Antepartum Haemorrhage (APH) - Block 5th PDF

Dr. Melad Alias Yalda Ass. Professor In Obstetrics & Gynecology Duhok Medical college Consultant In Obstetrics & Gynecology 1. The definition, causes, approach to diagnosis & management. 2. How to management of hypo-volaemic shock in Obstetrics. 3. Kinds of APH and how to differentiate be...

Dr. Melad Alias Yalda Ass. Professor In Obstetrics & Gynecology Duhok Medical college Consultant In Obstetrics & Gynecology 1. The definition, causes, approach to diagnosis & management. 2. How to management of hypo-volaemic shock in Obstetrics. 3. Kinds of APH and how to differentiate between them.  Definition Ante partum hemorrhage is defined as bleeding from the genital tract after the 24th competed weeks of gestation and before the onset of labor. At time of labor there is Show which some times misdiagnosed with APH  Incidence 2 - 5% of all pregnancies When assessing patient presenting with APH, digital examination should not be conducted until an U/S scan Has identified the location of the placenta. Placenta praevia : 1/3.. Abruption placenta: 1/3.. Local cause in the vagina and cervix : 1/3 * Cervical errosion & polyp * genital tract infection Un-determind causes Blood dyscrasias Vasa pravia : 1% Placenta implanted wholly or partially on the lower segment of the uterus. The lower segment does not contract in labor but is stretched in response to contractions. Before pregnancy is called isthmus portion.Underlies the loose fold of peritoneum that reflects from the bladder.. It Is covered by a full bladder anteriorly..Is within 8 cm of the internal cervical os at term Placenta praevia follows the low implantation of the embryo Multiparty.0.2% in nulliparous 5% in grand mult-parous ) Multiple pregnancy. Increasing maternal age Prioer C/S or uterine surgery No scar risk 4%, one scar 10-35% multiple scar 60-65% IVF cases Smoking Previous history of D&C excessive The classification grades of placenta praevia. Grade I The placenta reaches the lower segment but not the internal os. ( almost 2,5 – 3 cm away from the internal os ) Grade II the placenta reach the internal os but dose not cover it. Grade III the placenta covers the internal os before dilatation but not when dilated. Grade IV the placenta completely covers the internal os of the cervix even when dilated. Grade I Marginal Grade II Lateral Grade III Accenteric Partial Grade IV Central Complete Placenta previa can be associated with Abnormal lay & Malpresentation Pre- labour premature rupture of the membrane Intra uterine fetal growth restriction Increase the chance of operative delivery There is a risk that the placenta implant into , And thus invades into the previous scar. This is called a MORBID adherent placenta, and there are three types 1- Placenta accreta.Placenta is abnormally adherent to the lower uterin wall There is no decidua basalis, & the fibrinnoid layer is incompletly developed 2- Placenta increta Placenta is abnormally invading into the uterin wall ( myometrium ) 3- Placenta Perecreta. The placenta penetrates the myometrium & may invade nearby viscera  Painless Causeless Recurrence Asymptomatic diagnosed by routine U/S Painless bright red vaginal bleeding. ( 1/3 bleed before 30 weeks, 1/3 bleed between 30- 36 weeks , & 1/3 will present after 36 weeks )10% of all woman with PP will reach term without an episode of bleeding A persistent mal-presentation or high head in late pregnancy Causeless Recurrence  Examination Abdomen & uterus is soft Fetal parts are easily detected Fetal heart can be detected Presenting part is high not engaged Could be abnormal lay & presentation Most of low lying placenta will be corrected ( 5- 15% will have low lying placenta at 17 weeks 90% will resolve by 37 weeks ) This occur because of development of lower uterine segment. Migration Complete or partial diagnosed in 2nd. Trimester will persist in 26% & 2.5% of patient respectively All patient with PP before 24 weeks should have a U/S at 28, 32 & 34 weeks to reassess the position of the placenta. 1) U/S 2) MRI 3) Previously X ray to see the presenting part & if there is a distance between it & the maternal pelvis 4) angiography The initial management of a patient with bleeding PP & Abruptio placenta is very similar Hemodynamic state of the mother should be immediately evaluated & stabilization performed if necessary Gestational age should be assessed & the fetal heart rate should be monitored continuously  Placenta previa with bleeding 1)insert a broad – bore I.V cannula and start an infusion with crystalloid solution. 