الرحيم الرحمن الله الرحيم بسم الرحمن الله بسم

Antepartum Antepartum haemorrhage(APH)haemorrhage(APH)

By Dr. sallama kamelBy Dr. sallama kamel

DefinitionDefinition::

--APHAPH is defined as bleeding in the third is defined as bleeding in the third trimester of pregnancy, after 24weeks and trimester of pregnancy, after 24weeks and before the delivery of the fetusbefore the delivery of the fetus..

--It complicates It complicates 4 percent4 percent of all pregnancies of all pregnancies..

--It is an obstetric emergency because it It is an obstetric emergency because it endanger the life of both the mother and endanger the life of both the mother and fetusfetus..

--Hemorrhage remain the most frequent cause Hemorrhage remain the most frequent cause of maternal deathsof maternal deaths..

EtiologyEtiology::Placental causesPlacental causes::

11..Placenta previa (30% )Placenta previa (30% )..22..Abruptio placenta (34%)Abruptio placenta (34%)..

33..Vasa previa (1%)Vasa previa (1%)..Local causes (5%)Local causes (5%)::

11..CervicitisCervicitis..22..Cervical erosionCervical erosion..

33..Cervical carcinomaCervical carcinoma..44..Vaginal infectionVaginal infection..

55..Vaginal traumaVaginal trauma..In 30% of cases no cause can be foundIn 30% of cases no cause can be found..

Placenta previa and abruptio placenta represents the Placenta previa and abruptio placenta represents the main causes of APH and will be discusses in detailsmain causes of APH and will be discusses in details

Placenta previa (P.P.)Placenta previa (P.P.)..Means implantation of the placenta in the lower uterine segmentMeans implantation of the placenta in the lower uterine segment..

IncidenceIncidence::♠♠ It complicate It complicate 0.5%0.5% of pregnancies(1 in 200 pregnancies) of pregnancies(1 in 200 pregnancies)..

♠♠Bleeding from placenta previa account for about Bleeding from placenta previa account for about 30% of all cases of 30% of all cases of APHAPH..

Predisposing factorsPredisposing factors::11..MultiparityMultiparity..

22..Previous C/S scarPrevious C/S scar..33..Increasing maternal ageIncreasing maternal age..

44..Multiple gestationMultiple gestation..55..Prior placenta previaPrior placenta previa::

patient with a placenta previa has a 4% - 8% risk of having p.p. inpatient with a placenta previa has a 4% - 8% risk of having p.p. in subsequent pregnancysubsequent pregnancy..

66..Congenital anomaly of the uterus e.g. septate uterusCongenital anomaly of the uterus e.g. septate uterus..

What is the lower uterine segmentWhat is the lower uterine segment::

The lower segment can be defined as that part of the uterine wall which:

•Does not contract in labour but is stretched inresponse to contractions.

•Used to be the isthmus before pregnancy. •Underlies the loose fold of peritoneum that

reflects from the bladder. •Is covered by a full bladder anteriorly.

•Is within 8 cm of the internal cervical os at term.

Grading of placenta previaGrading of placenta previa

Grade .1 (lateral placenta)Grade .1 (lateral placenta)..The placenta implanted in the lower uterine segment The placenta implanted in the lower uterine segment but does not reach the internal osbut does not reach the internal os..Grade .2.(marginal placenta)Grade .2.(marginal placenta)..

The edge of the placenta reaches the internal os but The edge of the placenta reaches the internal os but not covering itnot covering it..Grade.3.(partial placenta previa)Grade.3.(partial placenta previa)..The placenta partially covering the internal osThe placenta partially covering the internal os..Grade.4.(complete placenta previa)Grade.4.(complete placenta previa)..The placenta cover the internal os completelyThe placenta cover the internal os completely..Grade 1&2 called minor P.P. grade 3&4 major P.PGrade 1&2 called minor P.P. grade 3&4 major P.P..

Grades of P.PGrades of P.P..

Clinical presentationClinical presentation::

11..Painless, recurrent unprovoked vaginal Painless, recurrent unprovoked vaginal bleedingbleeding::

--Placenta previa characteristically present with Placenta previa characteristically present with unprovoked painless bleedingunprovoked painless bleeding..

--Bleeding occurs as a result of disruption of the Bleeding occurs as a result of disruption of the placental attachment secondary to the development placental attachment secondary to the development and thinning of the lower uterine segmentand thinning of the lower uterine segment..

--In general those with complete previa bleeds earlier In general those with complete previa bleeds earlier and more heavily than those with a partial orand more heavily than those with a partial or

--The bleeding is usually recurrentThe bleeding is usually recurrent..--The mean gestational age at the onset of the first The mean gestational age at the onset of the first

bleeding is 30 weeks with one third presenting bleeding is 30 weeks with one third presenting before 30 weeksbefore 30 weeks..

