ANTEPARTUM HAEMORRHAGE

Obstetric Haemorrhage

Ranks as the First cause of maternal mortality accounting for 25 – 50 % of maternal deaths

APH: Epediology & Causes Magnitude: 4% of women may develop APH.

Causes: placenta previa (1/200) placental abruption (1/100) uterine rupture (<1% in scarred uterus) vasa previa (1/2000-3000) Local causes Unknown origin

Vasa Previa

Velamentous Insertion of the umbilical cord

I. ABRUPTIO PLACENTA

Definition: Early separation of the normally implanted

placenta after 28/40 and before the end of

second stage of labour

Recurrence: The risk of recurrent abruption in a

subsequent pregnancy is high.

Abruptio placenta: Classifications

Are based on

1. Extent of separation: Partial vs complete

2. Location of separation: Marginal Vs central

3. Clinical presentation: Revealed, concealed and

mixed

4. Clinical Severity: Mild, Moderate and Severe

Class 1 Mildest form: approx 48% of all cases.

• No vaginal bleeding to mild vaginal bleeding

• Slightly tender uterus• Normal maternal BP and

heart rate• No coagulopathy

(clotting problems)• No fetal distress

Clinical Severity

Class 2: moderate -approx 27% of all cases.

• No vaginal bleeding to moderate vaginal bleeding

• Moderate-to-severe uterine tenderness with possible tetanic contractions

• Maternal tachycardia with orthostatic changes in BP and heart rate

• Fetal distress• Low fibrinogen levels present

(causing clotting problems)

Class 3: Severe form: Approx 24% of all cases.

• No vaginal bleeding to heavy vaginal bleeding

• Very painful tetanic uterus

• Maternal shock

• Coagulopathy

• Fetal death

Clinical Severity

I. Abruptio placenta: Risk factors

Hypertensive Disease

Multiple pregnancy

Trauma

PPROM

I. Abruptio placenta: Risk factors

Anaemia

Polyhydramnios – sudden

↓intrauterine pressure

Short cord

Uterine leiomyoma: esp if located

behind the placental implantation

site, predispose to abruption

Abruptio Placenta: Abruptio Placenta: FeaturesFeatures

Pain and tenderness Initially localized then becomes

generalized due to endometrial injury – extravasations of blood

Vaginal bleeding Maternal distress Often I.U.F.D

Placental Abruption: Complications

Shock Acute renal failure

Cause: ?seriously impaired renal perfusion 2° to ↓CO and intrarenal vasospasm as in preeclampsia

DIC Consumptive coagulopathy 2° to

hypofibrinogenemia along with elevated levels of fibrinogen–fibrin degradation products

Placental Abruption: Complications

Fetal distress/demise

PPH

Couvelaire Uterus: Widespread extravasation of blood into the uterine

musculature and beneath the uterine serosa.

Sheehan syndrome

Puerperal sepsis

Placental Abruption: Management

Management depends on: fetal maturity, degree of severity, viability of the fetus/fetal distress

Treatment modalities Expectant management of pregnancy Induction/augmentation of labor Caesarean section

Placental Abruption: General Management

1. Delivery

Resuscitation

FFP, whole blood, IV fluids

Monitor BP

Catherization - monitor urine output

Placental Abruption: General Management

ARM

Induce/Augment labour

Oxytocin infusion or prostaglandin if

necessary to induce contractions

Bed site clotting time

Done regularly

Placental Abruption: General Management

2. Caesarean Section Indications for Caesarean Section

salvageable baby, Severe vaginal bleeding, Poor progress, Transverse lie, inadequate pelvis

Post delivery -watch out for PPH Why?

Myometrial myofibrin loose contractility Failure to clot

PLACENTA PRAEVIA PLACENTA PRAEVIA - DEGREES- DEGREES

1. Total placenta praevia

The internal cervical os is covered

completely by placenta.

2. Partial placenta praevia

The internal os is partially covered

by placenta.

PLACENTA PRAEVIA PLACENTA PRAEVIA - DEGREES- DEGREES

3. Marginal placenta praevia

The edge of the placenta is at the margin of the internal os.

4. Low-lying placenta

The placenta is implanted in the lower uterine segment such that the placental edge actually does not reach the internal os but is in close proximity to it.

PLACENTA PRAEVIA: PLACENTA PRAEVIA: Predisposing factors

Multiparity

Advanced maternal age

Prior C/S or other uterine surgery

Prior placenta previa

Placenta Previa: Diagnosis

Painless vaginal bleeding in 2nd/3rd trimester

Confirmed by ultrasound

Up to 10% may have simultaneous abruption

Maternal shock is uncommon with 1st

presentation of bleeding

Placenta Previa: Obstetric Management

Vaginal exams are avoided

If possible, delay delivery until fetus is mature.

34 weeks - buy time for steroids

Prevent contractions with tocolytics -indocid

Mobilize blood donors

Placenta Previa: Obstetric Management Resuscitate - IV fluid and blood, Monitor BP and amount of bleeding Deliveryi. Mild non persistent bleeding

GA 34 weeks Buy time for steroids and hospitalization. Prevent contractions with tocolytics - Mobilize blood donors Oral haematenics

GA 37 weeks = consider Elective CSii. Persistent bleeding requires immediate delivery

whatever the gestation

Placenta Previa: Management

Indications for delivery: Persistent bleeding requires delivery whatever the

gestation Active labor Documented fetal lung maturity 37 weeks gestational age. Excessive bleeding Development of another obstetric complication

mandating delivery

Placenta PraeviaPlacenta Praevia

Elective caesarean if 37 weeks

? Never cut through the placenta

PLACENTA PRAEVIA

Lower segment may need to be packed

Placenta previa may be assoc. with placenta accreta, increta or percreta → PPH

PPH - 2° to poorly contractile nature of the LS of uterus.

Comparison of Presentation of Abruption v. Previa v. Rupture

Abruption Previa Rupture

Abdominal pain present absent variable

Vaginal blood old fresh fresh

DIC common rare rare

Fetal distress common rare common

Vasa Previa “Umbilical vessels separate in the membranes

at a distance from the placental margin and some of the vessels (fetal) cross the internal os and occupy a position ahead of the presenting part of the fetus.”

ROM may cause fetal exsanguination.

High fetal mortality (50-75%)

Risk factor: multiple gestation (esp., triplets).

Vasa Praevia Diagnosis

Moderate vag bleeding + fetal distress Vessels may be palpable thru dilated cervix Vessels may be visible on ultrasound

Difficult to distinguish clinically from abruption.

Treatment C/S, Resuscitation of infant (volume)

Local & Unknown CausesLocal & Unknown Causes of APH of APH

Rupture of uterus

Carcinoma of cervix

Trauma

Cervical polyp

Bilharzia of cervix Cervicitis