aph antepartum hemorrhage
DESCRIPTION
ObGyn, obstetrical emergencyTRANSCRIPT
APH
By: Huzaifa Hamid
Definition
is defined as vaginal bleeding from 24 weeks to delivery of the baby.
Or any bleeding occurring in the antenatal period after 20 weeks gestation.
It complicates 2–5% of pregnancies. It is associated with increased risks of
fetal and maternal morbidity and mortality
Causes
• Erosion• Polyps• Cancer
• Varicosities
• Lacerations
• Abraptio p.
• Placenta p.
• Vasa previa
Initial steps in management of late pregnancy bleeding:
initial management: patient’s vitals FHM IV fluids
Order lab tests: CBC DIC workup (platelets, PT,
PTT, fibrinogen, and D-dimer)
Type and cross-match Ultrasound “The most
accurate”
further steps in management: Give blood transfusion for
large volume loss. Place Foley catheter and
measure urine output. Perform vaginal exam to
rule out lacerations. Schedule delivery if fetus is
in jeopardy or gestational age is ≥ 36 weeks.Never perform a digital or speculum examination in a patient
with late vaginal bleeding until a vaginal ultrasound first rules out placenta previa.
Apt, Kleihauer-Betke, and Wright’s stain tests determine if blood is fetal,
maternal, or both.
ABRUPTIO PLACENTA
Introduction
Definition:It is the separation of the placenta from its site of implantation before delivery of the fetus.
Varieties:- Total or partial- Revealed or Concealed
Incidence:1 in 200 deliveries
Placental Abruption
Pathophysiology
Initiated by bleeding into the decidua basalis, the bleeding splits the decidua, and a decidual hematoma forms. The hematoma leads to separation, compression, and destruction of the placenta adjacent to it.
a. The process may be self-limited, with no further complication to the pregnancy or may continue to become catastrophic.
b. Bleeding insinuates between the fetal membranes and uterus which may extravasate or may remain concealed. Concealed abruptions can often be more compromising to maternal hemodynamic status since they are generally underappreciated.
Risk Factors
Increased age & parity.
Hypertension. Preterm ruptured
membranes. Multiple gestation. Polyhydramnios.
Smoking. Cocaine use. Prior abruption. Uterine fibroid. Trauma
Clinical presentation
Vaginal bleeding. Constant and severe abdominal pain. Irritable, tender, and typically hypertonic
uterus. Evidence of fetal distress (if severe). Maternal shock. Disseminated intravascular coagulation.Up to 20% of placental abruptions can present without vaginal bleeding because
bleeding is concealed.
U|S for Abruptio placenta
Abratio Placenta
Diagnosis:Clinically: Late trimester painful bleeding Normal placental implantation Disseminated intravascular coagulopathy
(DIC)
Ultrasonography:
Management
Emergency CS
Vaginal Delivery
Conservative
Management
Emergency cesarean delivery: if maternal or fetal jeopardy is present as soon as the mother is stabilized.
Vaginal delivery: if bleeding is heavy but controlled or pregnancy is >36 weeks. Perform amniotomy and induce labor. Place external monitors to assess fetal heart rate pattern and contractions. Avoid cesarean delivery if the fetus is dead.
Conservative in-hospital observation: if mother and fetus are stable and remote from term, bleeding is minimal or decreasing, and contractions are subsiding. Confirm normal placental implantation with sonogram and replace blood loss with crystalloid and blood products as needed.
Complications
Maternal : Hypovolemia. DIC. Renal failure. Death. Uterine rupture
Fetal : Hypoxia. IUGR. IUFD. Anemia
PLACENTA PREVIA
Introduction
Definition:the placenta is implanted in the lower uterine segment.
Classification: Complete placenta previa: The placenta covers the
entire internal cervical os. Partial placenta previa: The placenta partially covers the
internal cervical os. Marginal placenta previa: One edge of the placenta
extends to the edge of the internal cervical os. Low-lying placenta: Within 2 cm of the internal cervical
os.Incidence: Complicates approximately 1 in 300 pregnancies.
Placenta Previa
Ultrasound performed in the second trimester may show a placenta previa in 5% to 15% of cases. However, as the lower uterine segment develops, over 90% of these previas will resolve. A repeat ultrasound
should be performed at 28 weeks to confi rm the presence of a placenta previa.
Placental migration
At 16 weeks 20% At 40 weeks 0.5% Why the difference?
TrophoTropism Placental migration
Next Slide …
Mechanism of migration
Pathophysiology of bleeding
Avulsion of villi, stretching of lower uterine segment
Risk Factors
Multiparty Increased maternal
age Previous placenta
previa Multiple gestation Previous C/S Uterine anomalies Maternal smoking
ART!!!
Presentation & Diagnosis
Late trimester bleeding Lower segment placental
implantation No pain MRI or Double set-up
Transabdominal US(95% accurate)
U|S Placenta Previa
Management
Emergency cesarean delivery
Conservative in-hospital observation
Vaginal delivery
Scheduled cesarean delivery
Management
Emergency cesarean delivery: if maternal or fetal jeopardy is present after stabilization of the mother.
Conservative in-hospital observation: Conservative management of bed rest is performed in preterm gestations if mother and fetus are stable and remote from term. The initial bleed is rarely severe. Confirm abnormal placental implantation with sonogram and replace blood loss with crystalloid and blood products as needed.
Vaginal delivery: This may be attempted if the lower placental edge is >2 cm from the internal cervical os.
Scheduled cesarean delivery: if the mother has been stable after fetal lung maturity has been confirmed by amniocentesis, usually at 36 weeks’ gestation.
Complications of Placenta praevia
Preterm delivery. PPROM. IUGR Malpresentation Fetal abnormalities ↑ number of C/S. morbidly adherent placenta Postpartum haemorrhage
morbidly adherent placenta
Placenta accreta: The placenta is abnormally attached directly to the myometrium.Placenta increta: The placenta invades the myometrium.Placenta percreta: The placenta penetrates completely through the myometrium.
If placenta previa occurs over a previous uterine scar the villi may invade beyond Nitabuch layer resulting in PLACETNA ACRETA
Summary
Abruptio Placenta Placenta Previa
Pain Yes No
Risk factors PreviousabruptionHypertensionTraumaCocaine abuse
Previous previaMultiparityStructuralabnormalities(e.g., fibroids)Advanced maternalage
Diagnosis:Sonogram
Placenta innormalposition ±retroplacentalhematoma
Placenta implantedover the loweruterine segment
Summary
Abruptio Placenta Placenta Previa
Management 1. Emergent c-section: Best choice for placenta previa or if patient/fetus is deteriorating.2. Vaginal delivery if ≥ 36 weeks or continued bleeding. May be attempted in placenta previa if placenta is > 2 cmfrom internal os.3. Admit and observe if bleeding has stopped, vitals and fetal heart rate (FHR) stable, or < 34 weeks.
Complication Disseminatedintravascularcoagulation
Placenta accreta/increta/percreta→ hysterectomy
Any question?