Antepartam haemorrhage
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Transcript of Antepartam haemorrhage
ANTEPARTAM ANTEPARTAM HAEMORRHAGEHAEMORRHAGE
IMMEDIATE DELIVERYIMMEDIATE DELIVERY
Significant bleeding from Significant bleeding from
birth canal after 24birth canal after 24thth week week
of gestation till de.of gestation till de.
CAUSESCAUSES
PLACENTALPLACENTAL Placenta PraeviaPlacenta Praevia Placental Placental
AbruptionAbruption Vasa PraeviaVasa Praevia
NON PLACENTALNON PLACENTAL Labour (Heavy show )Labour (Heavy show ) Uterine ruptureUterine rupture Local / Non Local / Non
obstetricalobstetrical Cervicitis Cervicitis Polyp Polyp LacerationsLacerations Bleeding DisordersBleeding Disorders ConginitalConginital acquiredacquired
PLACENTA PRAEVIAPLACENTA PRAEVIA
Implantation ofImplantation of
placenta in lowerplacenta in lower
uterine segmentuterine segment
Partial Partial Complete Complete
DEGREESDEGREES
MINOR MAJORMINOR MAJOR
MMaajjoorr
ETIOLOGYETIOLOGY
Scarred or poorly vascularized Scarred or poorly vascularized endometriumendometrium
Advancing ageAdvancing age MultiparityMultiparity Previous uterine surgeriesPrevious uterine surgeries
caeserian, myomectomy, D&C, caeserian, myomectomy, D&C, ERPCERPC
BleedingBleeding
Mechanical SeperationMechanical Seperation
Rupture of Cervical dilalatation Rupture of Cervical dilalatation intravaginal intravaginal
Venous lakes effacement Venous lakes effacement manipulationmanipulation
DIAGNOSISDIAGNOSIS
Presenting complaintsPresenting complaints
Painless vaginal bleedingPainless vaginal bleeding
Mild Moderate ProfuseMild Moderate Profuse
SHOCKSHOCK
CLINICAL FINDINGSCLINICAL FINDINGS
PallorPallor
Vital SignsVital Signs HemorrhageHemorrhage StableStable UnstableUnstable
AbdomenAbdomen Soft , relaxed , non tenderSoft , relaxed , non tender LieLie transverse/oblique transverse/oblique Presenting partPresenting part high high Fetal heartsFetal hearts present present
DIAGNOSISDIAGNOSIS
HistoryHistory Clinical examinationClinical examination UltrasonographyUltrasonography Colour DopplerColour Doppler C T scanC T scan MRIMRI
MRI USGMRI USG
MANAGEMENTMANAGEMENT
Depends Depends
Amount of hemorrhage Gestational Amount of hemorrhage Gestational ageage
MANAGEMENTMANAGEMENT
AirwayAirway I/V Line I/V Line 16 / 18 Gauge cannula16 / 18 Gauge cannula
Fluids Fluids crystalloids / colloids crystalloids / colloids
Blood transfusion /FFPBlood transfusion /FFP Indwelling urinary catheterIndwelling urinary catheter Inform Senior ObstetricianInform Senior Obstetrician Avoid pelvic examinationAvoid pelvic examination
MANAGEMENTMANAGEMENT
InvestigationsInvestigations Blood grouping & cross matchBlood grouping & cross match Complete blood countsComplete blood counts Coagulation profile (Platelet count, Coagulation profile (Platelet count,
APTT,PT,FDPs)APTT,PT,FDPs) Ultrasound scanUltrasound scan ( full bladder ) ( full bladder )
EXPECTANT MANAGEMENT EXPECTANT MANAGEMENT (Preterm fetus)(Preterm fetus)
AIM AIM To prolong pregnancy till Term To prolong pregnancy till Term
Haemodynamically stableHaemodynamically stable with mild bleeding with mild bleeding and no uterine contractionsand no uterine contractions
Close observationClose observation vital signs & vaginal vital signs & vaginal bleedingbleeding
Correction of anaemiaCorrection of anaemia Steroids for fetal lung maturationSteroids for fetal lung maturation Counseled and prepared for Caeserian Counseled and prepared for Caeserian
sectionsection
IMMEDIATE DELIVERYIMMEDIATE DELIVERY
Caeserian Section / HysterotomyCaeserian Section / Hysterotomy Haemodynamically unstable.Haemodynamically unstable.
Profuse vaginal bleeding.Profuse vaginal bleeding.
After 37 completed weeks of gestation.After 37 completed weeks of gestation.
If patients has palpable uterine If patients has palpable uterine contractions.contractions.
SURGEON / ANAESTHETIST SENIORSURGEON / ANAESTHETIST SENIOR
GENERAL ANAESTHESIAGENERAL ANAESTHESIA
COMPLICATIONSCOMPLICATIONS
MaternalMaternal Anaemia Anaemia ShockShock Complications of surgery & Complications of surgery &
AnaesthesiaAnaesthesia Post Partam hemorrhagePost Partam hemorrhage Maternal mortaliy Maternal mortaliy FetalFetal Morbidity / MortalityMorbidity / Mortality
PLACENTAL ABRUPTIONPLACENTAL ABRUPTION
Bleeding following Bleeding following premature premature separation of a separation of a normally situated normally situated placenta. placenta.
