• Bleeding from female genital tract after the 24th week of pregnancy before the birth of the baby (some define from 20th week and some up to 28th week )WHO• “ Bleeding from the female genital tract anytime after fetal viability but before delivery”• Incidence : 3-5% of all pregnancies 3 times more common in multiparous than nuliparous women .
Placenta - Physiology and function . Fetus entirely dependent on placenta until birth. . Maternal and fetal blood kept separate by placental barrier. . Protects the infant from infection and harmful substances. . Acts as endocrine organ - makes hormones to maintain pregnancy. . Made of 12-20 cotyledons. . Fetal blood transported to placenta via two umbilical arteries.
. Umbilical arteries get smaller and become arterioles then villi.. Villi suspended in pools of maternal blood in the lacunae.. Fetal blood returns to fetus via umbilical vein.
Placenta praevia Abnormally implanted placenta placed totally or partially in the lower segment of the uterus, rather than in the fundus. When the cervix begins to dilate and efface the placenta separates, allowing bleeding form the open vessels.
Placenta praevia: types • Complete placenta praevia • Partial placenta praevia • Marginal placenta praevia (placenta approaching the border of os )
Grading of placenta praevia: • 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 but not cover when os is dilated • Grade IV – The placenta covers and entirely surrounds the internal os even though os is fully dilated.
TYPES OF PLACENTA PREVIALOW LYING MARGINAL TOTALPARTIAL
Placenta praevia : Risk factors • Previous placenta praevia. • Multiple pregnancies- due to the placenta occupying a large surface area. • Mutiparity • Cigarette smoking • Increased maternal age • Endometritis • Previous caesarean section
Presentation Symptoms • Sudden, Painless ,Causeless recurrent vaginal bleeding (color Bright Red ) • No history of trauma to abdomen • Triggering factors may be present (e.g. Bleeding post coitus ) • Anemia symptoms which is proportionate visible blood loss (Tiredness, lassitude, weakness, dyspnoea, palpatation , pallor ) • Fetal distress but more dangerous for mother • In excessive blood loss >>> symptoms of shock ( faintness , tachycardia , hypotension , sweating ,cold & clammy extremities, oliguria, syncope
Physical Exam• Digital exam is contraindicated• Breech presentation or unstable lie or high presenting part• Soft and relaxed, non tender uterus which is proportionate to gestational age• Concurrent contractions with bleeding are present
Cervix PlacentaUterus A PLACENTA WHICH HAS IMPLANTED OVER THE OS
Midwifery Actions-Woman presents with painless bleeding• Calm attitude• Inform Obstetric staff• T, P, BP• CTG• Palpation• NO Vaginal Examination until location of placenta has been confirmed by ultrasound• Take history of amount of blood loss, explore possible causes.• Establish venous access• Take blood for Group & Matching, Full blood count, clotting IV fluids as prescribed
Midwifery Actions• Consider anxieties of woman in hospital with other children to care for• Possible visit to the neonatal unit• Include in discussions surrounding expectant birth date of the baby
Management• Assessing the airways, breathing, circulation• Cannula inserted for Drug administration ,Blood sampling ,IV fluid administration• In the absences of heavy vaginal bleeding , not in labour( B4 37 wk ) and bleeding stop spontaneously >>> Expectant Management• Ensure blood available• Monitor for anemia• Vitamins and Iron supplements should be taken• Anti D if Rh Neg• Steroids for fetal lung development
• If uncomplicated pregnancy no need of intervention• If needed tocolytics may be considered to administer antenatal steroids• Types of Tocolytics(anti-contraction medications or labour represents ) B2 agonist Calcium channel blockers Oxytocin antagonist – Atosiban NSAIDs Before the delivery the following should be consulted • Obstetric anesthesiologist • Interventional radiologist • General surgeon • Urologist
• Termination of Expectant Management when fetus is mature or dead or not compatible for life & mother is in danger ( heavy vaginal bleeding ) Normal spontaneous Vaginal delivery ???? OR Elective LSCS????
