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Antepartum hemorrhage


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Basics in APH

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Antepartum hemorrhage

  2. 2. Bleeding In Pregnancy Bleeding in early Pregnancy Antepartum hemorrhage (APH) Post partum Haemorrhage (PPH)
  3. 3. ANTEPARTUM HAEMORRHAGE Definition Antepartum hemorrhage (APH, prepartum hemorrhage) is bleeding from or into the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby (RCOG 2011) Epidemiology Affects 3-5% of all pregnancies 1/5th of preterm babies born in association of APH occurs in 2.8/1000 singleton pregnancies & 3.9/1000 twin pregnancies This definition of gestational age is based on the UK professional guidance for viability cut-off point of 24 weeks
  4. 4. Obstetric emergency Attention should be sought immediately If left untreated can lead to death of the mother &/or fetus Management reduce the risk of premature delivery & maternal/ perinatal morbidity/mortality IMPORTANCE
  5. 5. Placental abruption - Most common pathological cause (1/100) Placenta previa - Second most common pathological cause (1/200) Vasa previa- Often difficult to diagnose, frequently leads to fetal demise (1/2000-3000) Uterine rupture - (<1% in scarred uterus) CAUSES
  6. 6.  Bleeding from the lower genital tract Cervical bleeding – Cervicitis Cervical neoplasm Cervical polyp Cervical ectropion Vaginal 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 CAUSES CONT.…
  7. 7.  GI bleed - Hemorrhoids, inflammatory bowel disease, etc.  Urinary tract bleed – UTI, etc. BLEEDING THAT MAY BE CONFUSED WITH VAGINAL BLEEDING
  8. 8. Maternal complications •Anaemia •Infection •Maternal shock •Renal tubular necrosis •Consumptive coagulopathy •Postpartum haemorrhage •Prolonged hospital stay •Psychological sequelae •Complications of blood transfusion Fetal complications •Fetal hypoxia •Fetal growth restriction •Prematurity (iatrogenic & spontaneous) •Fetal death COMPLICATIONS OF APH
  9. 9. Definition Insertion of the placenta, partially or completely, in the lower segment of the uterus PLACENTA PREVIA
  10. 10. Previous placenta previa (adjusted OR 9.7) Rasmussen 2000 Previous Caesarean section (RR 2.6, 95% CI 2.3, 3.0) Ananth 1997 •One previous Caesarean section OR 2.2 (95% CI 1.4, 3.4) Hendricks1999 •Two previous Caesarean sections OR 4.1 (95% CI 1.9, 8.8) •Three previous Caesarean sections OR 22.4 (95% CI 6.4, 78.3) Previous termination of pregnancy Multiparity Advanced maternal age (>40 years) Multiple pregnancy RISK FACTORS FOR PLACENTA PREVIA
  11. 11. Deficient endometrium due to presence or history of: •Uterine scar •Endometritis •Manual removal of placenta •Curettage •Submucous fibroid Assisted conception Smoking (RCOG2011) CONT.…
  12. 12. Four types: Type I: Placenta encroaches lower segment but does not reach the internal os Type II: Reaches internal os but does not cover it Type III: Covers part of the internal os Type IV: Completely covers the os, even when the cervix is dilated DEGREES OF PLACENTA PREVIA
  13. 13.  Recurrent painless vaginal bleeding (not always)  Abdominal findings  Uterus- soft, relaxed, non tender & proportionate to POG  Contraction may be palpated  Abnormal presentations  High floating head in cephalic presentation  Maternal cardiovascular compromise  Fetal condition satisfactory until severe maternal compromise  Vulval inspection- presence of bleeding, character of blood  Vaginal examination- should not be done PLACENTA PREVIA- CLINICAL FEATURES
  14. 14. Diagnosis by ultrasound scan (USS) showing placenta coming in to lower segment Transvaginal ultrasound (TVS) is safe & is more accurate than transabdominal ultrasound (TAS) in locating placenta Leading edge within 2 cm from internal os or completely covering internal os is incompatible with normal vaginal delivery Transperineal (TPS) Colour Doppler flow study MRI INVESTIGATION
  15. 15. CONFIRMATION OF DIAGNOSIS Localisation of placenta Clinical Transabdominal ultrasonography By internal examination (double set up) Transvaginal ultrasonography Direct visualization during CS Transperineal ultrasonography Examination of placenta following delivery Colour doppler flow study MRI
  16. 16. Maternal  Major hemorrhage, shock & death Anemia in chronic hemorrhage Morbid adherence of Placenta : placenta accreta complicates approximately 10% of placenta previa cases Sensitization of mother for fetal blood in Rh (-) patients Post partum hemorrhage  Renal tubular necrosis & acute renal failure PLACENTA PREVIA- COMPLICATIONS
  17. 17. Fetal Prematurity Low birth weight Chronic & acute fetal hypoxia IUD Congenital malformation- 3 times more common PLACENTA PREVIA- COMPLICATIONS CONT….
