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DESCRIPTION
A -presentation describing in detail the causes for antepartum hemorrhage and its treatmentTRANSCRIPT
Antepartum Haemorrhage
Saad Bin Zafar Mahmood
DefinitionHemorrhage from the vagina
after the 24th week of gestation till end of pregnancy
Blood loss of greater than 300mls
Incidence : 3-5% of all pregnancies
Antepartum Haemorrhage: TypesSimple:
◦ Local Vagina – Trauma Cervical – Infection or tumor
- Blood dyscrasias Thrombocytopenia Anticoagulants
Complicated:◦ Abruptio Placentae◦ Placental praevia◦ Vasa Praevia
Abruptio PlacentaePremature separation of the placenta.
Pathophysiology of placental abruption:◦Bleeding into the decidua basalis layer◦Hematoma forms causing further
placental separation◦Fetal blood supply is further compromised◦Complication - Couvelaire Uterus
(Retroplacental blood goes into the peritoneal cavity)
ClassificationClinical classificationClass 0 - AsymptomaticClass 1 - Mild (represents
approximately 48% of all cases)Class 2 - Moderate (represents
approximately 27% of all cases)Class 3 - Severe (represents
approximately 24% of all cases)
Placental abruption: typesPlacental abruption can be broadly
classified into two types:◦ Revealed◦ Concealed◦ Mixed
Presentation Symptoms
◦Vaginal bleeding - 80%◦Abdominal or back pain and uterine
tenderness - 70%◦Fetal distress - 60%◦Abnormal uterine contractions (eg,
hypertonic, high frequency) - 35%◦Idiopathic premature labor - 25%◦Fetal death – 15%
Presentation Physical Examination
◦Should be done after stabilizing the patient
◦Ultrasound should be done first to assess the location of placenta. Only then should a digital pelvic exam be conducted
◦Profuse bleeding in waves◦Uterine contraction / Uterine hypertonus◦Shock◦Absence of fetal heart sounds◦Increased fundal height (due to hematoma)
Risk factors of Abruptio Placentae
◦Maternal hypertension◦Maternal trauma◦Cigarette smoking◦Alcohol consumption◦Cocaine use◦Short umbilical cord◦Maternal age <20 or >35 years◦Low socioeconomic status◦Elevated second trimester maternal serum
alpha-fetoprotein (associated with up to a 10-fold increased risk of abruption)
◦Previous placental abruption
InvestigationsLaboratory studies
◦CBC◦PT & APTT◦Fibrinogen levels◦BUN / creatinine
Imaging studies◦Transvaginal ultrasonography◦Transabdominal ultrasonography
Complications of Abruptio placentae - Maternal
Can lead
to DIC
Fetal complications include◦Hypoxia or hypoxic-ischemic encephalopathy
(HIE)◦growth retardation◦CNS abnormalities◦Intra uterine death.
Complications of Abruptio placentae – Fetal
Placenta praeviaImplantation of placenta over the internal
cervical os and therefore in front of the presenting part
Pathophysiology◦ Delay in implantation of blastocyst so that it
occurs in the lower part of uterus◦ In third trimester isthmus of uterus thins to form
lower uterine segment◦ Placental attachment is disrupted as the area
gradually thins in preparation of the onset of labor
◦ This leads to bleeding from the venus sinuses
Placenta previa: typesComplete placenta previaPartial placenta previaMarginal placenta previa (placenta
approaching the border of os)
Grading of placenta previa:Grade I – The placenta is in the lower
segment, but the lower edge does not reach the internal os.
Grade II – The lower edge of the low-lying placenta reaches, but does not cover the internal os.
Grade III – The placenta covers the internal os.
Grade IV – The placenta covers and entirely surrounds the internal os
Presentation Symptoms
◦Painless vaginal bleeding◦Bleeding stops spontaneously and recurs
with labor◦Malpresentation (Breech, transverse lie)
Physical Exam◦Digital exam is contraindicated◦Uterus is soft and non tender◦Concurrent contractions with bleeding
are present
Placenta previa : Risk factors
Previous placenta previa.Multiple pregnancies- due to the
placenta occupying a large surface area.
