Antepartum haemorrhage

H hH hAntepartumAntepartum HaemorrhageHaemorrhage

Definition:Definition: •Vaginal bleeding from

24 weeks of gestation to delivery of the baby

•The incidence is 3% The incidence is 3%

CausesCauses:Placental causes

Most worrying as potentially the mother d /f t ’ lif i dand /fetus’ life in danger

These include : Placental abruption Placenta praeviaPlacenta praevia Vasa pravia

:LOCAL CAUSESCervicitis Cervical carinoma Vaginal trauma or infectiong

•Antipartum haemorrhage should be taken seriously and any women presenting with y y p gahistory of fresh vaginal bleeding must be

investigated promptly and properly Theinvestigated promptly and properly. The key question is whether the bleeding is

placental and compromising the motherplacental and compromising the mother and /or fetus ,or whether it has aless

significant cause .

•Normally,it will be obvious from looking at h th th it ti i ia women whether the situation is in

extremis or not

A pale,tachycardiac women looking anoxious with a painful,firm abdomen ,clothes soaked in fresha painful,firm abdomen ,clothes soaked in fresh

blood and reduced fetal movement needs emergency assessment and managementemergency assessment and management

.Awomen has little bleeding with no systemic signs or symptoms represent a different end ofsigns or symptoms represent a different end of

spectrum

HISTORHISTORy :How much the bleeding g?Triggering factors?Triggering factors? Associated pain or contraction?contraction?

Is the baby moving?

Last cervical smearLast cervical smear (date/normal or abnormal)?

EXAMINATIONEXAMINATIONEXAMINATION:EXAMINATION:Pulse , blood pressure

Is the uterus soft or tender and firm?

Fetal heart auscultation/CTGFetal heart auscultation/CTG Speculum vaginal examination ,

with a particular importancewith a particular importance placed on visualizing the

cervixcervix (Having established the placenta

is not apraevia preferablyis not apraevia ,preferably using a portable US machine

INVESTIGATION:INVESTIGATION:Depending on the degree ofDepending on the degree of

full blood countbleeding , and if suspected praeviaclotting and if suspected praevia ,clotting

pints 6 match-crossor abruption ,of blood

(fetal size presentationUS (fetal size, presentation, US aminotic fluid, placental position

and abruption)and abruption)

Abruptio placentaAbruptio placentaIt is premature separation of the normally implanted placentanormally implanted placenta complicates 0.5 to 1.5 percent of all p ppregnancies

Predisposing factor:1.Hypertention2 Trauma2.Trauma3 Polyhydromnios with rapid decompression3.Polyhydromnios with rapid decompression on membrane rupture4.Tobacco use5.Cocaine use6 PROM6.PROM7.Short umbilical cord7.Short umbilical cord

8.maternal age >35 yg y

9.Placenta previa9.Placenta previa

10 Poor nutrition and anemia10.Poor nutrition and anemia

Pathophysiology:Pathophysiology:Placental sepeparation is initiated by:p p yHemorrhage into decidua basalis-----formation of decidual hematoma------the resulting separation of the decidua from the basal plate---the basal plate

further separation and bleeding with gcompression and destruction of placental tissuetissue

Bl d P thBlood Pathways:‐

*concealed hemorrhageg

*revealed hemorrhage*revealed hemorrhage

*Couvelair uterus

Di iDiagnosis:

Is clinical diagnosisg

Symptoms:Symptoms:

fInvestigations:draw blood for

Hb,cross matching.complete blood picture pcvpicture .pcvFibrinogen levelgPartial thromboplastin timeP th bi tiProthrombin time

Pelvic examFetal monitoring

Benefit of ultrasonography??Benefit of ultrasonography??3:3:

fi-confirm -exclude-finding co exsiting pathology

Abruptio placentae Normal fetal ultrasound

Maternal and fetal risks

-fetus at significant risk of hypoxia d d thand death

-mortality rate 35%,A.p. account for 15% of stillbirth15% of stillbirth

50%have neurological impairment-50%have neurological impairment

DIC 20%_DIC 20%

-hypovolemic shock-hypovolemic shock acute renal failure and acute-acute renal failure and acute

tubular necrosis-· if the site of placental attachment starts to if the site of placental attachment starts to hemorrhage after the delivery and loss of blood cannot be controlled by other meansblood cannot be controlled by other means, a hysterectomy (removal of the uterus) may bbecome necessary.

T t t i tTreatment in steps

GENERAL MEASURES · Abruptio placentae is an emergency, but there is usually time to obtain advice yby telephone and arrange safe transportation to the hospital. Panic is p pnot helpful. If the placenta separation is slight, you may be able to return home for g , y ybed rest and close observation after examination. · Hospitalization required (except for mild cases). The mother will be carefully ) ymonitored for symptoms of shock and signs of fetal distress, which include gabnormal heart rates.

With careful monitoring of maternal hemodynamic status,fetal monitoring serial evaluation of hematocrit and coagulation profile

fBlood products for replacement should always be availableyLarge bore i.v line should be securedFoley’s catheter for the monitoring of urine outputurine outputFluid resuscitation with ringerFluid resuscitation with ringer lactate,blood(whole or packed cells)

Indications for cesarean section in abruptio placentae

Prognosis:F t i t d ith iFactors associated with poor prognosis following increase the risk for death in o o g c ease t e s o deatboth the mother and baby:1 Closed cervix1.Closed cervix2.Delayed diagnosis and treatment of y gplacental abruption3 Excessive blood loss leading3.Excessive blood loss, leading to shock4.Hidden (concealed) uterine bleeding in pregnancyin pregnancy5.No labor