DR.EMAN ANTEPARTUM HAEMORRHAGE

Antepartum haemorrhage:-

Bleeding that occur after 24th week of gestation but prior to onset of labour.

Incidence: - 5%

!Causes

Placenta previa(PP)

Placental abruption(PA)

Vasa previa

Cervicitis

Trauma

Vulvovaginal varicosities

Genital tumour

Genital infection

50% due to PP & PA

!Abruptio placentae (AP):- Is the premature separation of the normally implanted placenta from the uterine wall due to uterine vessel hemorrhage into the decidua basalis.

-Incidence :- 1.5%.

-It is of 2 types:-

Revealed:- with external bleeding.

Concealed:- occurs when the placental margins remain adherent, retaining blood between the placenta and the uterus.

!Etiology

• Idiopathic

• Inherited thrombophilias.

• Maternal hypertension

• Advanced maternal age

• Multiparity

• Smoking

• Trauma.

• Rapid contraction of an over distended uterus may lead to abruption, such as with rupture of membranes with polyhydramnios, or delivery of an infant in a multiple gestation.

!Maternal Complications

• Hemorrhagic shock leading to ischemic necrosis of distant organs.

• Disseminated intravascular coagulation(D IC)

• Couvelaire's uterus (extra vasation of blood into uterine muscle) leading to uterine atony; rarely, Couvelaire's uterus may lead to uterine atony and massive haemorrhage, which necessitates aggressive measures, such as caesarean hysterectomy to control the bleeding.

!Fetal complications include:-

hypoxia leading to growth

restriction, anemia, prematurity, fetal

distress, hypoxic-ischemic

encephalopathy, and death.

!Diagnosis

History and Physical Examination

AP presents with vaginal bleeding and acute onset of constant abdominal pain(The presence of blood in the basalis stimulates uterine contractions, which results in abdominal pain). Maternal vital signs, fetal heart pattern, and uterine tone should be monitored. Fundal height can also be followed to look for concealed hemorrhage.

!Pelvic Examination: If placenta previa is ruled out, perform a speculum examination to look for vaginal or cervical lacerations and evaluate vaginal bleeding.

Ultrasonography: Although ultrasonography is relatively insensitive in diagnosing AP, a hypoechoic area between the uterine wall and placenta may be seen with large abruptions.

!Management.

• establishment of intravenous access with two large-bore catheters.

• fluid resuscitation.

• blood type and cross-match determination.

• continuous foetal monitoring.

• Rho (D) immunoglobulin should be administered to Rh-negative individuals.

• maternal vital signs should be assessed frequently.

!Term Gestation, Maternal and Fetal Hemodynamic Stability

✇One should plan for vaginal delivery with cesarean section reserved for the usual obstetric indications.

✇If the patient does not present in labor, induction of labor should be initiated.

✇Serial hematocrits, coagulation evaluation, fetal scalp electrode.

!Term Gestation, Maternal and Fetal Hemodynamic Instability

✇Aggressive fluid resuscitation should be performed as well as transfusion of packed red blood cells, fresh frozen plasma, and platelets as appropriate.

✇Once maternal stabilization is achieved, caesarean section should be performed, unless vaginal delivery is imminent.

!Preterm Gestation, Maternal and Fetal Hemodynamic Stability.

• Preterm, Absence of Labor. These patients should be followed closely with serial ultrasonographic examination for fetal growth starting at 24 weeks' gestation and antepartum fetal testing. Steroids should be administered to promote fetal lung maturity.

• Preterm, Presence of Labor:- If both maternal and fetal hemodynamic stability are established, tocolysis may be used in selective mild cases.

!Preterm Gestation, Maternal and Fetal Hemodynamic Instability.

Delivery should be performed after appropriate resuscitation.

!Placenta previa (PP) Is defined as the presence of placental tissue over or near the internal cervical os. PP can be classified into four types based on

the location of the placenta relative to the cervical os:

Complete or total previa, in which the placenta covers the entire cervical os.

Partial previa, in which the margin of the placenta covers partially cover internal os

marginal previa, in which the edge of the placenta l ies adjacent to the internal os;

Low-lying placenta, in which the placenta is located near (2 to 3 cm) to the internal os.