Possible complications• Uncontrollable bleeding• Anaemia• Infection• Renal failure due to severe shock• Hysterectomy• Sheehan’s syndrome as a result of severe shock(Damage to the pituitary gland – hypopituitarism)• Fetal hypoxia• Premature birth• Fetal death• Psychological effects
Abruptio Placentae Separation of the normally situated placenta from its uterine site of implantation after 20 weeks gestation, but before delivery of the placenta. ( Premature separation of the placenta )
Placental abruption: types • Placental abruption can be broadly classified into two types: • Revealed • Concealed • Mixed
Classification • Placental Grades : A . Grade 0 - Patient asymptomatic. Small retroperitoneal clot seen after delivery B. Grade 1 - Vaginal bleeding, may have abdominal tenderness or slight uterine tetany ,mom and baby not in distress. C. Grade 2 - Uterine tenderness, tetany with or without evidence of bleeding, baby shows signs of distress. D. Grade 3 - Uterine tetany , severe bleeding may not be visible. Baby is dead. Mom often has coagulopathy.
Risk factors of Abruptio Placentae• Trauma (Fall, accident, ECV )• Grandmutipra , Multiparity , Maternal hypertension• Sudden decompression of uterus – release of hydramnios ( after delivery of 1 st twin )• -Polyhydramnios with rapid decompression on membrane rupture• -cocaine use, tobacco use• -PPROM• -short umbilical cord , IUGR• Anti-coagulant threapy
Presentation • Symptoms • Vaginal bleeding - 80% ( Red or brown loss PV) • Abdominal or back pain and uterine tenderness - 70% • Abnormal uterine contractions (eg hypertonic, high frequency) - 35% • Idiopathic premature labor - 25% • Tense, firm uterus tender to palpate • Signs of shock • Reduced or excessive fetal movements • Fetal distress - 60% or no fetal heart • Fetal death – 15%
• 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 hypertonic • Shock • Absence of fetal heart sounds • Increased fundal height (due to hematoma)
Management• Stabilize the woman• T, P, BP• Full history• IV access• Blood for group & hold, Full blood count, Coag & Kleihauer if rh neg Caesarean Section Expectant Management • If unstoppable labour • If preterm • If fetal distress • No profuse haemorrhage • If life threatening Haemorrhage • Not life threatening • No fetal distress
Management • 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 • In case of fetal death mode of delivery is SVD
Complications of Abruptio placentae - Maternal Can lead to DIC
Complications of Abruptio placentae –Fetal • Fetal complications include • Hypoxia or hypoxic-ischemic encephalopathy (HIE) • growth retardation • CNS abnormalities • Intra uterine death.
Abruptio Placentae Placenta PreviaPain Abdominal pain, low back pain Painless unless in labourUterus Tender, irritable Nontender, soft (unless contracting) Not associated with abnormalPresentation Breech or high presenting part presentation Fetal tracing not affected since blood isFetus Fetal heart tracing abnormal, atypical maternal Shock/anemia out of proportion to Shock/anemia proportionate to bloodShock amount of blood seen seenImaging U/S cannot rule out U/S sensitive
Uterine rupture-management • It is an emergency • Laparotomy is urgently done • Uterine rupture can be an antepartum or postpartum event
Vasa praevia• When vasa praevia is diagnosed antenatally, an elective Caesarean section should be offered prior to the onset of labour.• In cases of vasa praevia, premature delivery is most likely, therefore, consideration should be given to administration of corticosteroids at 28 to 32 weeks
Antepartum hemorrhage Massive bleeding Call for help Evaluate ABCs Administer IV fluids Consider transfusion Consider CS History and Physical Examination Fetal monitoring Normal Bloody Severely distressed Uterine pain ?? Inflamed cervix or show fetus mucopurulent discharge Suspect VasaRoutine Evaluation No pain or pain only Pain between Probable cervical 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 if Cesarean if fetal Consider urgent SVD if fetal death delivery in labour distress lapartomy