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ANTEPARTUM
HEMORRHAGE
 Bleeding from or into the genital tract occurring
from 24th weeks of pregnancy and prior to the bi...
 It complicates 3-5% of pregnancies & is a leading
cause of perinatal & maternal mortality world wide.
 May be a sequela...
CAUSES OF ANTEPARTUM HEMORRHAGE
Placental bleeding
70%
Unexplained 20%
or
Indeterminate
(excluding
placental
bleeding and ...
 Bleeding ranges from spotting to life-threatening hemorrhage.
 Intercourse, trichomonas cervicitis, and recent pelvic e...
 The paradigm is that painful bleeding usually
means placental abruption, whereas painless
bleeding usually means placent...
 A common finding in pregnancy is a significant ectropion
of the cervix, particularly among women with a history of
using...
CAUSES OF BLEEDING IN THE SECOND HALF OF
PREGNANCY
 Hemorrhoids
 Vulva
 Varicose veins
 Tears or lacerations
 Vagina
...
FOCUSED HX & PHYSICAL EXAM ARE CRUCIAL
 How much Bleeding (quantity)
 Associated symptoms eg.abdominal pain or contracti...
BLEEDING
 Significant bleeding is an obstetric emergency requiring
immediate management, including ongoing monitoring of ...
 Staff should be ready for delivery, which is facilitated by
having a rapid response system in place for such
emergency s...
PLACENTA PREVIA
When the placenta is implanted partially or
completely over the lower uterine segment
(over and adjacent t...
 About 75% of women with placenta previa will have
at least one episode of bleeding.
 On average, this episode occurs at...
AETIOLOGY
 Dropping down theory- fertilized ovum
drops down and is implanted in lower
segment.
 Persistance of chorionic...
RISK FACTORS
 Increased maternal age >35 years
 Multiparity
 Previous placenta previa (risk 4-8%)
 History of previous...
TYPES
 Type I (low lying)- the major part of placenta is attached to
upper segment and only the lower margin encroaches t...
CAUSES OF BLEEDING
 Placental growth slows down in later
months
 Lower segment progressively dilates
 The inelastic pla...
CLINICAL FEATURES
SYMPTOMS
 Only symptom is unprovoked vaginal bleeding.
 Classical features- sudden onset, painless
app...
CLINICAL FEATURES
SIGNS
 Signs of anemia
Abdominal examination:
 Size of uterus proportionate to GA
 Uterus feels relax...
CONFIRMATION OF DIAGNOSIS
 Painless and recurrent vaginal bleeding in the 2nd
half of pregnancy should be considered as p...
DIFFERENTIAL DIAGNOSIS
 Abruptio placentae
 Local cervical lesions (polyps, carcinoma)
 Placenta accreta/increta/percre...
MANAGEMENT
 PREVENTION
 Adequate antenatal care
 Antenatal diagnosis of low lying placenta at 20 weeks with US
and repe...
All APH are to be admitted
• general and Abd ex along with vulval
inspection
• clinical assessment of blood loss
• blood s...
37 weeks
US evidence
Placental edge is clearly 2-3cm
away from the IO
Placental edge within 2cm of IO
Or placenta previa >...
MATERNAL COMPLICATION
pregnancy
• APH, with varying
degrees of shock
• malpresentation
• Premature labour
• Death due to m...
FETAL COMPLICATIONS
 LBW babies and repeated small bouts of hmg while
expectant treatment (chronic placental insufficienc...
PLACENTAL ABRUPTION
(ACCIDENTAL HAEMORRHAGE)
PLACENTAL ABRUPTION
 refers to an abnormal premature separation of an
otherwise normally implanted placenta.
 There are ...
 Abruption occurs when bleeding in
the decidua basalis causes separation
of the placenta and further bleeding.
 The clas...
