o&g update course 2012 hospital segamat

1. AntepartumAntepartum
Haemorrhage (APH)Haemorrhage (APH)
DR:HUSSEIN H AKLDR:HUSSEIN H AKL
O&G SPECIALISTO&G SPECIALIST
HOSPITAL SEGAMATHOSPITAL SEGAMAT
JOHORJOHOR

2. ContentsContents
• Definition
• Importance
• Causes
• Management of APH
• Prognosis

3. Bleeding
In
Pregnancy
Bleeding in
early
Pregnancy
Antepartum
haemorrhage
(APH)
Post partum
Haemorrhage
(PPH)

4. Antepartum HaemorrhageAntepartum Haemorrhage
• Antepartum haemorrhage (APH,prepartum
hemorrhage) is bleeding from the vagina during
pregnancy from twenty four weeks of gestational age
to term.
• Epidemiology
Affects 3-5% of all pregnancies
3 times more common in multiparous
than primiparous women

5. ImportanceImportance
• Obstetric emergency
• Attention should be sought immediately
• If left untreated can lead to death of the
mother and/or foetus
• Can leads to DVT
• Management reduce the risk of
premature delivery and
maternal/perinatal morbidity/mortality

6. CausesCauses
• Blood stained show (benign) - Most common cause of
APH
• Placental abruption - Most common pathological
cause (1/100)
• Placenta praevia - Second most common
pathological cause (1/200)
• Vasa praevia- Often difficult to diagnose, frequently
leads to foetal demise (1/2000-3000)
• Uterine rupture - (<1% in scarred uterus)

7. Causes ctd…Causes ctd…
• Bleeding from the lower genital tract
Cervical bleeding – Cervicitis , cervical
neoplasm, cervical polyp,
Cervical ectropion
Vagina bleeding - Trauma, neoplasm,
Vulval varices , infection
• Inherited bleeding problems - Very rare,
1 in 10,000 women
• Unexplained - No definite cause is diagnosed in
about 40% of APH

8. Bleeding that may be confusedBleeding that may be confused
with vaginal bleedingwith vaginal bleeding
• GI bleed - Hemorrhoids, inflammatory bowel
disease
• Urinary tract bleed - UTI

9. Placenta praeviaPlacenta praevia
• Definition
Insertion of the placenta, partially or fully,
in the lower segment of the uterus

10. EtiologyEtiology
• No definitive cause
• Endometrial factors:
– A scarred endometrium
– Curettage for several times
– Abnormal uterus
• Placental factors
– Large plcenta
– Abnormal formation of the placenta
• Development retardation of fertilized egg

11. Risk factors for Placenta praeviaRisk factors for Placenta praevia
• Multiparity
• Advanced maternal age
• Prior LSCS or other uterine surgery
• Prior placenta praevia
• Uterine structural anomaly
• Assisted conception

12. Degrees of Placenta praeviaDegrees of Placenta praevia

13. Classification of degrees ofClassification of degrees of
Placenta praeviaPlacenta praevia
• Four grades:
– Grade I: Placenta encroaches lower segment
but does not reach the cervical os
– Grade II: Reaches cervical os but does not
cover it
– Grade III: Covers part of the cervical os
– Grade IV: Completely covers the os, even
when the cervix is dilated

14. Placenta praevia-Placenta praevia- ClinicalClinical
FeaturesFeatures
• Recurrent painless vaginal bleeding (not always)
• Abdominal findings
Uterus is soft, relaxed and non tender
Contraction may be palpated
Presenting part is usually high
Abnormal presentations
• Maternal cardiovascular compromise
• Foetal condition satisfactory until severe maternal
compromise
• Vaginal examination- should not be done

15. InvestigationInvestigation
• Diagnosis by ultrasound scan showing that
the placenta coming in to the lower
segment
• Transvaginal ultrasound is safe and is more
accurate than transabdominal ultrasound in
locating the placenta
• Leading edge within the 2 cm from internal
os or completely covering the internal os is
incompatible with normal vaginal delivery

16. Placenta praevia-ComplicationsPlacenta praevia-Complications
Maternal
• Major hemorrhage, shock, and death
• Renal tubular necrosis and acute renal failure
• Post partum haemorrhage
• Morbid adherence of Placenta : placenta accreta
complicates approximately 10% of placenta praevia
cases
• Anaemia in chronic haemorrhage
• Sensitization of mother for foetal blood in Rh (-)
patients
• Disseminated intravascular coagulopathy (DIC)

17. Placenta praevia-Placenta praevia-
Complications cont….Complications cont….
Foetal
• IUD
• Hypoxic ischemic encephalopathy
• Cerebral paulsy
• Placental abruption
• Premature labour

18. Placental abruptionPlacental abruption
• Definition
Premature separation of a normally
situated placenta in a viable foetus
• Placental abruption should be considered
in any pregnant woman with abdominal
pain with or without PV bleeding, as mild
cases may not be clinically obvious

