Antepartum Haemorrhage PDF

Antepartum Haemorrhage Dr. Saja Aljawady definition Antepartum haemorrhage (APH) is usually defined as bleeding from the birth canal after the 24th week of pregnancy , It can occur at any time before delivery of the baby *bleeding following the birth o...

Antepartum Haemorrhage Dr. Saja Aljawady definition Antepartum haemorrhage (APH) is usually defined as bleeding from the birth canal after the 24th week of pregnancy , It can occur at any time before delivery of the baby *bleeding following the birth of the baby is postpartum haemorrhage. *Bleeding before 24 completed weeks of pregnancy is miscarriage,  Epidemiology It affects 3-5% of all pregnancies Up to 20% of very preterm babies are born in association with APH , which explains the association between APH and cerebral palsy. Aetiology 1-Placental causes: *Placental abruption *placenta previa *vasa previa *marginal placental bleeding.  2-Local causes: *Cervical causes (friable, ectropion) *genital tract trauma, infection, varicosities *rupture uterus ( scarred uterus ) 3-Inherited bleeding problems , DIC 4-unexplained Complications of APH Maternal complications 1-Anaemia 2-Infection 3-Maternal shock 4-Renal tubular necrosis 5-Consumptive coagulopathy 6-Postpartum haemorrhage 7-Prolonged hospital stay 8-Psychological squeals 9-Complications of blood transfusion fetal complications 1- Fetal hypoxia 2-Small for gestational age and fetal growth restriction 3-Prematurity (iatrogenic and spontaneous) 4- Fetal death Antepartum haemorrhage: assessment Initial assessment Rapid assessment of maternal and fetal condition is a vital first step as it may prove to be an obstetric emergency Include -history -maternal assessment -fetal assessment  HISTORY A basic clinical history should establish: Gestational age. Amount of bleeding (but don’t forget concealed abruption). Associated or initiating factors. Abdominal pain. Fetal movement Previous episodes of vaginal bleeding in this pregnancy. Leakage of fluid vaginally. Previous uterine surgery (including CS). Smoking and use of illegal drugs (especially cocaine). Blood group and rhesus status (will she need anti-D?). Previous obstetric history (placental abruption/intrauterine growth restriction (IUGR), placenta praevia). Position of placenta, if known from previous scan. Maternal assessment This should include: BP. Pulse. Other signs of haemodynamic compromise (e.g. peripheral vasoconstriction or central cyanosis). Uterine palpation for size, tenderness, fetal lie, presenting part (if it is engaged, it is not a placenta praevia). Fetal assessment Establish whether a fetal heart can be heard. Ensure that it is fetal and not maternal (remember, the mother may be very tachycardic). If fetal heart is heard and gestation is estimated to be 26wks or more, FHR monitoring should be commenced Investigations of APH 1-Complete blood count 2-Blood group and Rh 3-Cross match- depending on the estimated blood loss 4-Coagulation studies – if a coagulopathy is suspected or blood loss is massive. Low fibrinogen, increase D- dimer, prolong prothrombin time and APTT, and low platlates suggest DIC, usually following abruption 5-Kleihauer test- particularly important for RH negative women to determine the dose of anti-D required. The result of test is not immediate , however , to help in initial management  6-CTG- commenced as early as possible to ascertain fetal well being fetal well being and monitor uterine activity 7-Ultrasound – requested urgently if the placental site is unclear , to look for placenta preavia. In case of abruption ultrasound help to exclude placenta preavia 8-High vaginal swab and cervical swab should be sent if an infective cause of bleeding is suspected Management of APH Including history , assessment and investigations then ; Hospital admission for clinical assessment and management Resuscitation measure if shock present or severe bleeding Air ways. Breathing, oxygen mask. Circulation, insert two I.V lines using 2 large bore cannula. Insert folye’s catheter. Sample blood for investigations. Cross match of at least 4 pints blood. Check vital signs ( PR, RR, temperature, and blood pressure) and kept patient on chart observation.  Volume should be replaced by crystalloid, /colloid until blood available Sever bleeding urgent delivery. Advised to report all vaginal bleeding in antenatal care provider. Team work – senior obstetriacian ,anasthetist, neonatologist. Placenta praevia defined as placenta located partly or completely in lower uterine segment. Incidence 4\1000  CLASSIFICATION ( GRADES ) Grade I placental edge in the lower segment but not reaching the internal os. Grade II placental edge reaching the os but not covering it. Grade III placenta cover the os but not symmetrically ( incompletely ). Grade IV placenta covers the os symmetrically (completely ). I & II are minor II&IV are major Risk factors for placenta previa 1. Previous uterine surgery ; Caeserean section , myomectomy and curettage 2.previous history of placenta previa. 3.Multi-parity. 4.Increase maternal age 5. Multiple pregnancy. 6.Smoking. 7.Submucous fibroid. 8.Assisted reproduction  CLINICAL PICTURE symptoms Painless Causeless Recurrent bleeding after 24 weeks. signs 1*General examination -Pallor ,if present, will be proportionate to the amount of bleeding. -Depend on severity of bleeding ± anaemia 2*Abdominal examination -Uterus is soft and not tender. -Size of uterus usually correspond to gestational age -May be malpresentation – -if cephalic presentation non engagement head -Supra pubic fullness -Fetal heart sounds usually are normal Management of placenta previa After first aid ,canuulas , assessment with life saving procedures including IV fluids and preparation of 4 pints of blood Ultra sound for localization of placenta either trans abdominal or transvaginal. In transvaginal scan the probe inserted within vagina without touching the cervix. Per vaginal examination can done only in theatre and every thing ready for cesarean section. Expectant management Goal is to prolong pregnancy to term without putting mother life at risk. Indications: -No active bleeding. -Hemodynamically stable. -Gestational age < 37. -Assuring fetal condition. -No major fetal anomaly on US Expectant management includes : -Hospitalization -Correction of anaemia with blood transfusion if necessary. -Blood should always to be kept in bank. -Antenatal steroids to promote fetal lung maturity. -Anti D if patient Rh negative. -If uterine contractions present- tocolysis can be given to prolong pregnancy. Active management To terminate pregnancy irrespective to gestational age. Indications: -If active bleeding is present. -Hemodynamically unstable. -Gestational age >37 weeks. -Patient in labour. -Fetal distress present /FHR absent. -USG shows fetal anomaly or dead fetus.  Mode of delivery 1-In case of grade I & II placenta previa, anterior with no or mild vaginal bleeding vaginal delivery can be tried. 2-If the bleeding is severe or the placenta previa was grade III & IV caesarean section should be done by the hand of most senior obstetrician Complications of placenta previa 1-maternal complications Major hemorrhage , shock and even death. Anemia. Morbid adherent placenta : placenta accreta , increta, percreta. RH sensitization. PPH Renal tubular necrosis and acute renal failure. 2-Fetal complications Fetal prematurity Low birth weight Chronic and acute fetal hypoxia Intrauterine fetal death