RISK FACTORS
1. Maternal hypertension & preeclampsia
2. Multiple gestation
3. Advanced maternal age
4. Multiparity
5. Smok...
CLINICAL PRESENTATION
 Vaginal bleeding
 Common findings seen in 80% of cases (Dark red and non clotting)
 Abdominal pa...
 Clinical grounds of
painful vaginal bleeding
in association with
uterine tenderness &
hyperactivity
 US demonstrate ret...
COMPLICATIONS
1. Maternal mortality 1%
2. Recurrence of APH in 10% & ↑to
25% after 2nd episodes
3. Hypovolemic shock -conc...
DISTINGUISHING FEATURESPLACENTA PREVIA ABRUPTIO PLACENTAE
Clinical features
• nature of bleeding
• character of blood
• ge...
VASA PREVIA
VASA PREVIA
 Passage of fetal blood vessels over the internal os below the
presenting part of fetus
 Velamontous inserti...
DIAGNOSIS
 Apt test help distinguish fetal blood from maternal blood and may be
useful if the test is rapidly available a...
UTERINE RUPTURE
 spontaneous complete transection of the uterus from the
endometrium to the serosa
 Most cases of uterin...
Antepartum Hemorrhage
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Antepartum Hemorrhage

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Topic of Obstetrics and gynecology from Beckman 7th edition

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Antepartum Hemorrhage

  1. 1. ANTEPARTUM HEMORRHAGE  Bleeding from or into the genital tract occurring from 24th weeks of pregnancy and prior to the birth of the baby (third trimester bleeding) Topic presentation by: Dr. Noria Afghan Intern , MBBS graduate 2016
  2. 2.  It complicates 3-5% of pregnancies & is a leading cause of perinatal & maternal mortality world wide.  May be a sequelae relating to poor placental function, IUGR & premature delivery.  1/5 of every preterm babies are born in association with APH & known association of APH with cerebral palsy ( CP) can be explained by preterm delivery
  3. 3. CAUSES OF ANTEPARTUM HEMORRHAGE Placental bleeding 70% Unexplained 20% or Indeterminate (excluding placental bleeding and local lesions Extra placental causes 5% local cervico-vaginal lestions: -cervical polyp -carcinoma cervix -varicose vein -local trauma Placenta previa 35% Abruptio placenta 35%
  4. 4.  Bleeding ranges from spotting to life-threatening hemorrhage.  Intercourse, trichomonas cervicitis, and recent pelvic examinations are common precipitants of spotting because the cervix is more vascular and friable in pregnancy.  Bleeding from hemorrhoids may be mistaken for vaginal bleeding, but the difference is easily distinguished by examination.  At term, a woman’s total blood volume increases by about 40% and her cardiac output by about 30%.  About 20% of this term cardiac output is shunted to the pregnant uterus, so significant bleeding can be quickly catastrophic.  Severe hemorrhage is much less common than spotting but remains a leading cause of maternal and fetal morbidity and mortality.
  5. 5.  The paradigm is that painful bleeding usually means placental abruption, whereas painless bleeding usually means placenta previa.  Other important causes of bleeding include preterm cervical change, preterm labor, and uterine rupture .  In many cases, bleeding remains unexplained or is attributed to local lesions.  It is also important to consider bleeding from other organs, such as hemorrhoids from the anus or gross hematuria from acute cystitis
  6. 6.  A common finding in pregnancy is a significant ectropion of the cervix, particularly among women with a history of using oral contraceptives.  The ectropion is an area on the ectocervix where columnar epithelium has been exposed to vaginal acidity due to eversion of the endocervix.  The ectropion may appear reddened and “raw looking,” and mild bleeding can occur.  These findings may raise concerns about cancer, but they are actually benign.
