Aph team e

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Aph team e

  1. 1. 06/29/13 ANTEPARTUM HAEMORRHAGE TEAM E 11 – 08 –
  2. 2. 06/29/13 DEFINITION Bleeding per vaginam after the period of viability(28 weeks) of pregnancy and before labour (delivery of the baby). The incidence of APH in KBTH is 1.2-1.8% of total births and it accounts for about 8% of all caesarian sections in KBTH
  3. 3. 06/29/13 AETIOLOGY Bleeding from placenta site Placenta praevia Placenta abruption Bleeding from local causes in the genital tract Cervical polyps Friable condyloma acuminata Cervicitis Cervical carcinoma Florid vaginal candidiasis Vulva varicosities Vasa praevia Uterine rupture Unknown causes.
  4. 4. 06/29/13 Placenta Praevia
  5. 5. 06/29/13 Placenta Praevia Definition Placenta that is wholly or partially located in the lower uterine segment.
  6. 6. 06/29/13 RISK FACTORS * Increased surface area of the placenta +Multiple pregnancy +Succenturiate lobe +Membranacea +Extrachorialis Maternal age >35 Parity
  7. 7. 06/29/13 Risk Factors Previous uterine surgery -Caesarian section -Induced abortion -Metroplasty -Myomectomy -Cigarette smoking Firmly attached placenta
  8. 8. 06/29/13 A zygote that implants low in the uterus is likely to form a placenta that lies with close proximity to the cervix The placenta so located may Be aborted Migrate upward to the upper segment (placental migration) May fail to migrate upward. With failure of the placenta to migrate, the placenta remains in the lower uterine segment and over the internal os
  9. 9. 06/29/13 The etiology of PP is unknown. Bleeding is thought to occur in association with the development of the lower uterine segment in the third trimester. Placental attachment is disrupted as this area gradually thins in preparation for labour. Bleeding then ensues as the thinned lower uterine segment is unable to contract adequately to prevent blood flow from the open vessels.
  10. 10. 06/29/13 Grading Type 1: placenta is partially located in the lower segment and the lower edge of the placenta does not reach the internal os (lateral placenta praevia) Type 2: placenta is partially located in the lower segment and the lower edge of the placenta reaches the internal os but not cross it.(marginal placenta praevia) Type 3: placenta covers the internal os completely when the cervix is closed, but covers the internal os partially when the cervix is fully dilated (partial placenta praevia) Type 4: placenta completely covers the closed internal os and even at full dilatation covers it completely (central placenta praevia)
  11. 11. 06/29/13 Subgroups - A : anteriorly situated placenta - B : posteriorly situated placenta
  12. 12. 06/29/13 Complications Maternal PPH Postpartum sepsis Foetal Prematurity IUGR Congenital malformation Other risks -Cord prolapse -malpresentation -foetal anaemia -unexpected IUFD from severe maternal hypovolaemia
  13. 13. 06/29/13 Clinical presentation Usually presents in the 3rd Trimester Symptoms: painless spontaneous recurrent vaginal bleeding. First episode is usually not heavy (warning hemorrhage). The blood is fresh and clots readily. Symptoms of anaemia depending on the amount of blood loss
  14. 14. 06/29/13 Examination - Soft abdomen - Abnormal lie - Malpresentation - High presenting part at term - Fetal heart usually unaffected  SPECULUM EXAM - If local lesion suspected
  15. 15. 06/29/13 Diagnosis A good history Examination: a VE is absolutely contraindicated as it could lead to torrential bleeding Investigations for placenta localisation 1. Ultrasound 2. MRI 3. CT scan 4. Placenta arteriorgraphy 5. Reduced placentography 6. Radioisotope Tc 99
  16. 16. 06/29/13 Management of Placenta Praevia This depends on the severity of the bleeding and the gestational age of the pregnancy. However in all cases of praevia you admit the patient . Clinically assess the patient Resuscitate depending on the severity VAGINAL EXAMINATION IS CONTRAINDICATED Do a sterile speculum examination Ultrasound examination when the patient is stable.
  17. 17. 06/29/13 Expectant Management The main aim is to achieve maximum foetal maturity if possible - Patient is admitted - Clean white pad that does not form gel is inspected every morning - At least 2 units of blood should be cross matched and kept on the ward. - When patient is to visit the lavatory, she should inform the medical staff or colleague patient - At 37 completed weeks, repeat Ultra Sound to assess foetal wellbeing in preparation for delivery
  18. 18. 06/29/13 Put mother on fetal kick count Palpate for fetal parts Check the FH twice daily Ultrasound for placental localization at 34wks If there is severe bleeding, that will jeopardize the health of the mother, then immediate delivery, irrespective of GA must be carried out Also, if the patient is at 34wks and comes in with severe bleeding, delivery should be carried out
  19. 19. 06/29/13 Delivery Stage 1 & 2a – vaginal delivery if no contraindications. Stages 2b, 3 and 4 – Caesarian section is indicated C/S is also in the ff - Any patient with repeated bleeding - Severe bleeding - Presentation other than vertex - Other obstetric indications such as contracted pelvis.
