Antepartum hamorrhage

1. 1
ANTEPARTUM HAMORRHAGE
DEFINITION: Bleeding from the genital tract in pregnancy between 20 to 24 week’s gestation and the onset of
labour.
Incidens : 4% of all pregnancies.
It is associated with increased risks of fetal and maternal morbidity and mortality.
Causes:
Placental:
 Abruptio placenta.  Placenta previa.
Non-placental:
 Vasa previa.
 Bloody show
 Trauma.
 Uterine rupture.
 Cervicitis.
 Carcinoma.
 Idiopathic.
ABRUPTIO PLACENTA
DEFINITION: IT IS THE SEPARATION OF THE PLACENTA FROM ITS SITE OF IMPLANTATION BEFORE DELIVERY OF
THE FETUS.
INCIDENCE: 1 IN 200 DELIVERIES
TYPES OF PLACENTAL ABRUPTION:
 REVEALED PLACENTAL ABRUPTION: CAUSES VAGINAL BLEEDING.
 CONCEALED PLACENTAL ABRUPTION: INTERNAL BLEEDING
RISK FACTORS
 INCREASED AGE & PARITY.
 HYPERTENSIVE DISORDERS.
 PRETERM RUPTURED MEMBRANES.
 MULTIPLE GESTATION.
 POLYHYDRAMNIOS.
 SMOKING.
 COCAINE USE.
 UTERINE FIBROID.
 TRAUMA
CLINICAL PRESENTATION
 VAGINAL BLEEDING.  IUFD  FETAL DISTRESS.

2. 2
 NAUSEA & VOMITING  FREQ. CONTRACTION
 UTERINE TENDERNESS
OR BACK PAIN.
 UTERINE
HYPERTONUS.
CLASSIFICATION:
 GRADE 0
 ASYMPTOMATIC,
 GRADE 1
 EXTERNAL VAGINAL BLEEDING
 UTERINE TETANY AND TENDERNESS MAY
BE PRESENT
 NO SIGNS OF MATERNAL SHOCK
 NO EVIDENCE OF FETAL DISTRESS
 GRADE 2.
 EXTERNAL VAGINAL BLEEDING MAY OR
MAY NOT BE PRESENT
 UTERINE TENDER AND TENTANY
 NO SIGNS OF MATERNAL SHOCK
 SIGNS OF FETAL DISTRESS PRESENT
 GRADE 3
 EXTERNAL BLEEDING MAY OR MAY NOT BE
PRESENT
 MARKED UTERINE TETANY
 MATERNAL SHOCK
 FETAL DEATH OR DISTRESS
 COAGULOPATHY IN 30% OF THE CASES
DIAGNOSIS
 PHYSICAL EXAMINATION TO DETERMINE THE UTERINE RIGIDITY OR TENDERNESS.
 ABDOMINAL ULTRASOUND
 CBC
 FETAL MONITORING
 PELVIC EXAM
 VAGINAL ULTRASOUND
MANAGEMENT
 FETAL MONITORING FOR THE FETAL HEART RATE
 BLOOD TRANSFUSION IF ITS NEED
 ADMINISTER RH IMMUNE GLOBULIN IF THE PATIENT IS RH-

3. 3
 VAGINAL DELIVERY
 BLOOD PLASMA REPLACEMENT TO MAINTAIN FIBRINOGEN LEVEL
 CESAREAN DELIVERY IS OFTEN NECESSARY FOR FETAL AND MATERNAL STABILIZATION
PREVENTION
 DO NOT DRINK ANY ALCOHOL SUCH AS BEER AND WINE
 DO NOT SMOKE OR USE RECREATIONAL DRUGS DURING PREGNANCY
 GET EARLY AND REGULAR PRENATAL CARE
 EARLY RECOGNIZING AND MANAGING CONDITIONS IN THE MOTHER SUCH AS DIABETES AND HIGH
BLOOD PRESSURE ALSO DECREASE THE RISK OF PLACENTAL ABRUPTION .
COMPLICATIONS
 MATERNAL
 HYPOVOLEMIC SHOCK
 DIC (DISSEMINATED INTRAVASCULAR
COAGULATION)
 RENAL FAILURE.
 DEATH.
 UTERINE RUPTURE
 FETAL
 HYPOXIA.
 BRAIN DAMAGE
 IUGR.
 STILLBIRTH
 ANEMIA
PLACENTA PREVIA
DEFINITION: THE PRESENCE OF PLACENTAL TISSUE OVERLYING OR PROXIMATE TO THE INTERNAL CERVICAL OS
AFTER VIABILITY.
INCIDENCE: COMPLICATES APPROXIMATELY 1 IN 300 PREGNANCIES.
PREDISPOSING FACTORS:
 MULTIPARTY
 INCREASED MATERNAL AGE
 PREVIOUS PLACENTA PREVIA, RECURRENCE RATE 4-8%
 MULTIPLE GESTATION
 PREVIOUS CESAREAN SECTION
 UTERINE ANOMALIES
 MATERNAL SMOKING

4. 4
GRADES:
 GRADE 1: THE PLACENTAL EDGE IS IN THE LOWER UTERINE SEGMENT BUT DOES NOT REACH THE
INTERNAL OS (LOW IMPLANTATION).
 GRADE 2: THE PLACENTAL EDGE REACHES THE INTERNAL OS BUT DOES NOT COVER IT.
 GRADE 3: THE PLACENTA COVERS THE INTERNAL OS WHEN IT IS CLOSE AND IS ASYMMETRICALLY
SITUATED (PARTIAL).
 GRADE 4: THE PLACENTA COVERS THE INTERNAL OS AND IS CENTRALLY SITUATED (COMPLETE)
CLINICAL PRESENTATION
 BRIGHT RED VAGINAL BLEEDING WITHOUT PAIN
 PREMATURE CONTRACTIONS
 BABY IS BREECH IN TRANSVERSE POSITION
DIAGNOSIS
 HISTORY TAKING
 ABDOMINAL EXAMINATION
 LEOPOLD'S MANEUVERS
 FETAL HEART MONITORING
 VAGINAL EXAMINATION IS AVOIDING
MANAGEMENT
 ADMIT TO HOSPITAL
 CORTICOSTEROIDS
 BLOOD VOLUME REPLACEMENT TO MAINTAIN BLOOD PRESSURE
 AVOIDING INTERCOURSE
COMPLICATIONS OF PLACENTA PRAEVIA
 MATERNAL
 APH
 PPH
 INCREASE RISK OF PUERPERAL SEPSIS
 MALPRESENTATION; BREECH,
OBLIQUE, TRANSVERSE.
 FETAL
 IUGR
 PREMATURE DELIVERY
 DEATH