  18. 18. Definition Premature separation of a normally situated placenta in a viable fetus  Clinician should have high index of suspicion for diagnosis PLACENTAL ABRUPTIONPLACENTAL ABRUPTION
  19. 19. The most predictive is abruption in previous pregnancy A large observational study from Norway reported a 4.4% incidence of recurrent abruption (adjusted OR 7.8, 95% CI 6.5-9.2).Rasmussen et al 2009 Abruption recurs in 19-25% of women who have had two previous pregnancies complicated by abruption.(Tikkanen 2010) RISK FACTORS FOR PLACENTAL ABRUPTION
  20. 20.  Increased age and parity  Vascular diseases: hypertension in pregnancy, renal disease, SLE & APS  Mechanical factors: Trauma, amniocentesis, sudden decompression of uterus, polyhydramnios, multiple pregnancy  Smoking, cocaine use  Uterine myoma, septum  Supine hypotension syndrome RISK FACTORS FOR PLACENTAL ABRUPTION
  21. 21. Spasm of vessels in uteroplacental bed (decidual spiral artery) anoxic→ endothelial damage rupture of vessels & hemorrhage in decidua basalis→ → decidua splits decidual hematoma (retroplacental) separation,→ → compression, destruction of the adjacent placenta Large retroplacental clot PATHOPHYSIOLOGY
  22. 22.  Concealed abruption Revealed abruption  Mixed type TYPES OF ABRUPTION
  23. 23. Grade 0- Asymptomatic – small retroplacental clot Grade 1 (40%) - External vaginal bleeding present. Uterine tenderness and tetany may be present. NO SIGN OF MATERNAL SHOCK OR FETAL DISTRESS Grade 2 (45%) - External vaginal bleeding may or may not be present. NO SIGNS OF MATERNAL SHOCK, BUT FETAL DISTRESS IS PRESENT Grade 3 (15%) - External bleeding may or may not be present. Marked uterine tetany, a board-like rigidity on palpation. Persistent abdominal pain, MATERNAL SHOCK and fetal distress are present. Coagulopathy may become evident in 30% of cases. CLASSIFICATION OF PLACENTAL ABRUPTION
  24. 24. Mild type  Abruption≤ 1/3  Vaginal bleeding may be present or absent Severe type  Abruption > 1/3  Large retroplacental hematoma  Vaginal bleeding associated with persistent abdominal pain  Tenderness on the uterus  “Woody” hard uterus  Change of fetal heart rate – CTG changes  Features of hypovolemic shock  Painful vaginal bleeding  Pain- usually continuous DIAGNOSIS- CLINICAL FEATURES
  25. 25. Maternal Sensitization of Rh(-) mother for fetal blood Amnionic fluid embolism Post partum hemorrhage Hypovolemic shock Renal tubular necrosis & acute renal failure Disseminated intravascular coagulopathy (DIC) Puerperal sepsis Sheehan’s syndrome Maternal death COMPLICATIONS OF PLACENTAL ABRUPTION
  26. 26. Fetal Prematurity IUGR in chronic abruption Hypoxic ischemic encephalopathy Cerebral palsy Fetal death COMPLICATIONS OF PLACENTAL ABRUPTION
  27. 27. Ultrasonography  Mainly to exclude placenta previa  Can detect • Retroplacental hematoma • Fetal viability Most of the time findings will be negative Negative findings does not exclude placental abruption CTG – Sinusoidal pattern, Fetal tachycardia or bradycardia Laboratory investigations Investigation for Consumptive coagulopathy – Platelet count/BT/CT/PT/INR & APTT Liver and Renal function tests INVESTIGATIONS
  28. 28. Fetal blood vessels from placenta or umbilical cord cross the internal os beneath the baby Rupture of membranes lead to damage of the fetal vessels leading to exsanguination and death High fetal mortality (50-75%) VASA PRAEVIAVASA PRAEVIA
  29. 29. 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 RISK FACTORS OF VASA PREVIA
  30. 30.  Moderate vaginal bleeding + fetal distress  Vessels may be palpable through dilated cervix  Vessels may be visible on ultrasound (TV colour Doppler ultrasound)  Difficult to distinguish from abruption  Can look for fetal Hb (Kleihauer-Betke test) or nucleated RBC’s in shed blood  Tachycardia or bradycardia in CTG DIAGNOSIS - VASA PRAEVIA
  31. 31. Management of APH
  32. 32.  Advised to report all vaginal bleeding to antenatal care provider  Admit to hospital for clinical assessment & management  Senior staff must be involved – Senior obstetrician, anesthetist, neonatologist  May need resuscitation measures if in shock or severe bleeding  Airway(A), breathing(B) & circulation(C)  Two wide bore cannula  Take blood for Grouping, CBC, coagulation profile, Liver & renal function  Volume should be replaced by Crystalloid /colloid until blood is available  Severe bleeding or fetal distress: Urgent delivery of baby irrespective of gestational age MOTHER IS THE PRIORITY IN ABOVE MENTIONED CONDITIONMOTHER IS THE PRIORITY IN ABOVE MENTIONED CONDITION MANAGEMENT OF APH
