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Antepartum haemorrhage

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Title: Slide 1 Author: Khoujah ~ Last modified by: Khoujah ~ Created Date: 2/24/2009 10:44:17 PM Document presentation format: On-screen Show (4:3) Company – PowerPoint PPT presentation

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Title: Antepartum haemorrhage


1
Antepartum haemorrhage
  • antepartum haemorrhage (APH), also prepartum
    hemorrhage, is bleeding from the vagina during
    pregnancy from twenty four weeks gestational age
    to term.
  • It should be considered a medical
    emergency(regardless of whether there is pain)
    and medical attention should be sought
    immediately, as if it is left untreated it can
    lead to death of the mother and/or fetus.

2
Differential diagnosis of APH
  • placental abruption 15
  • placenta praevia 10
  • rarely caused by vasa praevia
  • Other causes include
  • incidental haemorrhage from a lesion of the
    cervix or vagina - infection, carcinoma, polyp,
  • show - expulsion of the mucus plug at the onset
    of labour
  • Other causes to consider include
  • rectal bleeding bleeding diatheses haematuria

3
Abruptio placenta
  • Abruptio placentae refers to separation of the
    normally located placenta after the 20th week of
    gestation and prior to birth.

4
Pathophysiology
  • Bleeding into the decidua basalis leads to
    separation of the placenta. Hematoma formation
    further separates the placenta from the uterine
    wall, causing compression of these structures and
    compromise of blood supply to the fetus. The
    myometrium in this area becomes weakened and may
    rupture with increased intrauterine pressure
    during contractions. A myometrium rupture
    immediately leads to a life-threatening
    obstetrical emergency

5
  • Severity of fetal distress correlates with the
    degree of placental separation. In near-complete
    or complete abruption, fetal death is inevitable
    unless an immediate cesarian delivery is
    performed.

6
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7
  • Frequency
  • Occurs in about 1 of all pregnancies throughout
    the world.
  • Mortality/Morbidity
  • Maternal and fetal death may occur because of
    hemorrhage and coagulopathy. The fetal perinatal
    mortality rate is approximately 15.

8
Causes
  • Maternal hypertension - Most common cause of
    abruption, occurring in approximately 44 of all
    cases
  • Idiopathic (probable abnormalities of uterine
    blood vessels and decidua)
  • Maternal trauma (eg, motor vehicle collision
    MVC, assaults, falls) - Causes 1.5-9.4 of all
    cases
  • Cigarette smoking
  • Alcohol consumption
  • Cocaine use
  • Short umbilical cord
  • Sudden decompression of the uterus (eg, premature
    rupture of membranes, delivery of first twin)
  • Retroplacental fibromyoma
  • Retroplacental bleeding from needle puncture (ie,
    postamniocentesis)
  • Advanced maternal age

9
Symptoms
  • Patients usually present with the following
    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

10
classification
  • Is based on extent of separation (ie, partial vs
    complete) and location of separation (ie,
    marginal or central).
  • Class 0 asymptomatic. Diagnosis is made
    retrospectively by finding an organized blood
    clot or a depressed area on a delivered placenta.
  • Class 1 mild and represents approximately 48 of
    all cases. Characteristics include the following
  • No vaginal bleeding to mild vaginal bleeding
  • Slightly tender uterus
  • Normal maternal BP and heart rate
  • No coagulopathy
  • No fetal distress

11
  • Class 2 moderate and represents approximately
    27 of all cases. Characteristics include the
    following
  • No vaginal bleeding to moderate vaginal bleeding
  • Moderate-to-severe uterine tenderness with
    possible tetanic contractions
  • Maternal tachycardia with orthostatic changes in
    BP and heart rate
  • Fetal distress
  • Hypofibrinogenemia (ie, 50-250 mg/dL)