  20. 20. 06/29/13 Vaginal Delivery The Double Set-up Approach Preparation -Two units of cross-matched blood in theatre -Patient starved over night -Two trolleys set, on for EUA and the other for CS Procedure -Two obstetricians, one to do EUA the other scrubbed for a CS if need be. -If EUA provokes heavy bleeding a CS is performed.
  21. 21. 06/29/13 Abruptio placentae
  22. 22. 06/29/13 Abruptio Plancentae Premature separation of a normally situated placenta before the delivery of the foetus Incidence-1.1% in KBTH and 95% results in perinatal deaths
  23. 23. 06/29/13 Aetiology Primarily unknown
  24. 24. 06/29/13 Predisposing Factors Maternal hypertension Chronic hypertension PIH Trauma to the abdomen Polyhydramnios PROM Anticoagulant therapy Advanced parity Low socio-economic status Smoking Obstetric procedures e.g.. External cephalic version, amniocentesis, amniotomy in polyhydramnios Increasing Maternal age
  25. 25. 06/29/13 Mechanism Follows spontaneous rupture of blood vessels at placenta bed with haematoma formation. Couvelaire uterus- blood dissect into the myometrium Deranged metabolic exchange- foetal hypoxia and probable death Release of tissue thromboplastin-DIC- consumptive coagulopathy- bleeding disorder
  26. 26. 06/29/13 Clinical presentation Revealed Concealed
  27. 27. 06/29/13 SYMPTOMS + Bleeding pv + Abdominal pain + Onset of premature labour
  28. 28. 06/29/13 Signs - Distressed patient - Hypovolaemic shock - ABDOMEN - Tender - Woody hard - Fetal parts difficult to palpate - Fetal Heart tone Slow/Absent
  29. 29. 06/29/13 Diagnosis Made by clinical judgement USG may help (retro-placental haematoma)
  30. 30. 06/29/13 Grading 1. Not recognised before delivery 2. Classical signs, Foetus alive 3. A. Foetus dead No Coagulopathy B. Foetus dead Coagulopathy present
  31. 31. 06/29/13 Differentials This must considered in terms of causes of vaginal bleeding and causes of abdominal pain. 1. Abdominal pains Acute appendicitis Pyelonephritis Twisted ovarian cyst Red degenerating uterine fibroid Retroperitoneal haemorrhage Rectus sheath haematoma Chorioamnionitis Lumbar or sacral strain Ruptured uterus
  32. 32. 06/29/13 2 Vaginal bleeding Placenta praevia Vasa praevia Local genital lesions
  33. 33. 06/29/13 Complications Maternal Life threatening maternal haemorrhage and shock DIC Increased risk of PPH Acute tubular necrosis of kidneys Uraemia Maternal death Foetal Hypoxia (asphyxia) Anaemia IUGR associated with expectant management Foetal death
  34. 34. 06/29/13 General Management Admit the patient Set up an IV line with a wide bore cannula Take blood for: FBC and sickling GXM (about 2-4 units of blood;2-4 units FFP) Coagulation profile (including platelet count) Clot observation test BUE and Cr LFT Rh status Apt test on vaginal bleed (if possible) IVF (crystalloids and colloids) while waiting for blood Pass catheter to measure urine output
  35. 35. 06/29/13 Specific Measures Expectant management Immediate delivery
  36. 36. 06/29/13 Expectant management This may be done for mild cases in which the foetus is immature. Such cases may develop mild localised tenderness over the uterus. USG identifies a small retro placental clot. Admit patient Pain relief Continuous electronic FHR monitoring (if available) Repeat USG for first few hours to monitor the rate of progression of retro placental clot. Mature foetal lung with corticosteroids Monitor foetus subsequently by daily foetal kick count 2x weekly CTG 2x weekly USG If abruption progresses deliver as soon as possible If abruption does not progress continue expectant management till 37 completed weeks and deliver.
  37. 37. 06/29/13 Immediate Delivery IUFD Resuscitate mother Induce labour (if no contraindications present) Aim at vaginal delivery CS may be necessary when there is uncontrollable maternal bleeding Live foetus Immediate delivery by CS( foetal distress) Vaginal delivery may be acceptable when patient presents in labour and rapid delivery is anticipated
  38. 38. 06/29/13 Prognosis Foetal outcome is very poor -hypoxia -prematurity Maternal death is very high but depends on availability of blood ;hard working house officers and residents; time of presentation.
  39. 39. 06/29/13 VASA PRAEVIA This is bleeding from foetal vessels. It often results from velamentamous insertion of the umbilical cord. The cord inserts at a distance from the placenta and it is not protected by Wharton’s jelly. The umbilical cord vessels traverse between the chorion and amnion without protection and might cross the os. Bleeding from foetal vessels is usually associated with abnormal foetal heart pattern and delivery should be rapid by emergency CS. Incidence is approx 1 per 5000 singleton delivery Foetal mortality is very high ;about 75 – 100% of cases of rupture these vessels. The apt test is used in diagnosis of vasa praevia by mixing suspected bloody vaginal fluid with water and centrifuging. The supernatant is mixed with 1.0% NaOH. A pink colour after another centrifuge indicates the presence of foetal blood
  40. 40. 06/29/13
  41. 41. 06/29/13 T H AN K YO U

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