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Antepartum haemorhage


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This is the full concept of APh for a medical student, No more detail is needed.

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Antepartum haemorhage

  1. 1. AntepartumAntepartum Haemorrhage (APH)Haemorrhage (APH) Nadir khan AurakzaiNadir khan Aurakzai Batch ‘’M’’Batch ‘’M’’ 08-23108-231 Ayub Medical College, AbbottabadAyub Medical College, Abbottabad
  2. 2. ContentsContents • Definition • Importance • Causes • Management of APH • Prognosis
  3. 3. Bleeding In Pregnancy Bleeding in early Pregnancy Antepartum haemorrhage (APH) Post partum Haemorrhage (PPH)
  4. 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. 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. 6. CausesCauses • 1: Placental causes: • A. Placental abruption • B. Placenta previa • C. Vasa previa • 2: Causes in genital tract: • A. Labour • B: rupture of uterus • C. Trauma • D. Infection (cervicitis & vulvovginitis) • E. Tumours
  7. 7. • 3: Bleeding disorders • A. Congenital (von willebrand’s disease) • B. Acquired ( DIC)
  8. 8. Placenta praeviaPlacenta praevia • Definition Insertion of the placenta, partially or fully, in the lower segment of the uterus
  9. 9. EtiologyEtiology • No definitive cause • Endometrial factors: – A scarred endometrium – Curettage for several times – Abnormal uterus • Placental factors – Large plcenta – Abnormal formation of the placenta
  10. 10. 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
  11. 11. Degrees of Placenta praeviaDegrees of Placenta praevia
  12. 12. Classification of degrees ofClassification of degrees of Placenta praeviaPlacenta praevia • Four grades: – Type I ( Low lying): Placenta encroaches lower segment but does not reach the internal os – Type II (Marginal placenta previa): Reaches internal os but does not cover it – Type III (Partial Placenta previa): Covers part of the internal os – Type IV (Complete): Completely covers the os, even when the cervix is dilated
  13. 13. 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
  14. 14. InvestigationInvestigation • 1: For Localization of placenta: • Ultrasound: • Abdominal ultrasound can easily diagnose placenta previa with an accuracy of 93- 97%. • Transvaginal ultrasound is safe and is more accurate than transabdominal ultrasound in locating the placenta • 2: Haematological Investigations: • A. Complete blood picture. • B. Blood grouping. C:Renal profile
  15. 15. 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 • Disseminated intravascular coagulopathy (DIC)
  16. 16. Placenta praevia-Placenta praevia- Complications cont….Complications cont…. Foetal • IUD • Hypoxic ischemic encephalopathy • Cerebral paulsy • Placental abruption • Premature labour
  17. 17. 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
  18. 18. EtiologyEtiology Risk factors 1.Increased age and parity 2.Vascular diseases: preeclampsia, maternal hypertension, renal disease,SLE 3.Mechanical factors: Trauma, intercourse Sudden decompression of uterus Polyhydroamnios Multiple pregnancy 4. Smoking, cocaine use, 5.Premature rupture of membranes
  19. 19. 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
  20. 20. Revealed abruption Concealed abruption
  21. 21. Diagnosis-Clinical FeaturesDiagnosis-Clinical Features •Vaginal bleeding associate with persistent abdominal pain • Tenderness on the uterus • “Woody” hard uterus • Change of foetal heart rate • Features of hypovolemic shock
  22. 22. Complication ofComplication of PlacentalPlacental abruptionabruption Maternal • Disseminated intravascular coagulopathy • Hypovolemic shock • Amnionic fluid embolism • Renal tubular necrosis and acute renal failure • Post partum haemorrhage • Maternal death
  23. 23. Complication ofComplication of PlacentalPlacental abruptionabruption Feotal • Premature labour • IUGR in chronic abruption • Hypoxic ischemic encepalopathy and cerebral paulsy • Foetal death
  24. 24. InvestigationsInvestigations • 1: Diagnostic investigations: • 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 • 2: Laboratory investigations 1. Investigation for Consumptive coagulopathy – Platelet count/BT/CT/PT/INR & APTT 2. Liver and Renal function tests
  25. 25. 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%)
  26. 26. Vasa praeviaVasa praevia
  27. 27. 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
  28. 28. Eccentric (velamentous) cord insertion
  29. 29. 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
  30. 30. Management of APH
  31. 31. 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 & FBC , coagulation profile,Liver & renal function
  32. 32. 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
  33. 33. Management of APH cont…Management of APH cont… History • Obtain a history if patient’s condition allow 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
  34. 34. 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  
  35. 35. Management of APH cont…Management of APH cont… Investigations • Arrange urgent ultrasound scan • Foetal monitoring Continuos electronic foetal monitoring is indicated
  36. 36. 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
  37. 37. Placenta praevia - ManagementPlacenta praevia - Management 1.Near term / Term • Delivery is considered Types I and II - May be able to deliver vaginally Types III and IV - Will require caesarean section by senior obstetrician
  38. 38. 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 • Medications may be given to prevent premature labour- Nifidipine, Atosiban
  39. 39. Placental abruption –Placental abruption – Management ctdManagement ctd • Small abruption Conservative management depending on gestational age Careful monitoring of feotal condition
  40. 40. 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
  41. 41. 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
  42. 42. 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