Antepartam haemorrhage

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Antepartam haemorrhage

  1. 1. ANTEPARTAM HAEMORRHAGE  IMMEDIATE DELIVERY
  2. 2. Significant bleeding from th birth canal after 24 week of gestation till de.
  3. 3. CAUSES PLACENTAL    Placenta Praevia Placental Abruption Vasa Praevia NON PLACENTAL     Labour (Heavy show ) Uterine rupture Local / Non obstetrical Cervicitis Polyp Lacerations Bleeding Disorders Conginital acquired
  4. 4. PLACENTA PRAEVIA Implantation of placenta in lower uterine segment   Partial Complete
  5. 5. DEGREES MINOR MAJOR M a j o r
  6. 6. ETIOLOGY Scarred or poorly vascularized endometrium  Advancing age  Multiparity  Previous uterine surgeries caeserian, myomectomy, D&C, ERPC
  7. 7. Bleeding Mechanical Seperation Rupture of Cervical dilalatation Venous lakes effacement intravaginal manipulation
  8. 8. DIAGNOSIS Presenting complaints Painless vaginal bleeding Mild Moderate Profuse SHOCK
  9. 9. CLINICAL FINDINGS  Pallor  Vital Signs Stable Unstable  Hemorrhage Abdomen Soft , relaxed , non tender Lie transverse/oblique Presenting part high Fetal hearts present
  10. 10. DIAGNOSIS  History  Clinical examination  Ultrasonography  Colour Doppler  C T scan  MRI
  11. 11. MRI USG
  12. 12. MANAGEMENT Depends Amount of hemorrhage Gestational age
  13. 13. MANAGEMENT  Airway  I/V Line  Fluids 16 / 18 Gauge cannula crystalloids / colloids  Blood transfusion /FFP  Indwelling urinary catheter  Inform Senior Obstetrician  Avoid pelvic examination
  14. 14. MANAGEMENT  Investigations  Blood grouping & cross match  Complete blood counts  Coagulation profile (Platelet count, APTT,PT,FDPs)  Ultrasound scan ( full bladder )
  15. 15. EXPECTANT MANAGEMENT (Preterm fetus)  AIM  Haemodynamically stable with mild bleeding and no uterine contractions Close observation vital signs & vaginal bleeding Correction of anaemia Steroids for fetal lung maturation Counseled and prepared for Caeserian section     To prolong pregnancy till Term
  16. 16. IMMEDIATE DELIVERY  Caeserian Section / Hysterotomy Haemodynamically unstable. Profuse vaginal bleeding. After 37 completed weeks of gestation. If patients has palpable uterine contractions. SURGEON / ANAESTHETIST GENERAL ANAESTHESIA SENIOR
  17. 17. COMPLICATIONS  Maternal Anaemia Shock Complications of surgery & Anaesthesia Post Partam hemorrhage Maternal mortaliy  Fetal Morbidity / Mortality
  18. 18. PLACENTAL ABRUPTION  Bleeding following premature separation of a normally situated placenta.
  19. 19. AETIOLOGY Advance age  Multiparity  Poor nutritional status  Past History ( recurrence 15 –20% )  Hypertention  Abdominal Trauma  Smoking  Uterine Decompression ( polyhydramniose , Twins )  Chorio amnionitis  Fibroid, Folic Acid deficiency 
  20. 20. PATHOPHYSIOLOGY Local Vascular injury (Pre eclampsia) Haematoma Formation in Decidua Basalis Separation of Placenta Venous Engorgement Abrupt uterine venous pressure
  21. 21. Revealed Concealed
  22. 22. SIGNS & SYMPTOMS Small separation of the placenta :   Vaginal bleeding ± Mild pain or discomfort. Abdominal pain. Back pain  Vital signs Stable Abdomen Soft/ Tenderness ±  Foetus  uncompromised
  23. 23. Large separation of the placenta:  Heavy vaginal bleeding.  Severe pain in the lower abdomen or back.  Hard, tender abdomen.  Shock (tachycardia, fall in BP rapid breathing, and dizziness).  Fetal distress;  Coagulopathy [DIC]) – Thromboplastine from fetal heart sounds inaudible. placenta is released into the mother's circulation causing blood clotting defects.  Renal cortical necrosis ---- Anurea
  24. 24. EXAMINATIOBN  GPE depends upon Hemorrhage.  Pallor  Pulse  B.P  ABDOMINAL EXAMINATION  Fundal height larger than dates  Hard and tender  Fetal Part and FHS  PELVIC EXAMINATION Exclude placenta praevia by USG P/S examination P/V examination
  25. 25. INVESTIGATIONS  Blood grouping. Blood Complete picture.  Coagulation Profile, Platelet counts, PT, APTT, FDPs Serum Fibrinogen  Renal Profile  Viral Serology 
  26. 26. INVESTIGATION : Ultrasonography (Useful but not reliable )
  27. 27. MANAGEMENT  I/V access       Two large bore cannulas. Save blood for cross match/ investigation(20 ml) I/V fluids Crystelloids /colloids Indwelling urinary catheter Analgesia Blood transfusions / Fresh frozen plasma ( Screened & Cross matched ) Vital Signs monitoring
  28. 28. MANAGEMENT  Expectant : Mild marginal Abruption with stable mother & Strict maternal & fetal monitoring.  fetus . Vaginal Delivery: If degree of separation is limited , revealed hemorrhage After amniotomy & oxytocin infusion short labour is expected. Dead fetus No complications
  29. 29. MANAGEMENT  Caeserian Section: Maternal Indications Uncontrollable revealed hemorrhage Rapidly expanding concealed hemorrhage Vaginal delivery is not imminent Fetal Indications Alive fetus with reasonable chances of survival
  30. 30. COMPLICATIONS  MATERNAL Shock (Hypovolemic, / Neurogenic ) DIC Renal failure PPH ( Couvelier uterus ,uterine atony , DIC ) Maternal mortality ( 0.5% --- 5 % )  FETAL Perinatal mortality ( 50 % --- 80 % )
  31. 31. FOLLOW UP  Follow up visits  Contraception  Counsel for chances of recurrence in next pregnancy ,  early antenatal booking

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