  33. 33. What is the role of clinical assessment in women presenting with an APH? To establish whether urgent intervention is required to manage maternal or fetal compromise The process of TRIAGE includes – •history taking to assess coexisting symptoms such as pain •an assessment of the extent of vaginal bleeding •cardiovascular condition of mother •assessment of fetal well-being MANAGEMENT OF APH
  34. 34. History Obtain history if no maternal compromise –  Colour and consistency of bleeding  Quantity & 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 fetal movements  Ascertain blood group  Previous cervical smear history if available MANAGEMENT OF APH CONT…
  35. 35. Examination To assess amount & cause of APH  Assess maternal & fetal well-being  Pallor, record temperature, pulse & BP  Perform abdominal examination • Note areas of tenderness & hypertonicity • Determine gestational age of fetus, presentation • & position, auscultate fetal heart No vaginal examination should be attempted at least until placenta previa is excluded Do speculum examination to assess cervix / bleeding & exclude local lesions   MANAGEMENT OF APH CONT…
  36. 36. Investigations  Arrange urgent ultrasound scan Does not exclude abruption Glantz and colleagues reported the sensitivity, specificity, and positive and negative predictive values of ultrasonography for placental abruption to be 24%, 96%, 88%, and 53%, respectively. Glantz C et al 2002  Fetal monitoring Continuous electronic fetal monitoring indicated where knowledge of fetal condition influence timing & mode of delivery MANAGEMENT OF APH CONT…
  37. 37.  Rhesus negative woman should have a Kleihauer test & be given prophylactic anti-D immunoglobulin  For preterm delivery between 24+0 & 34+6 weeks POG, antenatal corticosteroids - to promote fetal lung maturity (RCOG 2011) • Betamethasone • Dexamethasone MANAGEMENT OF APH CONT…
  38. 38. Role of tocolytic therapy in women presenting with APH having uterine activity – • preterm needing transfer to hospital with NICU facility • incomplete course of corticosteroids Calcium antagonist (Nifedipine) best avoided with cases of maternal hypotension Drug of choice should have fewest maternal cardiovascular side effects (RCOG 2011) MANAGEMENT OF APH CONT…
  39. 39. Depend on -  Cause of APH  Extent of bleeding  Presence of fetal distress  Gestational age & fetal maturity FURTHER MANAGEMENT OF APH
  40. 40.  Near term / Term Delivery is considered Type Ia, Ib & IIa - May be able to deliver vaginally Type IIb, III and IV - Will require caesarean section by senior obstetrician Should anticipate PPH  Pregnancy below 34 weeks POG Continuation of pregnancy better if possible • Need bed rest • Educate patient regarding condition & risk • cross matched blood should be reserved till delivery • Fetal well being & growth should be monitored –BPP,CTG,USS • Medications may be given to prevent premature labor- Nifedipine, Atosiban PLACENTA PRAEVIA - MANAGEMENT
  41. 41. Small abruption Conservative management depending on gestational age Careful monitoring of fetal condition Moderate or severe placental abruption •Restore blood loss •Ideally measure central venous pressure (CVP) & adjust transfusion accordingly •Prevent coagulopathy •Monitor urinary output •Delivery 1.Caesarean section 2.Vaginal- If coagulopathy present If fetus is not compromised If fetus is dead PLACENTAL ABRUPTION – MANAGEMENT
  42. 42. •Urgent delivery •Most of the time urgent LSCS •Neonatologist involvement •Aggressive resuscitation of the baby with blood transfusion following delivery VASA PREVIA MANAGEMENT
  43. 43.  Women presenting with APH before 37+0 weeks POG, where there is no maternal or fetal compromise & bleeding has settled, there is no evidence to support elective premature delivery of fetus  Following an episode of major APH that has settled or recurrent unexplained APH it is reasonable to arrange delivery of the fetus after 37+0 weeks POG  If presenting after 37+0 weeks it is important to establish if the bleeding is an APH or blood stained „show ; if the blood is streaked through mucus it is‟ unlikely to require active intervention  in the event of major APH, IOL with aim of achieving vaginal delivery should be considered in order to avoid adverse consequences potentially associated with a further APH POINTS TO REMEMBER
  44. 44. Fetus may die from hypoxia during heavy bleeding Perinatal mortality more than 50 per 1000 even with tertiary care facilities High rates of maternal mortality PROGNOSIS OF APH