22 . .malpresentationmalpresentation::--On abdominal examination it is common to find On abdominal examination it is common to find

malpresentation in association with placenta previa malpresentation in association with placenta previa (which are either breech or transverse lie in about (which are either breech or transverse lie in about 35%)35%)..

--Slight but inconsistent deviation of the presenting part Slight but inconsistent deviation of the presenting part from the midline and difficulty with palpating the from the midline and difficulty with palpating the presenting partpresenting part..

--The abdomen is usually soft and the fetal heart is The abdomen is usually soft and the fetal heart is normalnormal..

Diagnosis of placenta previaDiagnosis of placenta previa::

Placenta previa is almost exclusively diagnosed nowadays byPlacenta previa is almost exclusively diagnosed nowadays by ultrasoundultrasound . .

-An ultrasound scan will show the position of theplacenta clearly within the uterus .

-If the placenta lies in the anterior part of the uterus andreaches into the area covered by the bladder, it isknown as a low-lying placenta (before 24 weeks) and placenta praevia after 24 weeks

About 5%of patients have some degree of placenta previa on About 5%of patients have some degree of placenta previa on ultrasonic examination before 20 week’s gestation.ultrasonic examination before 20 week’s gestation.

With the development of the lower uterine segment, a relative With the development of the lower uterine segment, a relative upward placental migration occurs, with 90% of these resolves by upward placental migration occurs, with 90% of these resolves by the 3the 3rdrd trimester. trimester.

Clinical diagnosis of placenta previa.Clinical diagnosis of placenta previa.Clinical diagnosis of placenta previa Clinical diagnosis of placenta previa can be

made by palpating the placenta through the cervical os .

However this examination can precipitate profuse vaginal bleeding and it is only indicated when U/S is not available and the patient in labour with non-life-threatening vaginal bleeding.

Such examination should always be done Such examination should always be done in the theatre with every thing is prepared in the theatre with every thing is prepared for caesarian section with a complete for caesarian section with a complete operating team ready to operate should operating team ready to operate should vaginal examination precipitate substantial vaginal examination precipitate substantial bleedingbleeding

((the procedure called the procedure called examination in the examination in the theatretheatre or or double set examinationdouble set examination.(.(

ManagementManagement::

ASYMPTOMATIC LOW-LYING PLACENTA

• All women with a low-lying placenta diagnosedin early pregnancy should be rescanned at 34weeks’ gestation.

•There is no need to restrict work activities orsexual intercourse in women with a low-lyingplacenta on ultrasound unless they bleed.

•If the placenta praevia is still present at 34 weeks’gestation and is Grade I or II, the woman should berescanned on a fortnightly basis but need not be admitted unless they bleed.

Management of patient with bleedingManagement of patient with bleeding

As with any 3As with any 3rdrd trimester bleeding trimester bleeding::The patient condition should initially be stabilizedThe patient condition should initially be stabilized..Fetal monitoring institutedFetal monitoring instituted..Blood studies orderedBlood studies ordered..Blood products made available. Blood products made available. • Admit to hospital.

•Insert a broad-bore i.v. cannula and start an infusion of normal saline—if the woman is shocked start with a colloid infusion, e.g. Haemaccel.

•Take blood for cross-matching and haemoglobin estimation.

Once the diagnosis of placenta previa is established, management Once the diagnosis of placenta previa is established, management decision will depend ondecision will depend on : :

11 . .Gestational ageGestational age..22..Severity of bleedingSeverity of bleeding

11..When the pregnancy is pretermWhen the pregnancy is preterm

The aimThe aim is to is to obtain fetal maturation without obtain fetal maturation without compromising the mother’s healthcompromising the mother’s health..

11..if the bleeding is excessive:Delivery must be accomplished by caesarian section regardless the gestational age.

2 .When the bleeding is not profuse:The patient is managed expectantly in hospital on bed rest and blood transfusion if the woman is anaemic.

After several days without bleeding, she may be After several days without bleeding, she may be ambulate and even discharged if she lives nearbyambulate and even discharged if she lives nearby..

Instruct the patient to return at the first sign of Instruct the patient to return at the first sign of further bleedingfurther bleeding..

Her haematocrite should be followed her Her haematocrite should be followed her haemoglobin should be not less than 11gmhaemoglobin should be not less than 11gm..

Blood should always be available for the patientBlood should always be available for the patient..

•At 36–37 weeks’ presentation, a final ultrasoundshould be performed and acted upon:

)a (Grades III and IV placenta praevia shouldhave a Caesarean section between 37 and 38weeks’ gestation by an experienced obstetricianparticularly if the placenta is on the anterior wallof the uterus.

)b (If the presenting part is below the lower edgeof the placenta in Grade I, then it is safe to waituntil labour and these women can be expected todeliver vaginally.