  7. 7. CAUSES OF BLEEDING IN THE SECOND HALF OF PREGNANCY  Hemorrhoids  Vulva  Varicose veins  Tears or lacerations  Vagina  Cervix  Polyp  Ectropion  Glandular tissue (normal), which is friable  Severe cervicitis  Carcinoma  Intrauterine  Uterine rupture  Placenta previa  Placental abruption  Placenta accreta, increta, or percreta  Vasa previa
  8. 8. FOCUSED HX & PHYSICAL EXAM ARE CRUCIAL  How much Bleeding (quantity)  Associated symptoms eg.abdominal pain or contractions  Triggering factors (trauma, hypertension)  Baby movement  Personal & family Hx of bleeding disorders (von Willebrand )  Recent pap smear (carcinoma )  Vitals (PR, BP) ((blood loss >10-15%))  Inspect for petechiae , bruising (bleeding disorder & coagulopathy)  Uterine palpation(soft, tender, firm), signs of hemiperitoneum.  FHR auscultation / US(fetal presentation, placental position)  Inspect the vulva & Speculum vaginal examination to exclude cervical & vaginal causes *** Bimanual pelvic exam should not be done until placental position is confirmed by US  Full blood count , coagulation profile  Cross-match blood (4-6 units in suspected placenta pravia)
  9. 9. BLEEDING  Significant bleeding is an obstetric emergency requiring immediate management, including ongoing monitoring of vital signs and sufficient large-bore IV lines for the rapid administration of crystalloid fluid, blood, and blood products.  Blood studies should include CBC, coagulation profile, and a type and cross match for four units.  Regardless of the amount of bleeding, blood type and screen are necessary.  Patients who are Rh D-negative may require immunoglobulin to protect against the Rh D antigen, and a Kleihauer-Betke test to determine fetomaternal bleeding (to determine the amount of immunoglobulin needed once the bleeding has been controlled .)
  10. 10.  Staff should be ready for delivery, which is facilitated by having a rapid response system in place for such emergency situations.  Most likely, this will require an emergency caesarean delivery and, possibly, a general anesthetic.  If the bleeding is not sufficient to warrant emergency delivery and/or the fetus is preterm, then blood studies should be continued and IV access maintained.  An ultrasound examination should be performed to assess placental location and condition of the fetus.  The patient should be admitted to the hospital to allow for close monitoring.  Vaginal hemorrhage in the third trimester is one of the few real obstetric emergencies.
  11. 11. PLACENTA PREVIA When the placenta is implanted partially or completely over the lower uterine segment (over and adjacent to the internal os)
  12. 12.  About 75% of women with placenta previa will have at least one episode of bleeding.  On average, this episode occurs at around 29 to 30 weeks of gestation.  The incidence of placenta previa earlier in pregnancy (approximately 24 weeks) is 4% to 5% and decreases with increasing gestational age.
  13. 13. AETIOLOGY  Dropping down theory- fertilized ovum drops down and is implanted in lower segment.  Persistance of chorionic activity- in the decidua capsularis and its subsequent development into capsular placenta which comes in contact with the decidua vera of the lower segment.  Defective deciduaresults in spreading of chorionic villi over a wide are in the uterine wall to get nourishement.  Big surface area for the placenta (twins)
  14. 14. RISK FACTORS  Increased maternal age >35 years  Multiparity  Previous placenta previa (risk 4-8%)  History of previous c-section or any other scar in the uterus  Prior curettage  Placental size and abnormality (succenturiate lobe)  Smoking
  15. 15. TYPES  Type I (low lying)- the major part of placenta is attached to upper segment and only the lower margin encroaches the lower segment but not up to the os.  Type II (marginal)- the placenta reaches the margin of IO but does not cover it.  Type III (incomplete/partial central) the placenta covers the internal os partially (covers the IO when closed, but not entirely do so when fully dilated)  Type IV (central/total) –completely covers the IO even after it is fully dilated.  Partial & low-lying PP will often resolve by 32 -35 weeks of gestationStretching & thinning of the lower uterine segment which move the placenta away from the os (not upward migration of the placenta)  Mild degree- I and II anterior  Major degree- II posterior, III and IV
  16. 16. CAUSES OF BLEEDING  Placental growth slows down in later months  Lower segment progressively dilates  The inelastic placenta is sheared off the wall of vessels episode of bleeding  However, the separation can be provoked by trauma.  The blood is almost always maternal.