2)2)Take blood for cross matching 3) packed RBC should be given if sever anemia is evident or there is continuous uterine bleeding the goal hematocrit is at least 30%. 4) 4 units of blood should be crossed & held nearby. 5) The urine out put should be maintained above 30 ml/h 6) Give anti D immunoglobline for Rh –ve patient Subsequent management depend on ►Gestational age ►Stability of the mother & the fetus ►Amount of bleeding Delivery is always indicated ► If there is a non reassuring fetal heart rate despite resuscitation effort ► If there is life- threatening maternal hemorrhage ► If gestational age is ≥ 34 weeks & there is known fetal lung maturity Between 24 & 36 weeks , if maternal & fetal stability are assured conservative expectant management will be tried this include ► Hospitalization till bleeding is stopped ►hydration & blood transfusion are given if necessary ►Continues fetal heart monitoring required if there is continued bleeding or uterine contraction ►Bed rest , restrict activity give stool softener ,iron supplementation ►Steroid to promote fetal lung maturity if gestational age ≤ 34 After steroid , if no uterine activity & no bleeding , home therapy can be considered ♦ The patient should be instructed return to hospital if she experience contractions or bleeding ♦ Have 24 H contact via telephone & ability to return to the hospital at any time. ♦ Fetal growth, amniotic fluid index & placental localization should be assessed by U/S every 2 weeks. At 36-37 weeks’ presentation a final ultrasound should be performed and acted upon :- ►grades three and four placenta previa should have a C/S between 37 and 38 weeks’ gestation ► There is a possibility of perform hysterectomy ► If the presenting part is below the lower edge of the placenta in grade 1 , grade 2 anterior a trial of labor could be give for vaginal delivery Caesarean hysterectomy is required in 2/3 of patient with P accrete , there are several surgical option if uterine preservation is important 1)The placenta removed & the uterine defect over- sew 2)The area of accrete re-sected & the uterus repaired 3)Leaving the placenta inside , acceptable in patient who are not actively bleeding, the cord ligated & cut close to the base & the patient treated with antibiotics & methotrxate postpartum. The major cause of death in women with placenta previa now is postpartum hemorrhage ( PPH ) because the lower segment does not contract as in the upper segment & therefore maternal vessels of the placental bed may continue to bleed after delivery. This may lead to an emergency hysterectomy if the bleeding can’t be stopped Bleeding from placenta praevia is maternal in origin. The risk to the fetus is therefore mostly dependent upon the gestation at which it becomes necessarily to deliver the baby Abruptio Placenta is Define as the premature separation of the normally situated placenta after 24 weeks of gestation but prior to the delivery of the fetus it may occur as an ante-partum or intra- partum event Separation of more than 1/3 is life-threatening to the mother and fetus (Emergency condition) Premature separation of small area of the placenta may result in placental infracts. several small abruptions may precede a large abruption Concealed hemorrhage. Revealed hemorrhage Abroptio placenta The causes of abruption are not known but the following factor are associated ► Hypertension ► Multiparty 4th. Pregnancy carry a four time risk over 1st. Pregnancy ► Folate deficiency ►Trauma ECV & seat belt injuries ,domestic violence & blunt abdominal trauma. ► Decompression of over stretched uterus ( polyhydramnious , multiple pregnancy ) during membranes ruptured ► Previous placental abruption this increase the risk by 2-3 times ► Raised maternal serum Alfa feto protein in the absence of fetal malformation ( 6% ) Most placental abruption will present with the clinical triad , although many will not fill all 3 of the following categories : 1)Uterine bleeding , in case of revealed hemorrhage & hocked in case of concealed 2)Tetanic uterine activity ( ie , contractions ) 3) Fetal distress , is typically the first