12
  • Class 3 severe and represents approximately 24
    of all cases. Characteristics include the
    following
  • No vaginal bleeding to heavy vaginal bleeding
  • Very painful tetanic uterus
  • Maternal shock
  • Hypofibrinogenemia (ie, lt150 mg/dL)
  • Coagulopathy
  • Fetal death

13
Workup
  • Laboratory Studies
  • Hemoglobin
  • Hematocrit
  • Platelets
  • Prothrombin time/activated partial thromboplastin
    time
  • Fibrinogen
  • Fibrin/fibrinogen degradation products
  • D-dimer
  • Blood type
  • Imaging Studies
  • Ultrasonography helps determine the location of
    the placenta to exclude placenta previa
    Ultrasonography is not very useful in diagnosing
    placental abruption.
  • Retroplacental hematoma may be recognized in
    2-25 of all abruptions.

14
Manegement
  • The management of this condition is largely
    dependent on the severity of the haemorrhage and
    the condition of the mother and the fetus.
  • DO NOT PERFORM A DIGITAL EXAMINATION.

15
  • all patients with suspected placental abruption.
    This care includes the following
  • Continuous monitoring of vital signs
  • Continuous high-flow supplemental oxygen
  • One or 2 large-bore IV lines with normal saline
    (NS) or lactated Ringer (LR) solution
  • Monitoring amount of vaginal bleeding
  • Monitoring of fetal heart
  • Treatment of hemorrhagic shock, if needed

16
Mild abruption
  • admit to hospital
  • bed rest
  • iv line in situ
  • blood cross-match, FBC, clotting studies
  • localise placenta by ultrasound scan
  • inspection of cervix with a speculum
  • The patient may be discharged after 4-5 days if
    the bleeding does not recur. The pregnancy should
    be monitored using ultrasound measurements of
    fetal growth and cardiac monitoring, and fetal
    kick charts. Intercourse should be avoided

17
Sever cases
  • Closely observe the patient. inister supplemental
    oxygen.
  • Admtinuous fetal monitoring.
  • Administer IV fluids.
  • Perform aggressive fluid resuscitation to
    maintain adequate perfusion, if needed.
  • Monitor vital signs and urine output.
  • Crossmatch 4 units of packed red blood cells.
    Transfuse, if necessary.
  • Perform amniotomy to decrease intrauterine
    pressure, extravasation of blood into the
    myometrium, and entry of thromboplastic
    substances into the circulation.
  • Immediately deliver the fetus by cesarean
    delivery if the mother or fetus becomes unstable.
  • Treatment of coagulopathy or disseminated
    intravascular coagulation (DIC) may be necessary.
    Some degree of coagulopathy occurs in about 30
    of severe cases of placental abruption. The best
    treatment for DIC as a complication of placental
    abruption is immediate delivery.

18
prognosis
  • The recurrence rate of fetal abruption is as high
    as 1 in 10. Therefore, subsequent pregnancies
    have a risk of separation at any time and must be
    treated as high risk.
  •  

19
Placenta previa
  • Placenta previa is generally defined as the
    implantation of the placenta over or near the
    internal os of the cervix.

20
Classification
  • Total placenta previa occurs when the internal
    cervical os is completely covered by the
    placenta.
  • Partial placenta previa occurs when the internal
    os is partially covered by the placenta.
  • Marginal placenta previa occurs when the placenta
    is at the margin of the internal os.
  • Low-lying placenta previa occurs when the
    placenta is implanted in the lower uterine
    segment. In this variation, the edge of the
    placenta is near the internal os but does not
    reach it

21
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22
Pathophysiology
  • The exact etiology of placenta previa is unknown.
    The condition may be multifactorial and is
    postulated to be related to multiparity, multiple
    gestations, advanced maternal age, previous
    cesarean delivery, previous abortion, and
    possibly, smoking.

23
Frequency
  • Placenta previa complicates approximately 5 of
    1,000 deliveries and has a mortality rate of
    0.03.