  17. 17. CLINICAL FEATURES SYMPTOMS  Only symptom is unprovoked vaginal bleeding.  Classical features- sudden onset, painless apparently causeless and recurrent  Slight bleeding- “warning haemorrhage” in 2nd tri  Unrelated to activity- often occurs in sleep  50% cases Bleeding occurs before 36 weeks and earlier is more likely in major degrees.  No bleeding in central type until labour starts.  **Absence of pain is regarded as a distinguish factor between placenta previa and placental abruption
  18. 18. CLINICAL FEATURES SIGNS  Signs of anemia Abdominal examination:  Size of uterus proportionate to GA  Uterus feels relaxed, soft and elastic without tenderness  Persistence of malpresentation, increased frequency of twin pregnancy.  The head is floating in contrast to GA.  FHS is present.  Vulval inspection to check the character of the blood bright red  PVE is contraindicated outside OT
  19. 19. CONFIRMATION OF DIAGNOSIS  Painless and recurrent vaginal bleeding in the 2nd half of pregnancy should be considered as placenta previa unless proven otherwise.  US is the initial procedure to confirm/rule out. 1-Sonography TAS -high accuracy after 30th week TVS- 100% accurate than TAS TPS colour doppler flow study- prominent venous flow in the hypoechoic area 2-MRI CLINICAL -internal examination -direct visualization during c-section - Examination of placenta after Vaginal delivery -tongue shaped thin segment of placental tissue, rent on membranes on margin, abnormal attachement of cord. PLACENTOGRAPHY (Localization of placenta)
  20. 20. DIFFERENTIAL DIAGNOSIS  Abruptio placentae  Local cervical lesions (polyps, carcinoma)  Placenta accreta/increta/percreta  Vasa previa
  21. 21. MANAGEMENT  PREVENTION  Adequate antenatal care  Antenatal diagnosis of low lying placenta at 20 weeks with US and repeat US at 34weeks to confirm Dx  Significance of warning hemorrhage should not be ignored.  Colour flow doppler US to detect any placenta accreta. At HOME • Patient put to bed • To assess the blood loss • Quick abdominal examination • Vaginal examination must not be done TRANSFER TO HOSPITAL • Equipped hospital with blood transfusion, ER- cesarean and NICU • IV dextrose- saline started ADMISSION TO HOSPITAL • All cases of APH even if slight or absent
  22. 22. All APH are to be admitted • general and Abd ex along with vulval inspection • clinical assessment of blood loss • blood samples (Hb%,Hct, ABO, Rh group) • Resuscitation ( IV NS/transfusion using wide bore canula) • localization of placenta (US) EXPECTANT TREATMENT ACTIVE INTERFERENCE • no active vaginal bleeding • preg <37 weeks • good maternal status (Hb≥10gm%, Hct>30%) • good FHS • fetal well being is assured ( CTG reactive) • periodic inspection of the vulval pads and fetal surviellance at interval of 2-3 weeks. • supplementary hematinics and/transfusions • Tocolysis MgSO4 if bleeding associated with contractions •dexamethasone • Rh Ig to all Rh negative women. • if bleeding continous • preg >37 weeks • patient is in labour •FHS is absent • gross fetal malformation
  23. 23. 37 weeks US evidence Placental edge is clearly 2-3cm away from the IO Placental edge within 2cm of IO Or placenta previa > type I No internal examintaion Caesarean section Internal examination in OT ARM ± oxytocin Satisfactory progress of labour -Bleeding continues -no labour initiation C-sectionVaginal delivery • Delivery via caesarean birth is the rule unless it occurs earlier in pregnancy (i.e., at 20 weeks). • In a patient whose condition is stable, at 36 to 37 weeks of gestation, following amniocentesis to confirm fetal lung maturity. • If lung maturity is not demonstrated, the patient should be delivered at 37 to 38 weeks of gestation. • Earlier caesarean delivery may be required if bleeding occurs or if the patient goes into labor.
