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Ante partum haemorrhage


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o&g update course 2012 hospital segamat

o&g update course 2012 hospital segamat

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  • 2. ContentsContents • Definition • Importance • Causes • Management of APH • Prognosis
  • 3. Bleeding In Pregnancy Bleeding in early Pregnancy Antepartum haemorrhage (APH) Post partum Haemorrhage (PPH)
  • 4. Antepartum HaemorrhageAntepartum Haemorrhage • Antepartum haemorrhage (APH,prepartum hemorrhage) is bleeding from the vagina during pregnancy from twenty four weeks of gestational age to term. • Epidemiology Affects 3-5% of all pregnancies 3 times more common in multiparous than primiparous women
  • 5. ImportanceImportance • Obstetric emergency • Attention should be sought immediately • If left untreated can lead to death of the mother and/or foetus • Can leads to DVT • Management reduce the risk of premature delivery and maternal/perinatal morbidity/mortality
  • 6. CausesCauses • Blood stained show (benign) - Most common cause of APH • Placental abruption - Most common pathological cause (1/100) • Placenta praevia - Second most common pathological cause (1/200) • Vasa praevia- Often difficult to diagnose, frequently leads to foetal demise (1/2000-3000) • Uterine rupture - (<1% in scarred uterus)
  • 7. Causes ctd…Causes ctd… • Bleeding from the lower genital tract Cervical bleeding – Cervicitis , cervical neoplasm, cervical polyp, Cervical ectropion Vagina bleeding - Trauma, neoplasm, Vulval varices , infection • Inherited bleeding problems - Very rare, 1 in 10,000 women • Unexplained - No definite cause is diagnosed in about 40% of APH
  • 8. Bleeding that may be confusedBleeding that may be confused with vaginal bleedingwith vaginal bleeding • GI bleed - Hemorrhoids, inflammatory bowel disease • Urinary tract bleed - UTI
  • 9. Placenta praeviaPlacenta praevia • Definition Insertion of the placenta, partially or fully, in the lower segment of the uterus
  • 10. EtiologyEtiology • No definitive cause • Endometrial factors: – A scarred endometrium – Curettage for several times – Abnormal uterus • Placental factors – Large plcenta – Abnormal formation of the placenta • Development retardation of fertilized egg
  • 11. Risk factors for Placenta praeviaRisk factors for Placenta praevia • Multiparity • Advanced maternal age • Prior LSCS or other uterine surgery • Prior placenta praevia • Uterine structural anomaly • Assisted conception
  • 12. Degrees of Placenta praeviaDegrees of Placenta praevia
  • 13. Classification of degrees ofClassification of degrees of Placenta praeviaPlacenta praevia • Four grades: – Grade I: Placenta encroaches lower segment but does not reach the cervical os – Grade II: Reaches cervical os but does not cover it – Grade III: Covers part of the cervical os – Grade IV: Completely covers the os, even when the cervix is dilated
  • 14. Placenta praevia-Placenta praevia- ClinicalClinical FeaturesFeatures • Recurrent painless vaginal bleeding (not always) • Abdominal findings Uterus is soft, relaxed and non tender Contraction may be palpated Presenting part is usually high Abnormal presentations • Maternal cardiovascular compromise • Foetal condition satisfactory until severe maternal compromise • Vaginal examination- should not be done
  • 15. InvestigationInvestigation • Diagnosis by ultrasound scan showing that the placenta coming in to the lower segment • Transvaginal ultrasound is safe and is more accurate than transabdominal ultrasound in locating the placenta • Leading edge within the 2 cm from internal os or completely covering the internal os is incompatible with normal vaginal delivery
  • 16. Placenta praevia-ComplicationsPlacenta praevia-Complications Maternal • Major hemorrhage, shock, and death • Renal tubular necrosis and acute renal failure • Post partum haemorrhage • Morbid adherence of Placenta : placenta accreta complicates approximately 10% of placenta praevia cases • Anaemia in chronic haemorrhage • Sensitization of mother for foetal blood in Rh (-) patients • Disseminated intravascular coagulopathy (DIC)
  • 17. Placenta praevia-Placenta praevia- Complications cont….Complications cont…. Foetal • IUD • Hypoxic ischemic encephalopathy • Cerebral paulsy • Placental abruption • Premature labour
  • 18. Placental abruptionPlacental abruption • Definition Premature separation of a normally situated placenta in a viable foetus • Placental abruption should be considered in any pregnant woman with abdominal pain with or without PV bleeding, as mild cases may not be clinically obvious
