APH.pptx

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1. ANTEPARTUM HAEMORRHAGE Pre pare d by- JOISY S JOY Lecturer Mai Khadija Institute of Nursing Sciences , Jodhpur.

2. Introduction Death from hemorrhage still remains a leading cause of maternal mortality. APH is defined as bleeding from the genital tract in pregnancy from the age of viability(24 week’s gestation –WHO) and the onset of labour . It affects 4% of all pregnancies. It is a medical emergency. It is associated with increased risks of fetal and maternal morbidity and mortality.

3. Causes

4. PLACENTA PREVIA Is defined as the implantation of placenta partially or wholly in the lower uterine segment. About one-third cases of antepartum hemorrhage belong to placenta previa. The incidence of placenta previa ranges from 0.5–1% amongst hospital deliveries. In 80% cases, it is found in multiparous women.

5. Etiology The exact cause of implantation of the placenta in the lower segment is not known. The following risk factors are identified: Advancing maternal age Multiparity Multifetal /multiple gestations Prior caesarean delivery Smoking Prior placenta previa Uterine structural anomaly Assisted conception

6. Types or degrees Type—I (Low-lying): the placental edge is in the lower uterine segment but does not reach the internal os Type—II (Marginal): The placenta reaches the margin of the internal os but does not cover it. Divided into anterior and posterior. Type—III (Incomplete or partial central): The placenta covers the internal os partially (covers the internal os when closed but does not entirely do so when fully dilated). Type—IV (Central or total): The placenta completely covers the internal os even after it is fully dilated.

7. Cause of bleeding Bleeding results from small disruptions in the placental attachment during normal development and thinning of the lower uterine segment As the placental growth slows down in later months and the lower segment progressively dilates, the inelastic placenta is sheared off the wall of the lower segment. This leads to opening up of uteroplacental vessels and leads to an episode of bleeding.

8. Clinical features Bleeding: usually mild but it could be severe; recurrent, painless and causeless. Soft and non-tender uterus Normal fetal heart rate (unless there is severe bleeding or associated abruption). High presenting part. Fetal malpresentation (breech/transverse/oblique). General condition and anemia are proportionate to the visible blood loss

9. Abdominal examination The size of the uterus is proportionate to the period of gestation The uterus feels relaxed, soft and elastic without any localized area of tenderness. Persistence of malpresentation. There is also increased frequency of twin pregnancy. The head is floating in contrast to the period of gestation. The head cannot be pushed down into the pelvis. Fetal heart sound is usually present. Vulval inspection: the blood is bright red as the bleeding occurs from the separated utero-placental sinuses close to the cervical opening and escapes out immediately Vaginal examination is contraindicated

10. DIAGNOSIS: Painless and recurrent vaginal bleeding in the second half of pregnancy should be taken as placenta previa unless proved otherwise. Ultrasonography is the initial procedure either to confirm or to rule out the diagnosis . Localization of placenta Sonography Transabdominal ultrasound (TAS) Transvaginal ultrasound (TVS) Transperineal ultrasound Color Doppler flow study Magnetic resonance imaging (MRI) Clinical By internal examination (double set up examination) Direct visualization during caesarean section Examination of the placenta following vaginal delivery

11. Management PREVENTION: Adequate antenatal care Antenatal diagnosis at 20th week Significance of “warning hemorrhage” should not be ignored TREATMENT ON ADMISSION IMMEDIATE ATTENTION: Overall assessment of the case is quickly made as regards: Amount of the blood loss — by noting the general condition, pallor, pulse rate and blood pressure; Blood samples are taken for group, cross matching and estimation of hemoglobin;

12. A large-bore IV cannula is sited and an infusion of normal saline is started and compatible cross matched blood transfusion should be arranged; Gentle abdominal palpation to ascertain any uterine tenderness and auscultation to note the fetal heart rate Inspection of the vulva to note the presence of any active bleeding. FORMULATION OF THE LINE OF TREATMENT: The definitive treatment depends upon the duration of pregnancy, fetal and maternal status and extent of the hemorrhage.

