fibriods -where site of placental
attachment covers a fibroid, increased
risk of abruption
PROM esp with sudden decompression
as with polyhydramnios
Multiple pregnancy -cause is unclear

18. 18
Clinical presentation of
Abruption
Bleeding may be concealed or
revealed
Pain over the uterus with no
associated periodicity
Uterus is extremely hard and tender &
it does not relax. The HOF is large for
dates in concealed haemorrhage

19. 19
Clinical presentation of
Abruption cont’d
Fetal parts are difficult to palpate and
the FH may be inaudible
Faintness & collapse may occur, as
may signs of shock

20. 20
Diagnosis of Abruption
History
Examination & demonstration after
delivery, of a retroplacental clot
indenting the placental surface
U/S -has a minimal role in placental
abruption

21. 21
Management of Abruption
cont’d
Principles of management are:
«early delivery
«adequate blood transfusion
«adequate analgesia
«detailed monitoring of maternal & fetal
condition

22. 22
Management of Abruption
cont’d
Early delivery is vital & if the baby is
alive and the gestation age favors
extra uterine survival, delivery should
be by C/S even if the fetus is not
hypoxic.
If the fetus is dead, vaginal delivery is
preferred unless there is severe
haemorrhage and mother’s life is at
stake.

23. 23
Management of Abruption
cont’d
X-match at least 4 units of whole
blood, FFP
Clotting profile -bedside clotting
-fibrinogen levels
-platelets
Active management of third stage

24. ACTIVE MANAGEMENT OF THE
THIRD STAGE OF LABOUR
This has three components:
1.Administration of Oxytocin –to
enhance uterine contractions
2.Clamping the cord early –usually
before, alongside, or immediately
after giving the Oxytocin
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25. 3. Controlled cord traction is applied
with counter-pressureonthe uterus in
order to deliver the placenta
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