  • 19. Placental abruptionPlacental abruption Concealed haemorrhage Retro placental blood clot
  • 20. EtiologyEtiology Risk factors 1.Increased age and parity 2.Vascular diseases: preeclampsia, maternal hypertension, renal disease,SLE and APS 3.Mechanical factors: Trauma, intercourse Sudden decopression of uterus Polyhydroamnios Multiple pregnancy 4. Smoking, cocaine use, 5. Uterine myoma 6. Premature rupture of membranes 7. Supine hypotensive syndrome
  • 21. PathologyPathology • Main changes Hemorrhage into the decidua basalis decidua→ splits decidural hematoma separation,→ → compression, destruction of the placenta adjacent to it • Types of abruption 1. Revealed abruption 2. Concealed abruption 3. Mixed type
  • 22. Revealed abruption Concealed abruption
  • 23. Diagnosis-Clinical FeaturesDiagnosis-Clinical Features • Painful vaginal bleeding • Pain is usually continuous 1.Mild type • Abruption≤ 1/3 • Vaginal bleeding may be present or absent
  • 24. Diagnosis-Clinical Features ctdDiagnosis-Clinical Features ctd 2.Severe type • Abruption > 1/3 • Large retroplacental haematoma • Vaginal bleeding associate with persistent abdominal pain • Tenderness on the uterus • “Woody” hard uterus • Change of foetal heart rate –CTG changers • Features of hypovolemic shock
  • 25. Complication ofComplication of PlacentalPlacental abruptionabruption Maternal • Disseminated intravascular coagulopathy • Hypovolemic shock • Amnionic fluid embolism • Renal tubular necrosis and acute renal failure • Post partum haemorrhage • Sensitization of Rh(-) mother for foetal blood • Sheehan’s syndrome • Maternal death
  • 26. Complication ofComplication of PlacentalPlacental abruptionabruption Feotal • Premature labour • IUGR in chronic abruption • Hypoxic ischemic encepalopathy and cerebral paulsy • Foetal death
  • 27. InvestigationsInvestigations • Ultrasonography Mainly to exclude placenta praevia Can detect Retroplacental hematoma Feotal viability Most of the time findings will be negative Negative findings do not exclude placental abruption • CTG – Sinosoidal pattern,Feotal tachycardia or bradycardia • Laboratory investigations 1. Investigation for Consumptive coagulopathy – Platelet count/BT/CT/PT/INR & APTT 2. Liver and Renal function tests
  • 28. Vasa praeviaVasa praevia • Foetal blood vessels from the placenta or umbilical cord cross the internal os beneath the baby • Rupture of membranes leads to damage of the foetal vesseles leading to exsanguination and death • High foetal mortality (50-75%)
  • 29. Vasa praeviaVasa praevia
  • 30. Risk factorsRisk factors • Eccentric (velamentous) cord insertion • Bilobed or succenturiate lobe of placenta • Multiple gestation • Placenta praevia • In vitro fertilization (IVF) pregnancies • History of uterine surgery or D & C
  • 31. Succenturiate lobe Bilobate placenta Eccentric (velamentous) cord insertion
  • 32. Diagnosis - Vasa praeviaDiagnosis - Vasa praevia 1.Moderate vaginal bleeding + feotal distress 2.Vessels may be palpable through dilated cervix 3.Vessels may be visible on ultrasound (Transvaginal colour Doppler ultrasound) • Difficult to distinguish from abruption • Can look for feotal Hb (Kleihauer-Betke test) or nucleated RBC’s in shed blood • Tachycardia or bradycardia in CTG
  • 33. Rupture of UterusRupture of Uterus • Uterine scar dehiscence: – Foetal membranes remain intact, foetus is not extruded intraperitoneally, separation limited to old scar, peritoneum overlying is intact – Usually no foetal distress / maternal Hemorrhage • Uterine rupture: – Separation of scar ± extension, rupture of foetal membranes with extrusion – Results in foetal distress / maternal hemorrhage – Maternal mortality – Foetal mortality = 35%
  • 34. Rupture of UterusRupture of Uterus
  • 35. Rupture of UterusRupture of Uterus • High Index of clinical suspicion • In all cases of antepartum and intra partum haemorrhage uterine rupture must be excluded
  • 36. Risk factorsRisk factors •Scarred uteri –Previous caesarian section & other uterine surgeries •Grand multiparous •Inadvertent use of oxytocin & prostaglandins •Shoulder dystocia •Forceps deliveries •Trauma •Uterine abnormalities
  • 37. Rupture of Uterus-Rupture of Uterus-ClinicalClinical featuresfeatures Maternal • Pain in between contractions • Scar tenderness • Vaginal bleeding • Profound maternal tachycardia and Hypotension • Loss of uterine contractions • Haematurea • Postpartum haemorrhage may be a sign
  • 38. Rupture of Uterus-Rupture of Uterus-ClinicalClinical features cont..features cont.. Foetal • Foetal distress-CTG changers • Loss of station • Absence of FHS • Palpable foetal parts through maternal abdomen