13. Expectant management The aim is to continue pregnancy for fetal maturity without compromising the maternal health. Conduct of expectant treatment: Strict Bed rest; Investigations—like hemoglobin estimation, blood grouping and urine for protein are done; Periodic inspection of the vulval pads and fetal surveillance with USG at interval of 2–3 weeks; Supplementary hematinics should be given and the blood loss is replaced by adequate cross matched blood transfusion, if the patient is anemic; Steroid for lung maturation if gestational age is less than 34 weeks Use of tocolysis (magnesium sulfate) can be done if vaginal bleeding is associated with uterine contractions; Rh immunoglobin should be given to all Rh negative (unsensitized) women

14. Active management- delivery Cesarean delivery is done for all women with sonographic evidence of placenta previa where placental edge is within 2 cm from the internal os . It is especially indicated if it is posterior or thick

15. Complications MATERNAL During pregnancy: Antepartum haemorrhage, Malpresentation, Preterm labour. During labour: PROM, Cord prolapse, Intrapartum hemorrhage , Increased incidence of operative interference, Postpartum hemorrhage , Retained placenta, Shock. Puerperium: Sepsis, Subinvolution, Embolism FETAL: Low birth weight, Asphyxia, Intrauterine death, Birth injuries

16. ABRUPTIO PLACENTAE It is one form of antepartum hemorrhage where the bleeding occurs due to premature separation of normally situated placenta after the age of viability. Occurs in 1-2% of all pregnancies Perinatal mortality rate associated with placental abruption was 119 per 1000 births compared with 8.2 per 1000 for all others.

17. Types Revealed : Following separation of the placenta, the blood comes out of the cervical canal to be visible externally. Concealed : The blood collects behind the separated placenta or collected in between the membranes and decidua. Mixed : In this type, some part of the blood collects inside (concealed) and a part is expelled out (revealed).

18. Clinical classification Grade—0 : Clinical features may be absent. The diagnosis is made after inspection of placenta following delivery. Grade—1 (40%): ( i ) Vaginal bleeding is slight (ii) Uterus: irritable, tenderness may be minimal or absent (iii) Maternal BP and fibrinogen levels unaffected (iv) FHS is good. Grade—2 (45%): ( i ) Vaginal bleeding mild to moderate (ii) Uterine tenderness is always present (iii) Maternal pulse ↑, BP is maintained (iv) Fibrinogen level may be decreased (v) Shock is absent (vi) Fetal distress or even fetal death occurs. Grade—3 (15%): ( i ) Bleeding is moderate to severe or may be concealed (ii) Uterine tenderness is marked (iii) Shock is pronounced (iv) Fetal death is the rule (v) Associated coagulation defect or anuria may complicate

19. Risk factors The primary cause of placental abruption is unknown, but there are several associated conditions. Increased age and parity Preeclampsia Chronic hypertension Preterm ruptured membranes Multifetal gestation Hydramnios Cigarette smoking Folic acid deficiency Thrombophilias Cocaine use Prior abruption Uterine leiomyoma External trauma

20. Clinical presentation Bleeding: revealed/concealed, so clinical picture is important. Pain on the uterus and this increases in severity. Signs of shock ( hypovolaemia ): fainting and collapse. Woody hard tender uterus ( uterine tetany). Couvelaire uterus (Bluish uterus) Difficult to palpate the fetal parts and to hear the fetal heart. Normal fetal lie and presentation Ultrasonography: is done to confirm fetal viability, assess fetal growth & normality, measure liquor.

21. Management Treatment for placental abruption varies depending on gestational age and the status of the mother and fetus. Hospitalize History & examination Assess blood loss IV access, X match, DIC screen Assess fetal well-being Placental localization

22. Complications MATERNAL: Shock, Blood coagulation disorders, Oliguria and anuria, Postpartum haemorrhage, Puerperal sepsis, Acute renal failure: acute tubular or cortical necrosis. FETAL: IUGR, Anaemia, Premature delivery, Fetal distress and death