sign among patient who have continuous fetal heart monitoring during abruption, decrease placental exchange surface area or from sever maternal hypotension Women present with abdominal pain & varying degree of shock , the blood loss that is visible ( revealed hemorrhage ) is often les than the degree of shock On Examination * The uterus is woody hard due to a tonic contraction * The fetal part cannot felt * The fetus may be dead Minor abruptions are often not diagnosed until after delivery , they may present with 1) Mild abdominal pain associated with threatened preterm labor 2) Unexplained APH 3) Tenderness over one area of the uterus only (local tenderness ) Sever abruption may result in ► Shock from blood loss or large retro placental clot in concealed ► Disseminated intravascular coagulopathy ( DIC ) ► Oligurea or an urea due to hypovolaemia ► Minor degree of placental abruption may result in impaired fetal growth and / or hypoxic ischemic encephalopathy – cerebral palsy  Major is a life threatening for both the mother & fetus , if the fetus is still a live : 1)Insert two large –bore IV canula of normal saline / Colloid 2) Cross match of four units, Hb, coagulation profile 3) Perform an immediate C/S to save the fetus life ( high risk of post-partum hemorrhage ) 4) Adequate fluid replacement following the C/S 5) Leave an indwelling urinary catheter 6) Considered insertion of a central venous line  Allow deliver vaginally. Usually happens rapidly ( with 4- 6 hours ) as the abruption stimulate labor. if not in labor rupture of membranes usually leads to a rapid delivery. The relevant points of the management labor: 1)Epidural analgesia is contraindicated because of the risk of coagulopathy but a patient controlled of opiate infusion can be used 2)If a coagulopathy has developed ( prolonged APTT, PTT, increased fibrin degradation product , low platelets ) A) Give four unit of fresh frozen plasma B) Ask the blood bank to get 6 units of platelets ready The consumptive coagulopathy began to improve immediately after the uterus has been evacuated of its content. Marked abnormalities of the coagulations test usually resolve within 4-6 hours of delivery of the placenta Although no intervention has been shown to prevent Abruptio Placenta , Counseling patient against smoking & Cocaine abuse may reduce the risk, the same for antihypertensive drug to control maternal blood pressure Compare the presentation of placenta praevia with.placental abruption Placenta Praevia Placental Abruption No predisposing event Predisposing event Not associated with ↑BP Associated with ↑BP Painless Painful Distress unusual Distress common Abdomine soft, non-tender Abdo tender, tense, woody Fetal parts palpable May not feel fetal parts Abnormal lie/presentation Usually cephalic presentation CTG normal Abnormal CTG Coagulopathy late (if at all) Coagulopathy occurs early Urinary or anal bleeding may be reported as vaginal bleeding in error. 1) Cervicitis & vaginitis Occasional excessive infection specially with Candida 2) Cervical polyp Scanty bleeding can be seen with speculum 3) Cervical erosion 4)Cervical ectropion 5)Varicosities of the vagina Cancer of Cervix * Rare but important * Irregular bleeding & discharge. * If before 24 weeks hysterectomy & immediate Wertheim hysterectomy followed by radiation *according to the stage * If after 24 weeks wait 32 weeks then caesarean Wertheim hysterectomy followed by radiation according to the stage There are extremely rare bleeding may be seen in the following conditions : *Idiopathic thrombocytopenia *Von willibrands disease *Leukemia *Hodgkin's disease This occur from rupture of vasa praevia when there is velamentous insertion of cord vessels and these cross the cervical os. Diagnosis This condition usually present with scanty bleeding at the time of membranes rupture. it may be associated with alteration in the fetal heart rate producing a sinusoidal pattern vasa previa, unprotected blood vessels from the umbilical cord travel across the opening of your cervix The blood lost can be checked for fetal Hb by its resistant to alkalinization ( Kleihauer test ). It is suspected when an U/S reveal the presence of a succenturate lobe on the opposite side of the internal os to the placenta deliver the fetus as soon as possible and prepare to transfuse blood to the neonates