19. Placental abruptionPlacental abruption
Concealed
haemorrhage
Retro placental blood clot

20. EtiologyEtiology
Risk factors
1.Increased age and parity
2.Vascular diseases: preeclampsia, maternal
hypertension, renal disease,SLE and APS
3.Mechanical factors: Trauma, intercourse
Sudden decopression of uterus
Polyhydroamnios
Multiple pregnancy
4. Smoking, cocaine use,
5. Uterine myoma
6. Premature rupture of membranes
7. Supine hypotensive syndrome

21. PathologyPathology
• Main changes
Hemorrhage into the decidua basalis decidua→
splits decidural hematoma separation,→ →
compression, destruction of the placenta
adjacent to it
• Types of abruption
1. Revealed abruption
2. Concealed abruption
3. Mixed type

22. Revealed abruption Concealed abruption

23. Diagnosis-Clinical FeaturesDiagnosis-Clinical Features
• Painful vaginal bleeding
• Pain is usually continuous
1.Mild type
• Abruption≤ 1/3
• Vaginal bleeding may be present or
absent

24. Diagnosis-Clinical Features ctdDiagnosis-Clinical Features ctd
2.Severe type
• Abruption > 1/3
• Large retroplacental haematoma
• Vaginal bleeding associate with
persistent abdominal pain
• Tenderness on the uterus
• “Woody” hard uterus
• Change of foetal heart rate –CTG changers
• Features of hypovolemic shock

25. Complication ofComplication of PlacentalPlacental
abruptionabruption
Maternal
• Disseminated intravascular coagulopathy
• Hypovolemic shock
• Amnionic fluid embolism
• Renal tubular necrosis and acute renal failure
• Post partum haemorrhage
• Sensitization of Rh(-) mother for foetal blood
• Sheehan’s syndrome
• Maternal death

26. Complication ofComplication of PlacentalPlacental
abruptionabruption
Feotal
• Premature labour
• IUGR in chronic abruption
• Hypoxic ischemic encepalopathy and
cerebral paulsy
• Foetal death

27. InvestigationsInvestigations
• Ultrasonography
Mainly to exclude placenta praevia
Can detect
Retroplacental hematoma
Feotal viability
Most of the time findings will be negative
Negative findings do not exclude placental abruption
• CTG – Sinosoidal pattern,Feotal tachycardia or bradycardia
• Laboratory investigations
1. Investigation for Consumptive coagulopathy – Platelet
count/BT/CT/PT/INR & APTT
2. Liver and Renal function tests

28. Vasa praeviaVasa praevia
• Foetal blood vessels from the placenta or
umbilical cord cross the internal os beneath
the baby
• Rupture of membranes leads to damage of
the foetal vesseles leading to exsanguination
and death
• High foetal mortality (50-75%)

29. Vasa praeviaVasa praevia

30. Risk factorsRisk factors
• Eccentric (velamentous) cord insertion
• Bilobed or succenturiate lobe of placenta
• Multiple gestation
• Placenta praevia
• In vitro fertilization (IVF) pregnancies
• History of uterine surgery or D & C

31. Succenturiate lobe Bilobate placenta
Eccentric (velamentous) cord insertion

32. Diagnosis - Vasa praeviaDiagnosis - Vasa praevia
1.Moderate vaginal bleeding + feotal distress
2.Vessels may be palpable through dilated
cervix
3.Vessels may be visible on ultrasound
(Transvaginal colour Doppler ultrasound)
• Difficult to distinguish from abruption
• Can look for feotal Hb (Kleihauer-Betke test)
or nucleated RBC’s in shed blood
• Tachycardia or bradycardia in CTG

33. Rupture of UterusRupture of Uterus
• Uterine scar dehiscence:
– Foetal membranes remain intact, foetus is not
extruded intraperitoneally, separation limited to
old scar, peritoneum overlying is intact
– Usually no foetal distress / maternal Hemorrhage
• Uterine rupture:
– Separation of scar ± extension, rupture of foetal
membranes with extrusion
– Results in foetal distress / maternal hemorrhage
– Maternal mortality
– Foetal mortality = 35%

34. Rupture of UterusRupture of Uterus

35. Rupture of UterusRupture of Uterus
• High Index of clinical suspicion
• In all cases of antepartum and intra
partum haemorrhage uterine rupture must
be excluded

36. Risk factorsRisk factors
•Scarred uteri –Previous caesarian section
& other uterine surgeries
•Grand multiparous
•Inadvertent use of oxytocin &
prostaglandins
•Shoulder dystocia
•Forceps deliveries
•Trauma
•Uterine abnormalities

37. Rupture of Uterus-Rupture of Uterus-ClinicalClinical
featuresfeatures
Maternal
• Pain in between contractions
• Scar tenderness
• Vaginal bleeding
• Profound maternal tachycardia and Hypotension
• Loss of uterine contractions
• Haematurea
• Postpartum haemorrhage may be a sign