22..When the patient present in labour with When the patient present in labour with vaginal bleedingvaginal bleeding

the patient should be delivered by caesarean the patient should be delivered by caesarean section if section if placenta previa isplacenta previa is documented by documented by ultrasoundultrasound..

if the ultrasound diagnosis is uncertain, if the ultrasound diagnosis is uncertain, examination in the theatreexamination in the theatre can be done can be done..

In rare cases a patient with In rare cases a patient with marginal placentamarginal placenta previaprevia can be delivered vaginally provided that can be delivered vaginally provided that the fetal head compress the site of bleeding the fetal head compress the site of bleeding during labourduring labour..

In patient with In patient with grade one placenta previagrade one placenta previa (the placenta implanted in the lower (the placenta implanted in the lower segment but not reaching the cervical os (segment but not reaching the cervical os (

vaginal delivery is usually vaginal delivery is usually accomplishedaccomplished, although it should be done , although it should be done in a well controlled manner and settingin a well controlled manner and setting..

33..If the woman is Rh-negativeIf the woman is Rh-negative

There is increased risk of There is increased risk of feto-maternal feto-maternal transfusion and immunizationtransfusion and immunization..

So So anti-D immunoglobulinanti-D immunoglobulin should be given should be given..

A kleihauer-BetkeA kleihauer-Betke test should be done on test should be done on maternal bloodmaternal blood to determine the extent of the to determine the extent of the feto-maternal transfusionfeto-maternal transfusion so that an so that an appropriate larger dose of anti-D may be givenappropriate larger dose of anti-D may be given..

Maternal risks of placenta previaMaternal risks of placenta previa::There is increased maternal mortality and morbidityThere is increased maternal mortality and morbidity..Antepartum and intrapartum haemorrhage carry a constantAntepartum and intrapartum haemorrhage carry a constant threat to the life of patient with placenta previathreat to the life of patient with placenta previa..Bleeding may be due toBleeding may be due to::

11..Placenta previa itselfPlacenta previa itself.. 22 . .major cause of death in women with placenta

praevia now is postpartum haemorrhage (PPH).PPH is common because the lower segment does not contract and retract as in the upper segment, and therefore maternal vessels of the placental bed may continue to bleed after delivery. This may lead to an emergency hysterectomy if the bleedingcannot be stopped.

33..Associated placenta accretaAssociated placenta accreta..

Fetal risks of placenta previaFetal risks of placenta previa::

The perinatal mortality of patients with placenta previa The perinatal mortality of patients with placenta previa is higher than the general population and this is is higher than the general population and this is related torelated to::

11..PrematurityPrematurity (which is the main cause) (which is the main cause)..22..Higher incidence ofHigher incidence of IUGR IUGR (about 20% of pregnancies (about 20% of pregnancies

with placenta previa develops IUGR)with placenta previa develops IUGR)..33..MalpresentationMalpresentation (in 30% of cases) (in 30% of cases)..

44..Higher risk of Higher risk of preterm premature rupture of preterm premature rupture of membranesmembranes..

55..The presence of The presence of vasa previavasa previa which carry a perinatal which carry a perinatal mortality of 75%mortality of 75%..

Vasa previaVasa previa::

This is a rare conditionThis is a rare conditionVelamentous insertion of the umbilical cord in the Velamentous insertion of the umbilical cord in the membranesmembranes..

At the time of rupture of membranes (whether spontaneous At the time of rupture of membranes (whether spontaneous or artificial( the umbilicalor artificial( the umbilical

vessels will rupture causing massivevessels will rupture causing massive bleeding which is of fetal originbleeding which is of fetal origin..

..It is suspected when fetal heartIt is suspected when fetal heart shows sever bradycardia after ruptureshows sever bradycardia after rupture of membranesof membranes..Treatment is by immediate C/STreatment is by immediate C/S..

Placenta accretaPlacenta accreta::

Abnormal attachment of the placenta through the Abnormal attachment of the placenta through the myometrium as a result of defective decidua myometrium as a result of defective decidua formationformation..

11..IIt may be superficial t may be superficial ------------ placenta accretaplacenta accreta

22..The placental villi may invade partially through The placental villi may invade partially through the myometrium-the myometrium---------- - placenta incretaplacenta increta..

33..The villi may invade the serosa-The villi may invade the serosa----- ---- placenta placenta percretapercreta..

Risk factors for placenta accretaRisk factors for placenta accreta..

11..Previous uterine surgeryPrevious uterine surgery..

22..Placenta previaPlacenta previa..

33..Congenital anomalies of the uterusCongenital anomalies of the uterus..

There will be difficulty in delivering the placenta There will be difficulty in delivering the placenta with massive bleedingwith massive bleeding..

Two third of patients will require hysterectomy to Two third of patients will require hysterectomy to save their lifesave their life..