  24. 24. MATERNAL COMPLICATION pregnancy • APH, with varying degrees of shock • malpresentation • Premature labour • Death due to massive hmg • Abnormal placental adhesion to uterine wall • Accreta : placental tissue extends into superficial layer of the myometrium  with a history of CS delivery • Increta: extends completely through the myometrium • Percreta : extends completely through the myometrium to the serosa, s.t to bladder . Labour • PROM • Cord prolapse • Slow dilation of cervix • IPH-further sep • Operative delivery • PPH • Retained placenta • Risk of requiring hysterectomy following CS delivery puerperium • sepsis • Subinvolution • embolism
  25. 25. FETAL COMPLICATIONS  LBW babies and repeated small bouts of hmg while expectant treatment (chronic placental insufficiency and IUGR)  Asphyxia  IUFD  Birth injuries  Congenital malformation
  26. 26. PLACENTAL ABRUPTION (ACCIDENTAL HAEMORRHAGE)
  27. 27. PLACENTAL ABRUPTION  refers to an abnormal premature separation of an otherwise normally implanted placenta.  There are various types of abruption, depending upon the extent and region of separation.  A complete abruption occurs when the entire placenta separates.  A partial abruption exists when part of the placenta separates from the uterine wall.  A marginal abruption occurs when the separation is limited to the edge of the placenta  A significant abruption requiring delivery occurs in 1% of births
  28. 28.  Abruption occurs when bleeding in the decidua basalis causes separation of the placenta and further bleeding.  The classic presentation of abruption is vaginal bleeding with abdominal pain.  Smaller or marginal abruptions may present with bleeding only.  Concealed hemorrhage occurs when blood is trapped behind the placenta and is unable to exit.  Severe cases Painful uterine contractions, significant fetal heart rate abnormalities, and fetal demise
  29. 29. RISK FACTORS 1. Maternal hypertension & preeclampsia 2. Multiple gestation 3. Advanced maternal age 4. Multiparity 5. Smoking , cocaine use 6. Chorioamnionitis 7. Trauma (major risk factor) *FHR monitoring for a minimum of 4 hours is performed. 8. Previous abruption (  by 15-20 fold) 9. Elevated 2nd T. maternal serum AFP (10 fold) due to possible entry of AFP into the maternal circulation through the placental uterine interface
  30. 30. CLINICAL PRESENTATION  Vaginal bleeding  Common findings seen in 80% of cases (Dark red and non clotting)  Abdominal pain  Due to extravasations of blood into the myometrium (Couvelaire uterus)  Uterine contractions and tenderness  very frequent ,but S.T silent abruption described  Sign of hypovolemic shock if the blood loss is significant (↑ PR, ↓BP, peripheral vasoconstriction)  Nausea, anxiety, restlessness & fainting attack  Patients may present with absent or reduced fetal movements  Palpation:  In concealed & complete type Tender uterus described as woody hard ,the uterus may be larger than suggested gestation , the fetus is difficult to palpate  In partial type the uterine size is correlated with gestational age , the fetus may be easily palpated .  fetus may be unaffected or in distress or may be dead depending on the size of abruption & area of placental separation
  31. 31.  Clinical grounds of painful vaginal bleeding in association with uterine tenderness & hyperactivity  US demonstrate retro- placental clots & to exclude placenta preavia  Abruption may occur in the absence of US findings.  In some cases the diagnosis may be only made by inspection of placenta after 3rd stage of labour  Careful maternal haemodynamic monitoring  Fetal monitoring  fluid administration  Serial evaluation of the haematocrit & coagulation profile  Expectant management (preterm patients with less severe abruptions and minimal bleeding)  Delivery of the fetus  Vaginal (ARM & oxytoxin) -fetal death -mild to mod abruption with no fetal distress or CI  Cesarean -fetal distress DIGNOSIS MANAGEMENT