24
Causes
  • Prior uterine insult or injury
  • Risk factors
  • Prior placenta previa (4-8)
  • First subsequent pregnancy following a cesarean
    delivery
  • Multiparity (5 in grand multiparous patients)
  • Advanced maternal age
  • Multiple gestations
  • Prior induced abortion
  • Smoking

25
Symptoms
  • Vaginal bleeding
  • It is apt to occur suddenly during the third
    trimester.
  • Bleeding is usually bright red and painless. Some
    degree of uterine irritability is present in
    about 20 of the cases.
  • Initial bleeding is not usually profuse enough to
    cause death it spontaneously ceases, only to
    recur later.
  • The first bleed occurs (on average) at 27-32
    weeks' gestation.
  • Contractions may or may not occur simultaneously
    with the bleeding.

26
Physical
  • Profuse hemorrhage
  • Hypotension
  • Tachycardia
  • Soft and nontender uterus
  • Normal fetal heart tones (usually)
  • Vaginal and rectal examinations
  • Do not perform these examinations in the ED
    because they may provoke uncontrollable bleeding.
  • Perform examinations in the operating room under
    double set-up conditions (ie, ready for emergent
    cesarean delivery)

27
Workup
  • Laboratory Studies
  • Beta-human chorionic gonadotropin (beta-hCG)
    subunit
  • Rh compatibility
  • Fibrin split products (FSP) and fibrinogen levels
  • Prothrombin time (PT)/activated partial
    thromboplastin time (aPTT)
  • CBC-bld Group and cross matching
  • Apt test to determine fetal origin of blood (as
    in the case of vasa previa)
  • Wright stain applied to a slide smear of vaginal
    blood, looking for nucleated red blood cells
    (RBCs), not adult blood
  • Lecithin/sphingomyelin (L/S) ratio for fetal
    maturity, if needed

28
Imaging study
  • Transabdominal ultrasonography
  • A simple, precise, and safe method to visualize
    the placenta, this ultrasonography has an
    accuracy of 93-98.
  • Transvaginal ultrasonography
  • Recent studies have shown that the transvaginal
    method is safer and more accurate than the
    transabdominal . And also considered more
    accurate than transabdominal ultrasonography. In
    one study, 26 of placental localization
    diagnosed by transabdominal ultrasonography was
    later changed using transvaginal ultrasonography.

29
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30
Procedures
  • If the location of the placenta is unknown and
    sonography is not available, a double set-up
    bimanual examination under anesthesia (EUA) may
    be performed in the operating room.

31
Manegement
  • The principle objective of management is to
    prolong the pregnancy until the fetus is mature.
    Optimally, this is a gestational age of 37 weeks
    the neonatal mortality rate is not improved by
    further intrauterine development

32
  • Immediate steps include
  • admission to hospital that is equipped to deal
    with this condition
  • bed rest
  • cross matching of blood
  • transfusion if severe haemorrhage use O Rh-ve
    blood

33
  • If there is a diagnosis of a major placenta
    praevia then a caesarian section should be
    undertaken without vaginal examination.
  • If the diagnosis is in doubt or there is minor
    placenta praevia then there should be vaginal
    examination under anaesthesia this should be
    carried out when the fetus is as mature as
    possible and only in the setting of the operating
    theatre with preparations for caesarian section.

34
  • Rarely, placenta praevia haemorrhage may be so
    severe as to necessitate evacuation of the uterus
    despite fetal immaturity

35
Vasa Previa
  • Definition bleeding from umbilical vessels.
  • Diagnosis Apt test (hemoglobin alkaline
    denaturation test.
  • Complications bleeding is fetal in origin
    (mortality is gt75).
  • Treatment Emergent CS if fetus is viable.

36
Apt Test
  • Addition of 2-3 drops of alkaline solution to 1
    ml of blood.
  • Fetal erythrocyte are resistant to rupture and
    the mixture will remain red.
  • If the blood is maternal, erythrocytes will
    rupture and the mixture will turn browne.

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39
  • Thanx
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