ANTEPARTUM HAEMORRHAGE

Definition:

Bleeding from the genital tract after 22

weeks of pregnancy or during the 1st

stage of labor.

Classification:A. Placental Site Bleeding:

1. Placenta previa

2. Accidental haemorrhage.

B. Extra-Placental Bleeding:

1. Cervical erosion

2. Polyp

3. Carcinoma

4. Rupture of V. vein in the cervix

C. Rupture of Vasa Praevia – which is rare.

Placenta Praevia

DEFINITION:The placenta is implanted partially or totally on L.U.S.

INCIDENCE: 1:200

AE:1. Implantation of fertilized ovum in the isthmus.

2. Development of chorion in the decidua capsularis.

3. Abnormal large placenta.

DEGREES:1st degree: The lower edge of placenta reach the upper part of lower

uterine segment. Lateralis

2nd degree: The edge of the placenta reaches the int. OS but does not

cover the partially dilated cervix. Marginalis

3rd degree: Placenta is covered OS while the cervix partially dilated.

Incomplete centralis.

4th degree: Placenta is covered OS while cervix is completely dilated.

Complete centralis.

MECHANISM OF BLEEDING:

During labour sheering of placenta. due to uterine contraction.

CLINICAL PICTURE:

1. Painless2. Causeless3. Recurrent bleeding after 28 weeks.

SIGNSGeneral examination

◦ Depend on severity of bleeding ± anaemia

Abdominal examination◦ Nothing characteristic◦ Maybe malpresentation – non engagement head

Uterus is not tender Supra pubic fullness

Vaginal examination◦ Should not be done except in theatre◦ Vaginal examination is done when active treatment is indicated

Active Treatment will be done:1. Fetal maturity2. During labor (patient in labour)3. Severe bleeding.

INVESTIGATION:

1. Ultrasound – accurate

2. Radiology – this is in the past

3. Soft tissue placentography◦ Amniography – radio opaque substance

◦ Detection of fetal head displacement

◦ Public angiography

◦ Cystography – inject sodium iodide 12.5.

4. IV radio active istope

5. Thermography

TREATMENT

A. At home: In case of emergency

1. Cervix generally – no PV

2. Sterile vulval pad

3. Morphine + transfer to hospital

B. At Hospital:

1. Antenatal record – all investigation should be done including coagulation profile

2. Blood transfusion if needed

3. Abdominal examination

C. Not in Labour:

1. Severe bleeding – Cesarean section.

2. Mild bleeding.

Expect ttt less than 37 weeks do U/S

IN LABOUR:

ARM & Syntocinon Cesarean Section

1. Vertex 1. G. III, IV

2. Engaged head 2. Post p.p.

3. Degree I – III ant 3. Sever bleeding

4. OS opened 4. Not stop with ARM

5. Mild or moderate bleeding 5. Others as CPD

MANAGEMENT OF 3RD STAGECareful observation due to p.p. haemorrhage.

COMPLICATION:

Maternal:

During pregnancy

- ant. P. haemorrhage

- malpresentation

- prematurity

During labour

1st stage: - haemorrhage

- slow dilatation of cervix

- inertia

- PRM

2nd stage: - laceration of cervix

3rd stage: - p.p. haemorrhage

- retain part of placenta

DURING PEURPERIUM:1. Puerperal sepsis2. Sub involution

FOETAL:3. Perinatal mortality 10 – 15%4. Prematurity5. Fetal malformaiton 3-4%6. Asphyxia due to:

Anaemia hypoxia Separation of placenta Compression of placenta Prolapse cord

ACCIDENTAL HAEMORRHAGE

(Abruptio Placenta)

DEFINITION

Separation of normally situated placenta after 22 weeks gestation.

TYPES:

◦ Ext. (Revealed) Mild

◦ Concealed Severe

◦ Combined Moderate

INCIDENCE

1. About 1%

2. Severe form are seen more in primigravida

AE:

1. Toxaemia: 25 – 60%

◦ Spasm of vessel degenerage change.

◦ Rupture Hge

Toxaemia increased in patient with severe type

NON-TOXAEMIA: Trauma as ECV

Circumrellate placenta

Traction on cord

Sudden increased in IUP as R.M. in case of hydramnios

Vit. C, K, E, deficiency

Folate deficiency

Detachment of placenta after delivery of 1st twin.

PATHOLOGY:

All degree of placenta separation can occur from few millions to whole

placenta

Degeneration change in the decidual rupture haemorrhage in the decidual

basalis

A. 1. Decidual than splits

2. Leaving then layer adherent to myometrium

3. Decidual haematoma separation compression

B. Utero-placenta apoplexy (couviar’s ut)

C. Coagulation Defect

1. DIC low thromboplastin + fibrimolysin high FDP

2. Fibrinolysis

INVESTIGATION:

1. Urine analysis albumin PET

2. Fibrinogen

3. FDF Reveled

Clinical Picture

Symptoms:

4. Vaginal bleeding – dark, not severe

5. Tender abdomen

6. History of trauma

Sign:

A. General examination – hypertensive ± shock amount of blood.

1. Sign of hypertensive state of pregnancy

2. Shock if present

B. Abdominal examination

1. Nothing

2. Uterus is normal in size and consistency

3. Fetal parts are easily felt

4. F.H.S positive.

CLINICAL PICTURE Concealed antepartum haemorrhage

SYMPTOMS

Severe abdominal pain = abdominal dist.

Shock N + He

SIGN:

General Examination

Shock – concealed blood

- partly due to over distended uterus

Pulse rapid, BP subnormal, Temp. subnormal, Oedema

Abdominal examination:

Large uterus

Uterus hard & tender & rigid

F.H.S. are not heart

Vaginal examination:

No bleeding

Cervix is dilated

TREATMENT

REVEALED

Not in labor In labor

Before 37 After 37 active treatment OR CS in severe bleeding

Expected treatment

- RM uterine distension CS in cases of Prevent utero-renal reflex severe bleeding

Fetal distressOxytocin

CONCEALED

Living Dead – promote early CS vaginal delivery by:

* RM & Oxytocin* Clot observation

PROGNOSIS

A. Maternal

In the past, the maternal mortality was high now 1%

The maternal prognosis depend on:

1. Extent of placenta separation

2. Degree of coagulation defect

3. Degree of utero pl. apoplexy

4. Revealed or concealed haemorrhage

5. Adequacy of treatment

B. Fetal

100% in severe type

30 – 50% in revealed type

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