38. Rupture of Uterus-Rupture of Uterus-ClinicalClinical
features cont..features cont..
Foetal
• Foetal distress-CTG changers
• Loss of station
• Absence of FHS
• Palpable foetal parts through maternal
abdomen

39. ComplicationsComplications
• Maternal
– Hemorrhage
– Bladder rupture
– Maternal death
– PPH
– DIC
• Foetal
– Respiratory distress
– Hypoxia and cerebral paulsy
– Acidemia
– Death

40. Comparison of Presentation ofComparison of Presentation of
Abruption v. Previa v. RuptureAbruption v. Previa v. Rupture
Abruption Praevia Rupture
Abd. pain present absent variable
Vag. blood old or fresh fresh fresh
DIC common rare rare
Acute foetal common rare common
distress

41. Management of APH

42. Management of APHManagement of APH
• Admit to hospital for assessment and management
• May need resuscitation measures if shocked or severe
bleeding
Airway, breathing and circulation
Senior staff must be involved –Consultant
obstetrician and consultant anaesthetist,
neonatalogist
Two wide bore canula
Take blood for Grouping & DT,FBC , coagulation
profile,Liver & renal function

43. Management of APHManagement of APH
• Volume should be replaced by Crystalloid
/ colloid until blood is available
• Severe bleeding or feotal distress: Urgent
delivery of baby irrespective of
gestational age

44. Management of APH cont…Management of APH cont…
History
• Obtain a history if patient’s condition including:
• Colour and consistency of bleeding
• Quantity and rate of blood loss
• Precipitating factors i.e. Sexual intercourse,
Vaginal examination
• Degree of pain, site and type
• Placental location-review ultrasound report
if available
• Ascertain foetal movements
• Ascertain blood group

45. Management of APH cont…Management of APH cont…
Examination
• Assess maternal and foetal well-being
Pallor, record temperature, pulse and BP
• Perform abdominal examination
Note areas of tenderness and hypertonicity
Determine gestational age of foetus, presentation
and position, auscultate foetal heart
• No vaginal examination should be attempted at least until
a placenta praevia is excluded
• Do speculum examination to assess cervix / bleeding and
exclude local lesions

46. Management of APH cont…Management of APH cont…
Investigations
• Arrange urgent ultrasound scan
• Foetal monitoring
Continuos electronic foetal monitoring
is indicated

47. Management of APH cont…Management of APH cont…
• Rhesus negative woman should have a klihaver
test and be given prophylactic anti-D
immunoglobulin (Rhogum)
• For pre-term delivery when immediate delivery is
not necessary, maternal steroids - to promote
feotal lung maturity
Betamethasone
Dexamethasone

48. Further management of APHFurther management of APH
• Further management will depend on
Cause of the APH
Extent of bleeding
Presence of feotal distress
Gestational age and feotal maturity

49. Placenta praevia - ManagementPlacenta praevia - Management
1.Near term / Term
• Delivery is considered
Grades I and II - May be able to deliver
vaginally
Grades III and IV - Will require caesarean
section by senior obstetrician
• Should anticipate PPH

50. Placenta praevia – ManagementPlacenta praevia – Management
cont…cont…
2.Early in pregnancy
• Continuation of pregnancy better if possible
• Need bed rest
• Educate patient regarding condition and risk
• 3 pint of crossed matched blood should be
available till delivery
• Foetal well being and growth should be
monitored –KCC,CTG,USS
• Medications may be given to prevent premature
labour- Nifidipine, Atosiban

51. Placental abruption –Placental abruption –
Management ctdManagement ctd
• Small abruption
Conservative management depending
on gestational age
Careful monitoring of feotal condition

52. Placental abruption -Placental abruption -
managementmanagement
• Moderate or severe placental abruption:
• Restore blood loss
• Ideally measure central venous pressure (CVP) and
adjust transfusion accordingly
• Prevent coagulopathy
• Monitor urinary output
• Delivery
1.Caesarean section
2.Vaginal
If coagulopathy present
If feotus is not compromised
If feotus is dead

53. Rupture of UterusRupture of Uterus ManagementManagement
Emergency laparotomy
Deliver the baby
Uterine repair if possible specially in
primi gravida
PPH haemostasis sequence
Caesarian hysterectomy (may be
preferred)

54. Vasa Previa managementVasa Previa management
• Urgent delivery
Most of the time urgent LSCS
• Neonatologist involvement
• Aggressive resuscitation of the baby with
blood transfusion following delivery

55. Prognosis of APHPrognosis of APH
• Feotus may die from hypoxia during
heavy bleeding
• Perinatal mortality more than 50 per
1000 even with tertiary care facilities
• High rates of maternal mortality

57. Thank You
Egypt