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Ante partum hemorrhage :

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Title: Ante partum hemorrhage :


1
Ante partum hemorrhage
Islamic University of Gaza faculty of Nursing
2
  • Bleeding from the genital tract in late pregnancy
    after 24th weeks gestation and before the onset
    of labor.

3
  • effect on fetus
  • Fetal mortality
  • Fetal morbidity.
  • Still birth .
  • Neonatal death.
  • Hypoxia to baby.
  • Neurological damage to baby.

4
  • effect on the mother
  • (sever bleeding)
  • shock hemorrhagic.
  • DIC
  • permanent illness.
  • maternal death

5
  • Types of ante partum hemorrhage
  • 1. placenta previa.
  • 2. placenta abruption.
  • Initial intervention ApHge
  • reduce anxiety both parents.
  • Assess the situation.
  • History and details to know the
  • cause of bleeding.
  • Nature type of ApHge.
  • ?? D.D cause of bleeding.

6
Maternal condition
  • Assessment
  • - observe Pallor breathlessness - signs of shock
    .
  • Tachycardia , tachypnea - subnormal temperature
    and hypotension.
  • Assess amount of blood loss
  • gentle abd . examination.
  • Observe signs of labor.

7
  • . Dont do vaginal or rectal examination.
  • Avoid use of enema or suppositries,This will
    exacerbate the condition

8
fetal condition
  • ask about movement of the baby.
  • Auscultation FHR by CTG.
  • U/S
  • ? D.D
  • 1-location of the placenta.
  • 2-pain "continuous intermittent , painless.

9
  • 3-onset of bleeding after trauma , sexual inter
    course .
  • 4-Amount of visible blood
  • 5-color of blood Bright ,red , dark

10
  • 6-degree of shock.
  • 7-consistency of abdomen "tense, tender , soft ,
    board like"
  • 8-lie ,presentation, engagement.
  • 9-F.H.R positive ve.
  • 10-uls site of placenta.

11
  • Supportive treatment
  • Emotional support.
  • Fluid replacement , plasma ,blood.
  • Strong analgesia.
  • Bed rest.
  • Prepare for emergency ambulance

12
Placenta previa  
  • The placenta is partially or wholly implanted in
    the lower uterine segment either anterior or
    posterior wall.
  • Lower uterine segment stretch and grow after 12
    weeks
  • later weeks ,placenta separate and cause sever
    bleeding

13
  • -Cause of bleeding
  • Shearing stress between placental trophoblast and
    maternal venous blood sinus.
  • separation of placenta previa put mother and her
    fetus on risk.
  • degree of placenta previa

14
  • type I-
  • Majority of placenta in uus.
  • Vaginal birth.
  • Mild blood loss .
  • Mother and fetus in good condition

15
  • Type II
  • partially in lower uterine segment.
  • Near the cervical os.
  • Called placenta previa marginal's
  • Vaginal birth possible " placenta anterior"
  • Moderate blood loss.
  • Maternal shock.
  • Fetal hypoxia

16
  • Type III
  • placenta located over the internal cervical
    os ,but not centrally
  • -Sever bleeding
  • -C.S delivery better
  •  

17
  • Type IV
  • placenta located centrally over the internal
    cervical os
  • torrential Hge
  • C .S delivery.

18
  • Pictures of previa
  • painless vaginal bleeding.
  • soft uterus.
  • abd lax.
  • lie unstable.

19
  • presenting part above the pelvic brim.
  • uls confirm the DX and determine degree, vaginal
    bleed
  • this type never bleed . type I
  • early pregnancy heavy bleeding

20
  • Assessing of mother condition
  • Amount of vaginal bleeding.
  • Hx of small repeated blood loss (intervals)
  • After 20th weeks gestation.
  • Common after 34th weeks.

21
  • Degree of the Hge mild, moderate, sever.
  • Occur when doing activity, or even on bed rest.
  • Bright red color bleeding (fresh) .
  • Retro placental blood clot not formed "So no pain

22
  • General examination
  • V/S stable , signs of shock .
  • According to amount of blood loss.
  • Air hunger - RBCs carrying o2
  • pale skin cold moist .
  • lose of consciousness

23
Abdominal examination
  • -lieoblige, Transverse.
  • Head high not engaged. (PG)
  • -abdomen lax not tender
  • -contraindication to do vaginal examination, it
    will worse the condition
  • -quantify blood loss ,blood soaked material for
    fluid replacement

24
assessing fetal condition
  • -fetal activity
  • -cessation of fetal movement
  • -signs of hypoxia, bad CTG
  • -excessive fetal movement signs of fetal
    hypoxia
  • -u\s ,CTG ,pinards

25
Management depends on
  • amount of bleeding
  • -mother fetus condition
  • Location of placenta
  • Stage of pregnancy

26
  • Conservative management
  • -slight bleeding
  • -mother and fetus in well condition
  • -bed rest (hospitalization many weeks until
    bleeding stop)
  • -fetal kick chart
  • -CTG

27
  • -u\s
  • repeated, site of placenta
  • -fetal growth
  • -placental perfusion
  • -IUGR
  • -Psychological social care
  • -group education

28
  • -parent education
  • -visit special care baby unit
  • -answering question ?preterm birth
  • -sever bleeding ,reach maturity NVD
  • -37 weeks IOL
  • -risk of ppHge placenta lower uterine segment
    ,living ligature action is broken

29
  • -active management
  • Sever vaginal bleeding c.s regardless location
    of placenta ( preterm baby )
  • -CBC ,blood group ,cross match , clotting studies

30
  • -IV fluid rapidly ,several unit of blood may need
    infused rapidly
  • -consent form
  • -emergency blood group o ve
  • -anesthetics consultation
  • -intake output

31
  • -,epidural or general anesthesia
  • -comforting mother sharing information
  • -support partner
  • -placenta anterior
  • -type 3,4 require c.s even the baby died to stop
    hemorrhage prevent maternal death

32
  • Incidence
  • -comes after 20 weeks
  • -complicate 3-6 \1000
  • -multigravida 1\90
  • -

33
  • increasing age increase parity
  • -little percentage occur in prima gravida
  • Etiology unknown
  • -?smoker
  • -previous c.s
  • -recurrence 4-8
  •  

34
Complications
  • -maternal shock, resulting from blood loss and
    hypovolaemia
  • anesthetic and surgical complications, which
    are more common in women with major degrees of
    placenta praevia.
  • placenta accreta, in up to 15 of women with
    placenta praevia

35
  • air embolism, an occasional occurrence when the
    sinuses in the placental bed have been broken
  • postpartum hemorrhage occasionally
    uncontrolled hemorrhage will continue, despite
    the administration of uterotonic drugs at delivery

36
  • even following the best efforts to control it,
    and a ligation of the internal iliac artery, a
    caesarean hysterectomy may be required to save
    the woman's life
  • maternal death, a very rare outcome

37
  • fetal hypoxia and its sequelae due to placental
    separation
  • fetal death, depending on gestation and amount
    of blood loss
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