Cigarette smokingIncreased maternal ageUterine scar (previous caesarean
section)Endometritis
InvestigationsLaboratory studies
◦CBC◦PT & APTT
Imaging studies◦Transvaginal ultrasonography◦Transabdominal ultrasonography
Abruptio Placentae Placenta Previa
Pain Abdominal pain, low back pain Painless unless in labour
Uterus Tender, irritable Nontender, soft (unless contracting)
Presentation Not associated with abnormal presentation Breech or high presenting part
Fetus Fetal heart tracing abnormal, atypical
Fetal tracing not affected since blood is maternal
ShockShock/anemia out of proportion to amount of blood seen
Shock/anemia proportionate to blood seen
Imaging U/S cannot rule out U/S sensitive
Differential DiagnosisAbruptio Placentae Placenta Previa
Labour with bloody show Abruptio Placentae
Vasa previa Cervicitis
Vaginal trauma Premature rupture of membranes
Vaginitis Vaginitis
Preterm labour Preterm labour
Non Placental causes of APH
Vasa previa:
Vasa previa is a condition when fetal vessels traverse the fetal membranes over the internal os.
These vessels course within the membranes (unsupported by the umbilical cord or placental tissue) and are at risk of rupture when the supporting membranes rupture.
Management of Antepartum Hemorrhage
Initial management
Assessing the airways:Assessing the breathing:Assessing the circulation
Cannula inserted for◦Drug adminstration◦Blood sampling◦IV fluid adminstration
Placenta previaIf uncomplicated pregnancy no need of
interventionVitamins and Iron supplements should be
takenIf minimal bleeding expected management
may be continuedIf needed tocolytics may be considered to
administer antenatal steroidsBefore the delivery the following should be
consulted◦ Obstetric anesthesiologist◦ Interventional radiologist◦ General surgeon◦ Urologist
Placenta previaIf placental edge is more than 2cm from
internal cervial os trial of labour can be offered.
If the distance is less than 2cm cesarian section is done although an SVD can be done
Delivery is mostly done at 36-37 weeks of gestation
Low transverse uterine incision is usedIf the patient is at risk of invasive
placentation than informed consent should be taken for cesarian hysterectomy
Abruptio placentaeVitamins and Iron supplements should be takenInitial managementTransfusion, correction of coagulopathy and Rh
immune globulin if neededCesarian section preferable mode of delivery
◦ Vertical incision◦ Hysterectomy might be needed if severe blood loss
Tocolytics may be used in case of preterm delivery only if◦ Hemodynamically stable◦ No fetal distress◦ Preterm fetus may benefit from corticosteroid therapy
In case of fetal death mode of delivery is SVD
Types of tocolyticsTypes of Tocolytics
B2 agonist
Calcium channel blockers
Oxytocin antagonist – Atosiban
NSAIDs
Uterine rupture-managementIt is an emergency Laprotomy is urgently doneUterine rupture can be an
antepartum or postpartum event
Vasa previa
When vasa previa is diagnosed antenatally, an elective Caesarean section should be offered prior to the onset of labour.
In cases of vasa previa, premature delivery is most likely, therefore, consideration should be given to administration of corticosteroids at 28 to 32 weeks
Antepartum hemorrhage
History and Physical Examination
Fetal monitoring
Massive bleeding
Normal Bloody show
Routine Evaluation
Severely distressed fetus
Suspect Vasa Previa
Urgent Cesarean delivery
Inflamed cervix or mucopurulent
discharge
Probable cervical infection
Culture and treat as
appropriate
Uterine pain ??
No pain or pain only with
contractions. Non tender fundus
Pain between contractions and
tender fundus
Cesarean delivery if in
labour
Suspect Placenta previa
Immediate ultrasound
examination if available
Consider abruptio
placentaeConsider uterine
rupture
Consider urgent lapartomy
Monitor fetus. Supportive
mother care
Cesarean if fetal distress
SVD if fetal death
Call for helpEvaluate ABCsAdminister IV
fluidsConsider
transfusionConsider CS