Aph Antepartum hemorrhage


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ObGyn, obstetrical emergency

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Aph Antepartum hemorrhage

  1. 1. APH By: Huzaifa Hamid
  2. 2. Definition  is defined as vaginal bleeding from 24 weeks to delivery of the baby.  Or any bleeding occurring in the antenatal period after 20 weeks gestation.  It complicates 2–5% of pregnancies.  It is associated with increased risks of fetal and maternal morbidity and mortality
  3. 3. Causes • Erosion • Polyps • Cancer • Varicosities • Lacerations • Abraptio p. • Placenta p. • Vasa previa
  4. 4. Initial steps in management of late pregnancy bleeding: initial management:  patient’s vitals  FHM  IV fluids Order lab tests:  CBC  DIC workup (platelets, PT, PTT, fibrinogen, and D- dimer)  Type and cross-match  Ultrasound “The most accurate” further steps in management:  Give blood transfusion for large volume loss.  Place Foley catheter and measure urine output.  Perform vaginal exam to rule out lacerations.  Schedule delivery if fetus is in jeopardy or gestational age is ≥ 36 weeks. Never perform a digital or speculum examination in a patient with late vaginal bleeding until a vaginal ultrasound first rules out placenta previa. Apt, Kleihauer-Betke, and Wright’s stain tests determine if blood is fetal, maternal, or both.
  6. 6. Introduction  Definition: It is the separation of the placenta from its site of implantation before delivery of the fetus.  Varieties: - Total or partial - Revealed or Concealed  Incidence: 1 in 200 deliveries
  7. 7. Placental Abruption
  8. 8. Pathophysiology Initiated by bleeding into the decidua basalis, the bleeding splits the decidua, and a decidual hematoma forms. The hematoma leads to separation, compression, and destruction of the placenta adjacent to it. a. The process may be self-limited, with no further complication to the pregnancy or may continue to become catastrophic. b. Bleeding insinuates between the fetal membranes and uterus which may extravasate or may remain concealed. Concealed abruptions can often be more compromising to maternal hemodynamic status since they are generally underappreciated.
  9. 9. Risk Factors  Increased age & parity.  Hypertension.  Preterm ruptured membranes.  Multiple gestation.  Polyhydramnios.  Smoking.  Cocaine use.  Prior abruption.  Uterine fibroid.  Trauma
  10. 10. Clinical presentation  Vaginal bleeding.  Constant and severe abdominal pain.  Irritable, tender, and typically hypertonic uterus.  Evidence of fetal distress (if severe).  Maternal shock.  Disseminated intravascular coagulation.Up to 20% of placental abruptions can present without vaginal bleeding because bleeding is concealed.
  11. 11. U|S for Abruptio placenta
  12. 12. Abratio Placenta Diagnosis: Clinically:  Late trimester painful bleeding  Normal placental implantation  Disseminated intravascular coagulopathy (DIC) Ultrasonography:
  13. 13. Management Emergency CS Vaginal Delivery Conservative
  14. 14. Management  Emergency cesarean delivery: if maternal or fetal jeopardy is present as soon as the mother is stabilized.  Vaginal delivery: if bleeding is heavy but controlled or pregnancy is >36 weeks. Perform amniotomy and induce labor. Place external monitors to assess fetal heart rate pattern and contractions. Avoid cesarean delivery if the fetus is dead.  Conservative in-hospital observation: if mother and fetus are stable and remote from term, bleeding is minimal or decreasing, and contractions are subsiding. Confirm normal placental implantation with sonogram and replace blood loss with crystalloid and blood products as needed.
  15. 15. Complications Maternal :  Hypovolemia.  DIC.  Renal failure.  Death.  Uterine rupture Fetal :  Hypoxia.  IUGR.  IUFD.  Anemia
  17. 17. Introduction Definition: the placenta is implanted in the lower uterine segment. Classification:  Complete placenta previa: The placenta covers the entire internal cervical os.  Partial placenta previa: The placenta partially covers the internal cervical os.  Marginal placenta previa: One edge of the placenta extends to the edge of the internal cervical os.  Low-lying placenta: Within 2 cm of the internal cervical os. Incidence: Complicates approximately 1 in 300 pregnancies.
  18. 18. Placenta Previa Ultrasound performed in the second trimester may show a placenta previa in 5% to 15% of cases. However, as the lower uterine segment develops, over 90% of these previas will resolve. A repeat ultrasound should be performed at 28 weeks to confi rm the presence of a placenta previa.
  19. 19. Placental migration  At 16 weeks 20%  At 40 weeks 0.5%  Why the difference?  TrophoTropism Placental migration
  20. 20. Mechanism of migration
  21. 21. Pathophysiology of bleeding Avulsion of villi, stretching of lower uterine segment
  22. 22. Risk Factors  Multiparty  Increased maternal age  Previous placenta previa  Multiple gestation  Previous C/S  Uterine anomalies  Maternal smoking ART!!!
  23. 23. Presentation & Diagnosis  Late trimester bleeding  Lower segment placental implantation  No pain  MRI or Double set-up Transabdominal US (95% accurate)
  24. 24. U|S Placenta Previa
  25. 25. Management Emergency cesarean delivery Conservative in-hospital observation Vaginal delivery Scheduled cesarean delivery
  26. 26. Management  Emergency cesarean delivery: if maternal or fetal jeopardy is present after stabilization of the mother.  Conservative in-hospital observation: Conservative management of bed rest is performed in preterm gestations if mother and fetus are stable and remote from term. The initial bleed is rarely severe. Confirm abnormal placental implantation with sonogram and replace blood loss with crystalloid and blood products as needed.  Vaginal delivery: This may be attempted if the lower placental edge is >2 cm from the internal cervical os.  Scheduled cesarean delivery: if the mother has been stable after fetal lung maturity has been confirmed by amniocentesis, usually at 36 weeks’ gestation.
  27. 27. Complications of Placenta praevia  Preterm delivery.  PPROM.  IUGR  Malpresentation  Fetal abnormalities  ↑ number of C/S.  morbidly adherent placenta  Postpartum haemorrhage
  28. 28. morbidly adherent placenta Placenta accreta: The placenta is abnormally attached directly to the myometrium. Placenta increta: The placenta invades the myometrium. If placenta previa occurs over a previous uterine scar the villi may invade beyond Nitabuch layer resulting in PLACETNA ACRETA
  29. 29. Summary Abruptio Placenta Placenta Previa Pain Yes No Risk factors Previous abruption Hypertension Trauma Cocaine abuse Previous previa Multiparity Structural abnormalities (e.g., fibroids) Advanced maternal age Diagnosis: Sonogram Placenta in normal position ± retroplacental hematoma Placenta implanted over the lower uterine segment
  30. 30. Summary Abruptio Placenta Placenta Previa Management 1. Emergent c-section: Best choice for placenta previa or if patient/fetus is deteriorating. 2. Vaginal delivery if ≥ 36 weeks or continued bleeding. May be attempted in placenta previa if placenta is > 2 cm from internal os. 3. Admit and observe if bleeding has stopped, vitals and fetal heart rate (FHR) stable, or < 34 weeks. Complication Disseminated intravascular coagulation Placenta accreta/ increta/percreta → hysterectomy
  31. 31. Any question?