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  • 1. Antepartum Haemorrhage Saad Bin Zafar Mahmood
  • 2. Definition Hemorrhage from the vagina after the 24th week of gestation till end of pregnancy Blood loss of greater than 300mls Incidence : 3-5% of all pregnancies
  • 3. Antepartum Haemorrhage:Types Simple: ◦ Local  Vagina – Trauma  Cervical – Infection or tumor - Blood dyscrasias  Thrombocytopenia  Anticoagulants Complicated: ◦ Abruptio Placentae ◦ Placental praevia ◦ Vasa Praevia
  • 4. Abruptio Placentae Premature separation of the placenta. Pathophysiology of placental abruption: ◦ Bleeding into the decidua basalis layer ◦ Hematoma forms causing further placental separation ◦ Fetal blood supply is further compromised ◦ Complication - Couvelaire Uterus (Retroplacental blood goes into the peritoneal cavity)
  • 5. Classification Clinical classification Class 0 - Asymptomatic Class 1 - Mild (represents approximately 48% of all cases) Class 2 - Moderate (represents approximately 27% of all cases) Class 3 - Severe (represents approximately 24% of all cases)
  • 6. Placental abruption: types Placental abruption can be broadly classified into two types: ◦ Revealed ◦ Concealed ◦ Mixed
  • 7. Presentation Symptoms ◦ Vaginal bleeding - 80% ◦ Abdominal or back pain and uterine tenderness - 70% ◦ Fetal distress - 60% ◦ Abnormal uterine contractions (eg, hypertonic, high frequency) - 35% ◦ Idiopathic premature labor - 25% ◦ Fetal death – 15%
  • 8. Presentation Physical Examination ◦ Should be done after stabilizing the patient ◦ Ultrasound should be done first to assess the location of placenta. Only then should a digital pelvic exam be conducted ◦ Profuse bleeding in waves ◦ Uterine contraction / Uterine hypertonus ◦ Shock ◦ Absence of fetal heart sounds ◦ Increased fundal height (due to hematoma)
  • 9. Risk factors of AbruptioPlacentae ◦ Maternal hypertension ◦ Maternal trauma ◦ Cigarette smoking ◦ Alcohol consumption ◦ Cocaine use ◦ Short umbilical cord ◦ Maternal age <20 or >35 years ◦ Low socioeconomic status ◦ Elevated second trimester maternal serum alpha-fetoprotein (associated with up to a 10- fold increased risk of abruption) ◦ Previous placental abruption
  • 10. Investigations Laboratory studies ◦ CBC ◦ PT & APTT ◦ Fibrinogen levels ◦ BUN / creatinine Imaging studies ◦ Transvaginal ultrasonography ◦ Transabdominal ultrasonography
  • 11. Complications of Abruptio placentae - Maternal Can lead to DIC
  • 12. Complications of Abruptio placentae –Fetal  Fetal complications include ◦ Hypoxia or hypoxic-ischemic encephalopathy (HIE) ◦ growth retardation ◦ CNS abnormalities ◦ Intra uterine death.
