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Antepartum Hemorrhage

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... Perform a transvaginal ultrasound scan on all women in whom a low-lying placenta is suspected from their transabdominal anomaly ... case, the unprotected fetal ... – PowerPoint PPT presentation

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Title: Antepartum Hemorrhage


1
Antepartum Hemorrhage
  • Abdulah Al-TayyemMDJBOG
  • Consultant ObGyn
  • Urogynaecology
  • Zarka Govern. Hospital

2
  • Definition
  • APH is bleeding from or within the genital
    tract after 24 W of gestation.
  • Causes
  • Placenta previa the most common
    causes
  • Abruptio placentae
  • Rupture uterus
  • Local causes trauma,infection,tumors.
  • Vasa previa

3
Placenta previa
  • Is the implantation of the placenta in the lower
    uterine segment with different grades of
    encroachment on the cervix.
  • Bleeding is -painless
  • -causless

4
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5
classification
6
6
7
APH
  • Per vaginam blood loss gt15 ml after 20 weeks
    gestation
  • 5 of all pregnancies
  • Accounts for 20 -25 of perinatal mortality

7
8
Severity of bleeding
Volume Estimate Percent of circularity volume Type
500 ml or gt 10-15 compensated
1000-1500 ml 15-25 mild
1500-2000 ml 25-35 moderate
2000-3000 ml 35-50 Severe (shock)
8
9
Abruptio Placentae
  • Is premature separation of a normally implanted
    placenta, may be precipitated by a sudden
    increase in blood pressure or trauma
  • Fetal parts are difficult to feel.
  • Feta heart sound may be absent
  • Sings of hypovolemia
  • Coagulopathies occur in 30 of cases

10
Diagnosis
  • History
  • Present obstetric history
  • Symptoms of hypovolemia
  • Symptoms of pre-eclampsia
  • Lower abdominal pain or colic
  • The presence or absence of fetal movements
  • History of ROM or labour pains
  • Previous uterine operations
  • History of sexual intercourse before onset of
    bleeding
  • History of trauma or recent surgery

11
Physical examination
  • General examination-tachycardia,hypotenstion
  • -sings of
    shock
  • -lower limb
    edema.
  • Abdominal examination -abdominal tinderness,or
    rigidity
  • -fundable
    level
  • -FHS
  • -consistency of
    the uterus?
  • Pelvic examination
  • -Don not perform a digital vaginal
    examination at this stage.
  • -Inspect the external genitalia and vagina
    for
  • -amount of blood loss
  • -sings of trauma or infection.

12
Investigations
  • Laboratory investigations
  • -ABO blood group and Rh type
  • -Crossmatch at 2 units of blood
  • -CBC
  • -Fibrinogen, PTT, PT,CT
  • -Serume creatinine or BUN
  • -Urine analysis for protein and RBCs

13
  • Perform a transvaginal ultrasound scan on all
    women in whom a low-lying placenta is suspected
    from their transabdominal anomaly scan (at
    approximately 2024 weeks) to reduce the numbers
    of those for whom follow-up will be needed.
  • Transvaginal ultrasound is safe in the presence
    of placenta praevia and is more accurate than
    transabdominal ultrasound in locating the
    placenta.

14
Ultrasound
  • Confirm the fetal viability
  • Localize the site of placenta,and its relation to
    the cervix
  • Estimating the gestational age
  • Detecting the presence of retroplacental hematoma
  • In case of sever bleeding, do not wait for an US
    examination .Begin first aid management and the
    quickly start active management .
  • Even if the amount of bleeding is mild NEVER
    perform PV examination until placenta previa has
    been excluded by US

15
Diagnosis of Antepatrm Hemorrhage
  • Painless vaginal bleeding after 24w.?
  • Symptoms and sings
  • -shock -bleeding may be precipitated
    by intercourse
  • -relaxed uterus -normal fetal condition
  • -fetal presentation not in the pelvis/ lower
    uterine pole feels empty.
  • Dg Placenta previa

16
  • Vaginal bleeding after 24 w,intermitent,or
    constant abdominal pain?
  • Symptoms and sings
  • -Shock -tense/tender uterus
  • -decreased /absent fetal movements.
  • -fetal distress/absent fetal heart sound.
  • Dg Abruptio placentae.
  • ( R/O co-exciting PIH)

