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بسم الله الرحمن الرحيمAph


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بسم الله الرحمن الرحيمAph

  1. 1. ‫بسم ال الرحمن الرحيم‬ Antepartum(haemorrhage(APH By Dr. sallama kamel
  2. 2. :DefinitionAPH is defined as bleeding in the third-trimester of pregnancy, after 24weeks and.before the delivery of the fetus.It complicates 4 percent of all pregnancies-It is an obstetric emergency because it-endanger the life of both the mother and.fetusHemorrhage remain the most frequent cause-.of maternal deaths
  3. 3. :Etiology:Placental causes (.Placenta previa (30%.1(.Abruptio placenta (34%.2(.Vasa previa (1%.3(:Local causes (5%.Cervicitis.1.Cervical erosion.2.Cervical carcinoma.3.Vaginal infection.4.Vaginal trauma.5.In 30% of cases no cause can be foundPlacenta previa and abruptio placenta represents themain causes of APH and will be discusses in details
  4. 4. .(.Placenta previa (P.P.Means implantation of the placenta in the lower uterine segment:Incidence(.It complicate 0.5% of pregnancies(1 in 200 pregnancies ♠Bleeding from placenta previa account for about 30% of all cases of♠.APH:Predisposing factors.Multiparity.1.Previous C/S scar.2.Increasing maternal age.3.Multiple gestation.4:Prior placenta previa.5 patient with a placenta previa has a 4% - 8% risk of having p.p. in.subsequent pregnancy.Congenital anomaly of the uterus e.g. septate uterus.6
  5. 5. :What is the lower uterine segmentThe lower segment can be defined as that part of:the uterine wall whichDoes not contract in labour but is stretched in •.response to contractions.Used to be the isthmus before pregnancy•Underlies the loose fold of peritoneum that •.reflects from the bladder.Is covered by a full bladder anteriorly•.Is within 8 cm of the internal cervical os at term •
  6. 6. Grading of placenta previa.(Grade .1 (lateral placentaThe placenta implanted in the lower uterine segment.but does not reach the internal os(.Grade .2.(marginal placentaThe edge of the placenta reaches the internal os but.not covering it(.Grade.3.(partial placenta previa.The placenta partially covering the internal os(.Grade.4.(complete placenta previa.The placenta cover the internal os completely.Grade 1&2 called minor P.P. grade 3&4 major P.P
  7. 7. .Grades of P.P
  8. 8. :Clinical presentationPainless, recurrent unprovoked vaginal.1:bleedingPlacenta previa characteristically present with -.unprovoked painless bleedingBleeding occurs as a result of disruption of the-placental attachment secondary to the development.and thinning of the lower uterine segment In general those with complete previa bleeds earlier - and more heavily than those with a partial or
  9. 9. .The bleeding is usually recurrent-The mean gestational age at the onset of the first -bleeding is 30 weeks with one third presenting.before 30 weeks:malpresentation. 2On abdominal examination it is common to find-malpresentation in association with placenta previa(which are either breech or transverse lie in about(.35%Slight but inconsistent deviation of the presenting part -from the midline and difficulty with palpating the.presenting partThe abdomen is usually soft and the fetal heart is -.normal
  10. 10. :Diagnosis of placenta previa  Placenta previa is almost exclusively diagnosed nowadays by. ultrasoundAn ultrasound scan will show the position of the-. placenta clearly within the uterusIf the placenta lies in the anterior part of the uterus and-reaches into the area covered by the bladder, it is known as a low-lying placenta (before 24 weeks( and placentapraevia after 24 weeks About 5%of patients have some degree of placenta previa onultrasonic examination before 20 week’s gestation. With the development of the lower uterine segment, a relativeupward placental migration occurs, with 90% of these resolves bythe 3rd trimester.
  11. 11. Clinical diagnosis of placenta previa. Clinical diagnosis of placenta previa can be made by palpating the placenta through the cervical os . However this examination can precipitate profuse vaginal bleeding and it is only indicated when U/S is not available and the patient in labour with non-life-threatening vaginal bleeding.
