Antepurtum Haemorage

1. ANTEPARTUM
HAEMORRHAGE
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2. DEFINITON
 APH is defined as bleeding from or
into the genital tract after the 28th
week of pregnancy but before the
birth of the baby.
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3. APH
Placental
bleeding
Placenta
Praevia
Abruptio
Placenta
Unexplained
Extra
placental
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4. PLACENTAPRAEVIA
 DEFINITION:
When the placenta is implanted partially or
completely over the LUS, it is called Placenta
Praevia.
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5. AETIOLOGY
 DROPING DOWN THEORY
 DEFECTIVE DECIDUA
 BIG SURFACE AREA OF PLACENTA
 PERSISTENCE OF CHORIONIC ACTIVITY
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6. TYPES
 Type I ( Lateral) : Major part of placenta is
attached to upper segment & only lower margin
encroaches onto LUS but not upto the os.
 Type II ( Marginal) : Placenta reaches internal os
but doesn’t cover it.
 Type III ( Incomplete central) : Placenta
completely covers the internal os when closed but
does not entirely do so when fully dilated.
 Type IV ( Central) : Placenta completely covers
the internal os even after it is fully dilated.
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7. TYPES
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8. CLINICALFEATURES
 SYMPTOMS
 VAGINAL BLEEDING
 SUDDEN IN ONSET
 PAINLESS
 RECURRENT
 APPARENTLY CAUSELESS
 UNRELATED TO ACTIVITY
 OFTEN OCCURS DURING SLEEP
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9. SIGNS
 GC & Pallor = visible blood loss.
 Per abdomen examination
 Fundal height = period of amenorrhoea
 Feel of uterus soft, relaxed & elastic
 No area of tenderness
 Fetal parts well palpated
 F.H.S. Usually present.
 Vulval inspection is done
 Per vaginal examination done in O.T.
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10. INVESTIGATIONS
 CBC, ESR, BLOOD GROUP & Rh FACTOR
 USG ABDOMEN
 MRI ABDOMEN
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11. MATERNALCOMPLICATIONS
• Haemorrhage with shock
• Malpresentation
• Premature labour
DURING
PREGNANCY
• PROM
• Cord prolapse
• Intrapartum haemorrhage
• PPH
DURING
LABOUR
• Sepsis
• Subinvolution
DURING
PUERPERIUM
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12. FETALCOMPLICATIONS
 Low birth weight
 IUD
 Congenital malformation
 Asphyxia
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13. MANAGEMENT
 All cases of APH to be hospitalised.
 Treatment on admission
 Immediate attention
 Formulation of line of treatment
Expectant treatment
Active interference.
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14. IMMEDIATEATTENTION
Vulval inspection
Gentle P/A examination
IV fluids
Do Hb%, ABO & Rh grouping
Amount of blood loss
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15. FORMULATION OF LINE OF
TREATMENT
1. Expectant treatment: Advocated by Macafee &
Johnson.
 Bed rest for at least 2-3 days after vaginal bleeding.
 Investigations: Hb%, ABO & Rh grouping,
Urine – Protein
 FHS
 Supplementary haematinics.
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16. 2. Active interference
 Vaginal examination in OT followed by
 Low rupture of membranes
 Caesarean section
 Caesarean section without internal examination
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17. ABRUPTIO PLACENTA
 SYNONYMS: Accidental Haemorrhage, Ablatio
placenta, Premature separation of placenta.
 DEFINITION: Form of APH where the bleeding
occurs due to premature separation of normally
situated placenta.
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18. AETIOLOGY
 High birth order pregnancies
 Advancing age of mother
 Poor socio-economic condition
 Malnutrition, smoking
 Tendency of recurrence
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20. VARIETIES
1. REVEALED: Following placental separation, the
blood passes between the membranes & decidua
& comes out of cervical canal & visible
externally. Commonest type.
2. CONCEALED: Blood collects behind separated
placenta or collected in between membranes &
decidua. This type is rare.
3. MIXED: Some part of blood collects inside &
part expelled out. Quite common
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21. CLINICALFEATURES
 Depend on
I. Degree of Placental separation
II. Speed at which separation occurs
III. Amount of blood concealed inside the uterine
cavity.
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22. CLINICAL
FEATURES
REVEALED MIXED
SYMPTOMS ABDOMINAL PAIN
FOLLOWED BY SLIGHT
VAGINAL BLEEDING
ACUTE INTENSE
ABDOMINAL PAIN
WITH SLIGHT VAGINAL
BLEEDING
CHARACTER CONTINOUS DARK
COLOUR
DARK OR SEROUS
GENERAL
CONDITION
= BLOOD LOSS > VISIBLE BLOOD LOSS
PALLOR RELATED WITH VISIBLE
BLOOD LOSS
> VISIBLE BLOOD LOSS
FUNDAL
HEIGHT
= PERIOD OF GESTATION DISPROPORTIONATELY
ENLARGED
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23. CLINICAL
FEATURES
REVEALED MIXED
UTERINE FEEL NORMAL FEEL WITH
LOCALISED
TENDERNESS
UTERUS TENSE,
TENDER RIGID
FETAL PARTS IDENTIFIED EASILY DIFFICULT TO MAKE
OUT
FHS USUALLY PRESENT USUALLY ABSENT
URINE OUTPUT NORMAL DIMINISHED
INVESTIGATIONS
Hb%
COAGULATION
PROFILE
URINE FOR
PROTEIN
↓ = BLOOD LOSS
USUALLY DISTURBED
ABSENT
↓ > BLOOD LOSS
CT ↑
PRESENT
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24. COMPLICATIONS
 MATERNAL
 HAEMORRHAGE
 SHOCK
 OLIGURIA & ANURIA
 BLOOD COAGULATION DISORDERS
 PPH
 PUERPERAL SEPSIS
 FETAL
 PREMATURITY
 ANOXIA
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25. MANAGEMENT
1. PREVENTION, EARLY DETECTION &
EFFECTIVE THERAPY OF PRE-ECLAMPSIA
2. AVOIDANCE OF TRAUMA
3. TO AVOID SUDDEN DECOMPRESSION OF
UTERUS
4. ROUTINE ADMINISTRATION OF FOLIC
ACID SUPPLEMENTS.
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26. GENERALMANAGEMENT
 GENERAL & ABDOMINAL CONDITION
 FETAL STATUS
 ASSESSMENT OF BLOOD LOSS
 HB% , COAGULATION PROFILE, ABO & RH
GROUP
 RESUSCITATION
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27. REVEALED
 Patient in labour
 ARM + Oxytocin if needed
 Patient not in labour
 > 38 WKS : ARM + Oxytocin
 < 38 WKS
Bleeding stops : Expectant treatment
Try to continue pregnancy up to 38 wks
 Bleeding p/v continuing : ARM
Oxytocin
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28. CONCEALED
 Sedation
 Blood transfusion
 Urine output
 ARM + Oxytocin if needed
 No response
 ↓ Fibrinogen
 Oliguria
 Caeserean section
 Hysterectomy ( rare)
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29. THANK YOU
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