  • 13. Placenta praevia Implantation of placenta over the internal cervical os and therefore in front of the presenting part Pathophysiology ◦ Delay in implantation of blastocyst so that it occurs in the lower part of uterus ◦ In third trimester isthmus of uterus thins to form lower uterine segment ◦ Placental attachment is disrupted as the area gradually thins in preparation of the onset of labor ◦ This leads to bleeding from the venus sinuses
  • 14. Placenta previa: types Complete placenta previa Partial placenta previa Marginal placenta previa (placenta approaching the border of os)
  • 15. Grading of placenta previa: Grade I – The placenta is in the lower segment, but the lower edge does not reach the internal os. Grade II – The lower edge of the low-lying placenta reaches, but does not cover the internal os. Grade III – The placenta covers the internal os. Grade IV – The placenta covers and entirely surrounds the internal os
  • 16. Presentation Symptoms ◦ Painless vaginal bleeding ◦ Bleeding stops spontaneously and recurs with labor ◦ Malpresentation (Breech, transverse lie) Physical Exam ◦ Digital exam is contraindicated ◦ Uterus is soft and non tender ◦ Concurrent contractions with bleeding are present
  • 17. Placenta previa : Risk factors Previous placenta previa. Multiple pregnancies- due to the placenta occupying a large surface area. Cigarette smoking Increased maternal age Uterine scar (previous caesarean section) Endometritis
  • 18. Investigations Laboratory studies ◦ CBC ◦ PT & APTT Imaging studies ◦ Transvaginal ultrasonography ◦ Transabdominal ultrasonography
  • 19. Abruptio Placentae Placenta PreviaPain Abdominal pain, low back pain Painless unless in labour Nontender, soft (unlessUterus Tender, irritable contracting) Not associated with abnormalPresentation Breech or high presenting part presentation Fetal heart tracing abnormal, Fetal tracing not affected sinceFetus atypical blood is maternal Shock/anemia out of Shock/anemia proportionateShock proportion to amount of to blood seen blood seenImaging U/S cannot rule out U/S sensitive
  • 20. Differential DiagnosisAbruptio Placentae Placenta PreviaLabour with bloody show Abruptio PlacentaeVasa previa CervicitisVaginal trauma Premature rupture of membranesVaginitis VaginitisPreterm labour Preterm labour
  • 21. Non Placental causes of APH
  • 22. Vasa previa: Vasa previa is a condition when fetal vessels traverse the fetal membranes over the internal os. These vessels course within the membranes (unsupported by the umbilical cord or placental tissue) and are at risk of rupture when the supporting membranes rupture.
  • 23. Management of AntepartumHemorrhage
  • 24. Initial management Assessing the airways: Assessing the breathing: Assessing the circulation Cannula inserted for ◦ Drug adminstration ◦ Blood sampling ◦ IV fluid adminstration
  • 25. Placenta previa If uncomplicated pregnancy no need of intervention Vitamins and Iron supplements should be taken If minimal bleeding expected management may be continued If needed tocolytics may be considered to administer antenatal steroids Before the delivery the following should be consulted ◦ Obstetric anesthesiologist ◦ Interventional radiologist ◦ General surgeon ◦ Urologist
  • 26. Placenta previa If placental edge is more than 2cm from internal cervial os trial of labour can be offered. If the distance is less than 2cm cesarian section is done although an SVD can be done Delivery is mostly done at 36-37 weeks of gestation Low transverse uterine incision is used If the patient is at risk of invasive placentation than informed consent should be taken for cesarian hysterectomy
  • 27. Abruptio placentae Vitamins and Iron supplements should be taken Initial management Transfusion, correction of coagulopathy and Rh immune globulin if needed Cesarian section preferable mode of delivery ◦ Vertical incision ◦ Hysterectomy might be needed if severe blood loss Tocolytics may be used in case of preterm delivery only if ◦ Hemodynamically stable ◦ No fetal distress ◦ Preterm fetus may benefit from corticosteroid therapy
  • 28. Types of tocolyticsTypes of TocolyticsB2 agonistCalcium channel blockersOxytocin antagonist – AtosibanNSAIDs
  • 29. Uterine rupture-management It is an emergency Laprotomy is urgently done Uterine rupture can be an antepartum or postpartum event
  • 30. Vasa previaWhen vasa previa is diagnosed antenatally, an elective Caesarean section should be offered prior to the onset of labour. In cases of vasa previa, premature delivery is most likely, therefore, consideration should be given to administration of corticosteroids at 28 to 32 weeks
  • 31. Antepartum hemorrhage Massive bleeding Call for help Evaluate ABCs Administer IV fluids Consider transfusion Consider CS History and Physical Examination Fetal monitoringNormal Bloody Severely Uterine pain ?? Inflamed cervix or show distressed fetus mucopurulent discharge Routine Suspect Vasa No pain or pain only Pain between Probable cervical Evaluation Previa with contractions. contractions and infection Non tender fundus tender fundus Culture and treat as appropriate Suspect Placenta previa Consider abruptio placentae Consider uterine Immediate rupture ultrasound examination if Monitor fetus. available Supportive mother care Urgent Cesarean Cesarean delivery Cesarean if fetal Consider urgent SVD if fetal death delivery if in labour distress lapartomy