Incidence: - 0.5%

!Etiology.

• Endometrial scarring

• Advancing maternal age

• Multiparity

• Multiple pregnancy.

Placenta previa is associated with a doubling of the rate of congenital malformations.Previa is also associated with fetal malpresentation.

!Abnormal growth of the placenta into the uterus can result in one of the following three complications:

Placenta Previa Accreta. placenta adheres to the uterine wall without the usual intervening decidua basalis.

Placenta Previa Increta. placenta invades the myometrium.

Placenta Previa Percreta. placenta penetrates the entire uterine wall, into bladder or bowel.

!!

!Diagnosis

History. PP presents with acute onset of painless vaginal bleeding.

Examination. If PP is present, digital examination iscontraindicated, a speculum examination can be used to evaluate the presence and quantity of vaginal bleeding, maternal vital signs, abdominal exam, uterine tone, and fetal heart rate monitoring should be evaluated. Vaginal sonography is the gold standard for diagnosis of previa.

!Management

• Standard Management of symptomatic patients with PP includes initial hospitalization with hemodynamic stabilization.

• continuous maternal and fetal monitoring.

• Steroids should be given to promote lung maturity for gestations between 24 and 34 weeks.

• Rho (D) immunoglobulin should be administered to Rh-negative mothers.

!Term Gestation, Maternal and Fetal Hemodynamic Stability.

Complete Previa. Patients with complete previa at term require caesarean section.

Partial, Marginal Previa. These patients may deliver vaginally; however, a double setup in the operating room is recommended.

!Term Gestation, Maternal and Fetal Hemodynamic Instability.

Delivery is indicated with evidence of non reassuring fetal heart rate tracing,

life-threatening maternal haemorrhage, Delivery should then occur via caesarean section.

!Preterm Gestation, Maternal and Fetal Hemodynamic Stability

Labor Absent. Patients at 24 to 37 weeks' gestation with PP who are hemodynamically stable can be managed expectantly until fetal lung maturity has occurred. Current recommendations for each episode of bleeding include

• Hospitalization until stabilized

• Bed rest

• Blood transfusions to keep pcv above 30%

• Fetal testing with serial ultrasounds

• Tocolysis is usually not warranted unless used for the administration of antenatal steroids .

• After initial hospital, care as an outpatient may be considered if the bleeding has stopped for more than 1 week, and the following criteria are met:

• The patient can maintain bed rest at home.

• The patient has a responsible adult present at all times who can assist in an emergency situation.

• The patient lives near the hospital with available transportation to the hospital.

• Once a patient has been hospitalized for three separate episodes of bleeding, she remains in the hospital until delivery. Labor Present. If the patient and fetus are stable, tocolysis may be considered

!Preterm Gestation, Maternal and Fetal Hemodynamic Instability.

Maternal stabilization with resuscitative measures. Once stable, the patient should be delivered by cesarean section.

!!!

Placenta previa

• Painless

• Less distress

• Soft abdomen

• abnormal lie & presentation

• CTG usually normal

• No pre eclampsia

• No coagulation defect

• Most dangerous for mother

!!Vasa previa (VP)

Vasa previa (VP) can occur when the umbilical cord inserts into the membrane of the placenta instead of the central region of the placenta. When one of these vessels is located near the internal os, it is at risk of rupturing and causing fetal hemorrhage.

Incidence :- 0.03%

!Clinical Manifestations.

Although VP is a rare cause of bleeding, patient usually presents with an acute onset of vaginal bleeding in the setting of ruptured membranes.The bleeding is associated with an acute change in fetal heart pattern; emergency caesarean section is indicated. If VP is diagnosed antenatally, elective caesarean section should be scheduled at 36 to 38 weeks.

!!BY: Hazha F.Rasheed

Edited By Mohammed Musa

Placental abruption

• Painful

• More distress

• Tense tender abdomen

• Normal lie & presentation

• CTG abnormal

• Ass with preeclampsia

• Coagulation defect

• More dangerous for fetus.