  32. 32. COMPLICATIONS 1. Maternal mortality 1% 2. Recurrence of APH in 10% & ↑to 25% after 2nd episodes 3. Hypovolemic shock -concealed 4. Acute renal failure- ATN 5. DIC- Abruption is the most common cause of coagulopathy in pregnancy - low plt and fibrongen, prolonged PT/aPTT 6. PPH -coagulation failure /Couvelaire uterus-Rarely, blood penetrates the uterus to such an extent that the serosa becomes blue or purple in color. 7. Feto-maternal haemorrhage lead to severe Rh sensitization in Rh negative mother - A Kleihauer-Betke or similar test is essential 1. Perinatal mortality: 4.5 % - 60% depending on neonatal facilities & closely related to the gestational age & associated complication like HTN & growth restriction 2. IUGR due to presence of maternal hypertension & pre eclampsia 3. Neonatal anemia MATERNAL FETAL
  33. 33. DISTINGUISHING FEATURESPLACENTA PREVIA ABRUPTIO PLACENTAE Clinical features • nature of bleeding • character of blood • general condition and anemia • features of pre- eclempsia •Bleeding (duration) • painless -causeless and recurrent, always revealed •bright red • proportionate to visible blood loss ------- Often ceases within 1-2 hr • painful, cont. revealed/concealed •dark coloured • out of proportion in concealed or mixed • present in one third cases Continuous Abdominal examination • height of the uterus • feel of uterus • malpresentation • FHS •DIC •Associated history • proportionate • soft and relaxed • common, head is high floating •Present •Normal •rare • disproportionate(conceled) • tense, tender and rigid --------------- • absent in concealed. TC then BC, Loss of variability,Decelerations, IUFD Severe •Trauma, hypertension Multiple gestation Polyhydramnios Placentography US placenta in lower segment Placenta in upper segment Vaginal examination Placenta felt on the lower segment Placenta not felt
  34. 34. VASA PREVIA
  35. 35. VASA PREVIA  Passage of fetal blood vessels over the internal os below the presenting part of fetus  Velamontous insertion of the cord the vessels inserted into the membrane between the amnion & chorion instead of into placenta and are not protected by Wharton jelly or when there is a succenturiate lobe across the os from the main placenta  Incidence 1:2500 pregnancies  Rupture of a fetal vessel occurs rarely in pregnancy, but the risk is greatest with vasa previa  In case of rupture of the membrane these vessels may be torn & vaginal bleeding occur quickly lead to fetal death as fetal blood volume is so small  Blood loss is fetal blood  Fetal mortality approaches 60% if rupture is not detected before delivery.
  36. 36. DIAGNOSIS  Apt test help distinguish fetal blood from maternal blood and may be useful if the test is rapidly available and bleeding is worrisome but not significant enough to warrant emergency delivery. Blood + water hemolysis Centrifuged Supernatent + sodium hydroxide  (fetal blood pink, maternal yellow brown)  TVS with color Doppler  FHR abnormality seen (fetal TC , BC & sinusoidal pattern indicate severe fetal anemia)  When performing ARM it is important to ensure that no pulsating vessels are present  In suspicion of vasa previa, fetus should be delivered as quickly as possible usually by CS
  37. 37. UTERINE RUPTURE  spontaneous complete transection of the uterus from the endometrium to the serosa  Most cases of uterine rupture occur at the site of a prior cesarean delivery.  partial rupture/uterine dehiscence If the peritoneum remains intact  With complete rupture and fetal expulsion into the abdomen, fetal mortality ranges from 50% to 75%.  Fetal survival depends in large part on whether a substantial portion of the placenta remains attached to the uterine wall until delivery is accomplished.  Cesarean delivery is imperative to ensure neonatal survival and decrease maternal morbidity

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