  • 39. ComplicationsComplications • Maternal – Hemorrhage – Bladder rupture – Maternal death – PPH – DIC • Foetal – Respiratory distress – Hypoxia and cerebral paulsy – Acidemia – Death
  • 40. Comparison of Presentation ofComparison of Presentation of Abruption v. Previa v. RuptureAbruption v. Previa v. Rupture Abruption Praevia Rupture Abd. pain present absent variable Vag. blood old or fresh fresh fresh DIC common rare rare Acute foetal common rare common distress
  • 41. Management of APH
  • 42. Management of APHManagement of APH • Admit to hospital for assessment and management • May need resuscitation measures if shocked or severe bleeding Airway, breathing and circulation Senior staff must be involved –Consultant obstetrician and consultant anaesthetist, neonatalogist Two wide bore canula Take blood for Grouping & DT,FBC , coagulation profile,Liver & renal function
  • 43. Management of APHManagement of APH • Volume should be replaced by Crystalloid / colloid until blood is available • Severe bleeding or feotal distress: Urgent delivery of baby irrespective of gestational age
  • 44. Management of APH cont…Management of APH cont… History • Obtain a history if patient’s condition including: • Colour and consistency of bleeding • Quantity and rate of blood loss • Precipitating factors i.e. Sexual intercourse, Vaginal examination • Degree of pain, site and type • Placental location-review ultrasound report if available • Ascertain foetal movements • Ascertain blood group
  • 45. Management of APH cont…Management of APH cont… Examination • Assess maternal and foetal well-being Pallor, record temperature, pulse and BP • Perform abdominal examination Note areas of tenderness and hypertonicity Determine gestational age of foetus, presentation and position, auscultate foetal heart • No vaginal examination should be attempted at least until a placenta praevia is excluded • Do speculum examination to assess cervix / bleeding and exclude local lesions  
  • 46. Management of APH cont…Management of APH cont… Investigations • Arrange urgent ultrasound scan • Foetal monitoring Continuos electronic foetal monitoring is indicated
  • 47. Management of APH cont…Management of APH cont… • Rhesus negative woman should have a klihaver test and be given prophylactic anti-D immunoglobulin (Rhogum) • For pre-term delivery when immediate delivery is not necessary, maternal steroids - to promote feotal lung maturity Betamethasone Dexamethasone
  • 48. Further management of APHFurther management of APH • Further management will depend on Cause of the APH Extent of bleeding Presence of feotal distress Gestational age and feotal maturity
  • 49. Placenta praevia - ManagementPlacenta praevia - Management 1.Near term / Term • Delivery is considered Grades I and II - May be able to deliver vaginally Grades III and IV - Will require caesarean section by senior obstetrician • Should anticipate PPH
  • 50. Placenta praevia – ManagementPlacenta praevia – Management cont…cont… 2.Early in pregnancy • Continuation of pregnancy better if possible • Need bed rest • Educate patient regarding condition and risk • 3 pint of crossed matched blood should be available till delivery • Foetal well being and growth should be monitored –KCC,CTG,USS • Medications may be given to prevent premature labour- Nifidipine, Atosiban
  • 51. Placental abruption –Placental abruption – Management ctdManagement ctd • Small abruption Conservative management depending on gestational age Careful monitoring of feotal condition
  • 52. Placental abruption -Placental abruption - managementmanagement • Moderate or severe placental abruption: • Restore blood loss • Ideally measure central venous pressure (CVP) and adjust transfusion accordingly • Prevent coagulopathy • Monitor urinary output • Delivery 1.Caesarean section 2.Vaginal If coagulopathy present If feotus is not compromised If feotus is dead
  • 53. Rupture of UterusRupture of Uterus ManagementManagement Emergency laparotomy Deliver the baby Uterine repair if possible specially in primi gravida PPH haemostasis sequence Caesarian hysterectomy (may be preferred)
  • 54. Vasa Previa managementVasa Previa management • Urgent delivery Most of the time urgent LSCS • Neonatologist involvement • Aggressive resuscitation of the baby with blood transfusion following delivery
  • 55. Prognosis of APHPrognosis of APH • Feotus may die from hypoxia during heavy bleeding • Perinatal mortality more than 50 per 1000 even with tertiary care facilities • High rates of maternal mortality
  • 56. Thank You Egypt