17
  • Bleeding(intra-abdominal and/or vaginal)?
  • Sever abdominal pain(may decreas after rupture)?
  • Previous uterine scar?
  • - shock -abdominal distention/free fluid.
  • -abnormal uterine contour -tender
    abdomin
  • -easily palpable fetal parts -rapid maternal
    puls
  • -absent fetal movements and FHS
  • Dg Ruptured uterus

18
  • Mild vaginal bleeding after 24 w(mild)?
  • Symptoms and sings
  • -clinically stable
  • -fetal assessment showed fetal distress
  • that can not be explained by the mild
    bleeding.
  • Dg Vasa previa

19
Complications of placenta previa
  • -shock
  • -postpartum hemorrhage
  • Women with placenta previa are at high risk for
    PPH and placenta accreta/increta
  • a common finding is at the site of a previous
    cesarean section

20
Complications of abruptio placentae
  • Maternal shock
  • Fetal death
  • Uterine atony
  • Amniotic fluid embolism
  • Caogulopathy( 30)
  • Renal failure
  • The principal cause of maternal death is
    renal failure due to prolonged hypotension .
  • Don not underestimate the amount of the
    hemorrhage

21
Management
  • General rules
  • -call for help -keep women NPO
  • -remember that mother and the neonate
  • require evaluation and intervention if needed

22
First aid management
  • Insert 2 wide bore cannulae
  • Blood for CBC,crossmatch
  • Immediately star iv crystalloid solutions
  • Provide 100 oxygen via mask
  • Warm the women
  • Insert Foley catheter
  • Monitor blood pressure and pulse/ 5 min
  • Monitor urine output /hour

23
Indications of when to terminate pregnancy
  • Women in labour
  • Bleeding is heavy(evidente or hidden) manifested
    by shock
  • Gestational age equals or more 37 w
  • There is fetal distress
  • There is IUFD and /or fatal congenital anomalies
    by US

24
When to use conservative management
  • Bleeding is light or has stopped AND
  • The fetus is alive AND
  • The fetus is premature.
  • Cases of abruptio placentae which are diagnosed
    only on US examination, with no clinical finding(
    no bleeding, no shock, no tender or tonically
    contracted uterus)

25
  • In abruptio placentae
  • When the clinical diagnosis is clear
  • Or in the presence of acute fetal distress. Do
    not waste your time for US examination.
  • US is neither sensitive nor specific diagnosis
    modality in abruptio placentae

26
Monitoring during hospital say
  • Check pulse every 3o min/2h, then hourly/6h,
    then every 4 h.
  • Perform gentle uterine massage/30 min
  • APH predispose for PPH
  • Check for vaginal bleeding
  • Check urine output/ 2h

27
Conditions that should be met before discharge
  • No active bleeding
  • No fever
  • Open bowel
  • Stable general condition
  • Satisfactory urine output
  • No wound complications

28
Management of Placenta praevia in a Pregnancy of
viable gestational age
-

Bleeding
-
Expectant management
Fetal distress


C/Section
Fetal lung maturity
-
-
Sono assessment q 3-4 weeks
-

Placental migration
Bleeding
Trial of labor
-

Complete resolution

Trial of labor (low-lying only)
Double set-up
28
29
Comparison of presentation of abruption v.
praevia v. rupture
Abruption Praevia Rupture
Abdominal pain Yes No variable
Vaginal bleeding Old dark Fresh Fresh
DIC Common Rare Rare
Fetal distress Common Rare Common
29
30
  • Associated with velamentous insertion of the
    umbilical cord (1 of deliveries)
  • Bleeding occurs with rupture of the amniotic
    membranes (the umbilical vessels are only
    supported by amnion
  • Bleeding is FETAL (not maternal as with placenta
    praevia)
  • Fetal death may occur with trivial symptoms

31
31
32
Comparison of presentation of abruption v.
praevia v. rupture
Abruption Praevia Rupture
Abdominal pain Yes No variable
Vaginal bleeding Old dark Fresh Fresh
DIC Common Rare Rare
Fetal distress Common Rare Common
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