AETIOLOGYAETIOLOGY
Advance ageAdvance age Multiparity Multiparity Poor nutritional status Poor nutritional status Past History ( Past History ( recurrence 15 –20% )recurrence 15 –20% ) HypertentionHypertention Abdominal Trauma Abdominal Trauma Smoking Smoking Uterine Decompression Uterine Decompression ( polyhydramniose , Twins )( polyhydramniose , Twins ) Chorio amnionitis Chorio amnionitis Fibroid, Folic Acid deficiencyFibroid, Folic Acid deficiency
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Local Vascular injuryLocal Vascular injury ((Pre eclampsiaPre eclampsia))
Haematoma Formation in Haematoma Formation in Decidua BasalisDecidua Basalis
Separation of PlacentaSeparation of Placenta
Venous Venous EngorgementEngorgement
Abrupt uterine venous Abrupt uterine venous pressurepressure
Revealed Concealed Revealed Concealed
SIGNS & SYMPTOMSSIGNS & SYMPTOMS
Small separation of Small separation of the placentathe placenta::
Vaginal bleeding Vaginal bleeding ±± Mild pain or discomfort.Mild pain or discomfort. Abdominal pain. Abdominal pain.
Back pain Back pain
Vital signs StableVital signs Stable Abdomen Abdomen
Soft/ Tenderness ±Soft/ Tenderness ±
FoetusFoetus uncompromiseduncompromised
Large separation of the placenta:Large separation of the placenta:
Heavy vaginal bleeding.Heavy vaginal bleeding.
Severe pain in the lower abdomen or back.Severe pain in the lower abdomen or back.
Hard, tender abdomen.Hard, tender abdomen.
Shock (tachycardia, fall in BP rapid breathing, and Shock (tachycardia, fall in BP rapid breathing, and dizziness).dizziness).
Fetal distress; fetal heart sounds inaudible.Fetal distress; fetal heart sounds inaudible.
Coagulopathy Coagulopathy [DIC]) – Thromboplastine from placenta is [DIC]) – Thromboplastine from placenta is
released into the mother's circulation causing blood clotting released into the mother's circulation causing blood clotting defects. defects.
Renal cortical necrosis ---- AnureaRenal cortical necrosis ---- Anurea
EXAMINATIOBNEXAMINATIOBN
GPEGPE depends upon Hemorrhagedepends upon Hemorrhage.. PallorPallorPulse Pulse B.PB.P
ABDOMINAL EXAMINATIONABDOMINAL EXAMINATIONFundal height larger than datesFundal height larger than datesHard and tender Hard and tender Fetal Part and FHSFetal Part and FHS
PELVIC EXAMINATIONPELVIC EXAMINATIONExclude placenta praevia by USG Exclude placenta praevia by USG P/S examinationP/S examinationP/V examinationP/V examination
INVESTIGATIONSINVESTIGATIONS
Blood grouping. Blood grouping. Blood Complete picture.Blood Complete picture. Coagulation Profile,Coagulation Profile,
Platelet counts, PT, APTT, FDPs Platelet counts, PT, APTT, FDPs
Serum FibrinogenSerum Fibrinogen Renal ProfileRenal Profile Viral SerologyViral Serology
INVESTIGATIONINVESTIGATION
: : Ultrasonography (Useful but not reliable )Ultrasonography (Useful but not reliable )
MANAGEMENTMANAGEMENT
I/V access I/V access Two large bore cannulas.Two large bore cannulas. Save blood for cross match/ Save blood for cross match/
investigation(20 ml)investigation(20 ml) I/V fluids Crystelloids /colloidsI/V fluids Crystelloids /colloids Indwelling urinary catheterIndwelling urinary catheter AnalgesiaAnalgesia Blood transfusions / Fresh frozen plasmaBlood transfusions / Fresh frozen plasma
( Screened & Cross matched )( Screened & Cross matched ) Vital Signs monitoringVital Signs monitoring
MANAGEMENTMANAGEMENT Expectant Expectant : : Mild marginal Abruption with stable mother & Mild marginal Abruption with stable mother &
fetusfetus . . Strict maternal & fetal monitoring.Strict maternal & fetal monitoring.
Vaginal Delivery:Vaginal Delivery: If degree of separation is limited ,If degree of separation is limited , revealed hemorrhage revealed hemorrhage After amniotomy & oxytocin infusion short labour After amniotomy & oxytocin infusion short labour
is expected.is expected. Dead fetusDead fetus No complicationsNo complications
MANAGEMENTMANAGEMENT
Caeserian Section:Caeserian Section:
Maternal IndicationsMaternal Indications
Uncontrollable revealed hemorrhageUncontrollable revealed hemorrhage
Rapidly expanding concealed hemorrhageRapidly expanding concealed hemorrhage
Vaginal delivery is not imminentVaginal delivery is not imminent
Fetal IndicationsFetal Indications Alive fetus with reasonable chances of Alive fetus with reasonable chances of
survivalsurvival
COMPLICATIONSCOMPLICATIONS
MATERNAL MATERNAL Shock (Shock (Hypovolemic, / Neurogenic )Hypovolemic, / Neurogenic )
DICDICRenal failure Renal failure PPH PPH ( Couvelier uterus ,uterine atony , DIC )( Couvelier uterus ,uterine atony , DIC )Maternal mortality ( 0.5% --- 5 % )Maternal mortality ( 0.5% --- 5 % )
FETALFETALPerinatal mortality ( 50 % --- 80 % )Perinatal mortality ( 50 % --- 80 % )
FOLLOW UPFOLLOW UP
Follow up visitsFollow up visits ContraceptionContraception Counsel for chances of recurrence in Counsel for chances of recurrence in
next pregnancy , next pregnancy , early antenatal bookingearly antenatal booking