  12. 12. Such examination should always be donein the theatre with every thing is preparedfor caesarian section with a completeoperating team ready to operate shouldvaginal examination precipitate substantial bleedingthe procedure called examination in the)(.theatre or double set examination
  13. 13. :ManagementASYMPTOMATIC LOW-LYING PLACENTAAll women with a low-lying placenta diagnosed •in early pregnancy should be rescanned at 34.weeks’ gestationThere is no need to restrict work activities or•sexual intercourse in women with a low-lying.placenta on ultrasound unless they bleed’If the placenta praevia is still present at 34 weeks•gestation and is Grade I or II, the woman should berescanned on a fortnightly basis but need not be.admitted unless they bleed
  14. 14. Management of patient with bleeding:As with any 3rd trimester bleeding. The patient condition should initially be stabilized. Fetal monitoring instituted. Blood studies ordered. Blood products made available. • Admit to hospitalInsert a broad-bore i.v. cannula and start an infusion of normal saline—if •.the woman is shocked start with a colloid infusion, e.g. Haemaccel.Take blood for cross-matching and haemoglobin estimation •Once the diagnosis of placenta previa is established, management: decision will depend on.Gestational age. 1Severity of bleeding.2
  15. 15. When the pregnancy is preterm.1The aim is to obtain fetal maturation without.compromising the mother’s health:if the bleeding is excessive.1Delivery must be accomplished by caesarian.section regardless the gestational age:When the bleeding is not profuse. 2The patient is managed expectantly inhospital on bed rest and blood transfusion if.the woman is anaemic
  16. 16. After several days without bleeding, she may be.ambulate and even discharged if she lives nearby Instruct the patient to return at the first sign of.further bleeding Her haematocrite should be followed her.haemoglobin should be not less than 11gm. Blood should always be available for the patient
  17. 17. At 36–37 weeks’ presentation, a final ultrasound •:should be performed and acted upona) Grades III and IV placenta praevia should)have a Caesarean section between 37 and 38weeks’ gestation by an experienced obstetricianparticularly if the placenta is on the anterior wall.of the uterusb) If the presenting part is below the lower edge )of the placenta in Grade I, then it is safe to waituntil labour and these women can be expected to.deliver vaginally
  18. 18. When the patient present in labour with.2vaginal bleedingthe patient should be delivered by caesareansection if placenta previa is documented by.ultrasoundif the ultrasound diagnosis is uncertain,.examination in the theatre can be done In rare cases a patient with marginal placentaprevia can be delivered vaginally provided thatthe fetal head compress the site of bleeding.during labour
  19. 19. In patient with grade one placenta previa(the placenta implanted in the lower ( segment but not reaching the cervical osvaginal delivery is usuallyaccomplished, although it should bedone in a well controlled manner and.setting
  20. 20. If the woman is Rh-negative.3There is increased risk of feto-maternal.transfusion and immunization.So anti-D immunoglobulin should be givenA kleihauer-Betke test should be done onmaternal blood to determine the extent of thefeto-maternal transfusion so that an.appropriate larger dose of anti-D may be given
  21. 21. :Maternal risks of placenta previa. There is increased maternal mortality and morbidity  Antepartum and intrapartum haemorrhage carry a constant.threat to the life of patient with placenta previa: Bleeding may be due to.Placenta previa itself.1major cause of death in women with placenta. 2).praevia now is postpartum haemorrhage )PPHPPH is common because the lower segment does not contract andretract as in the upper segment, and therefore maternal vessels of the placental bed may continue to bleed after delivery. This maylead to an emergency hysterectomy if the bleeding.cannot be stopped.Associated placenta accreta.3
  22. 22. :Fetal risks of placenta previaThe perinatal mortality of patients with placenta previais higher than the general population and this is:related to(.Prematurity (which is the main cause.1Higher incidence of IUGR (about 20% of pregnancies.2(.with placenta previa develops IUGR(.Malpresentation (in 30% of cases.3Higher risk of preterm premature rupture of.4.membranesThe presence of vasa previa which carry a perinatal.5.mortality of 75%
  23. 23. :Vasa previaThis is a rare conditionVelamentous insertion of the umbilical cord in the.membranesAt the time of rupture of membranes (whether spontaneousor artificial) the umbilical vessels will rupture causing massive.bleeding which is of fetal origin It is suspected when fetal heart. shows sever bradycardia after rupture.of membranes.Treatment is by immediate C/S
  24. 24. :Placenta accretaAbnormal attachment of the placenta throughthe myometrium as a result of defective decidua.formationIt may be superficial ------ placenta accreta.1The placental villi may invade partially through .2.the myometrium------ placenta incretaThe villi may invade the serosa----- placenta.3.percreta
  25. 25. .Risk factors for placenta accreta.Previous uterine surgery.1.Placenta previa.2.Congenital anomalies of the uterus.3There will be difficulty in delivering the placenta.with massive bleedingTwo third of patients will require hysterectomy their life