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1. VAGINAL BLEEDING IN LATE PREGNANCY (APH) Basic Obstetrics - 202 4 DR. DAVID BREWEN CONTEH

2. Signs of haemorrhage How much blood does a pregnant woman have? Bloodloss BP Signs 10% 500 ml Normal Tachycardia 25% 1250 ml Normal Weak, tachycardia, cold skin 30- 35% > 1500 ml Systolic 70 - 80 mmHg Shock! Tachycardia, sweating, pallor

3. Any bleeding from the genital tract after 22 weeks Incidence is about 4% of all pregnancies All cases are to be admitted in the hospital and should be handled as a MEDICAL EMERGENCY ! Definition of APH

4. Causes of Bleeding in Late Pregnancy ??

5. Life- Threatening Causes of Bleeding in Late Pregnancy Placenta praevia Abruption Uterine rupture Vasa praevia ‘Bloody show’ Cervix: ectopy; cervicitis; polyp; carcinoma Vaginal trauma The cause of APH often remains ‘INDETERMINATE’

6. Medical approach - APH A B C Pulse, blood pressure, temperature Assess fundal height (GA), ANC book? Fetal lie (abnormal?) Ultrasound: vital?, position of placenta, estimate fetal weight NO digital vaginal exam unless placental location known

7. Placenta previa What are the symptoms?

8. Placenta previa Painless bleeding 2nd or 3rd trimester or at term often following sexual intercourse Occasionally preterm contractions FHR usually present

9. Placenta previa

10. Marginal previa

11. Treatment – Placenta previa Preterm (< 37 weeks GA) With no active bleeding expectant management no intercourse or digital examination With ongoing heavy bleeding Assure patient circulatory stable, CM blood C/S indicated With slight bleeding?

12. Treatment – Placenta previa Term (after 37 weeks GA) C/S indicated Also if the baby is dead! Have in mind: Placenta previa anterior High blood loss expected Has a higher risk to be a placenta increta

13. Placental Abruption

14. Placental Abruption What are the symptoms?

15. Patient History - Abruption Pain = ‘hallmark’ symptom (but not always present) mild cramp to severe pain back pain – think posterior abruption uterus may be “tense and tender” or “woody” frequent, palpable contractions Uterus is “irritable” FHR usually not present

16. Placental Abruption Why.. .. pain .. dead fetus .. dark blood

17. Placental Abruption

18. Epidemiology of Abruption Occurs in up to 1% of pregnancies Can be complete or partial Risk factors hypertensive diseases of pregnancy previous history of abruption Smoking / cocaine trauma overdistension of the uterus Malaria

19. Bleeding with Abruption Amount of “revealed” bleeding may be misleading Bloody amniotic fluid Retroplacental clot (“concealed” haemorrhage) Risk of disseminated intravascular coagulopathy (DIC)

20. Approach – placental abruption Assess maternal (and fetal) stability If possible delay delivery to stabilize patient and to find blood products May require C/S (review fetal/maternal status) – Blood loss is often underestimated – early resort to transfusion Prepare for massive PPH Prepare for neonatal resuscitation

21. Uterine Rupture History of previous C/S Excessive uterine stimulation with Oxytocin Prior rupture Previous uterine surgery Trauma Multiparity Malpresentation (Shoulder dystocia) Be aware rupture may have ocurred even if baby is already delivered vaginally! (uncontrolled PPH!)

22. Signs of Impending Uterine Rupture Maternal tachycardia – this may be the only sign FHR changes / IUFD Vaginal bleeding Continuous pain Haematuria Any of these may be the only presenting feature

23. Signs of manifest Uterine Rupture Contractions stop Acute fundal height changes or absence of FHR Loss of engagement of head Palpable fetal parts through maternal abdomen Profound maternal tachycardia and hypotension Vaginal bleeding

24. Pain Timing Fetal heart Blood Uterus Placenta previa No contractions Before labour + Bright red blood Soft Abruption Painful contractions, no pause During labour +/- Dark red blood Hard Uterine rupture Abdominal tenderness During prolonged/ obstructed labour - Dark but often very little or absent Irregular Differences of Placenta previa, abruption and uterine rupture