Antepartum Haemorrhage

By

Dr Shuhaila Ahmad / A/Prof Dr Zaleha

Definition

Bleeding from the genital tract from 22 weeks POA until delivery of the fetus

Why 22 weeks POA?This is because fetus is considered to be salvageable

at this gestation(WHO= 22 weeks/ 500g or more)

**Lower segment starts to form at 28 weeks until 34 weeks

Incidence of APH

2 to 5 % of all pregnancies (at term)The earlier the gestation , the higher the

incidence.

Causes

Placenta praevia (30%)Abruptio placenta (22%)Indeterminate cause(42%)Local causes (5%)

– cervical polyp/ carcinoma– cervical erosion/ cervicitis– laceration

Vasa praevia -very rare

Complications of APH

an aem ia D IV C H yp ovo lu m ic sh ock P os tp artu mh aem orrh ag e

M ate rn a l

Maternal mortality

Complications Of APH

d ea th o rd is tress

an aem ia IU G R p rem atu rity

F e tu s

Fetal loss14%

PLACENTA PRAEVIA

Definition

Placenta that is situated wholly or partially in the lower segment

Types of placenta praevia

Typ e 1 Typ e 2

M in or

Typ e 3 Typ e 4

M ajo r

P lacen tap raevia

Type 1

Lower edge of placenta encroaches the lower segment

(within 5 cm from the internal os)-by ultrasound.

Internal os

Type 2

The lower edge of the placenta reaches the internal os but does not cover it

Internal os

Type 3

The placenta covers the os but not centrally

Internal os

Edge of placenta

Type 4

The placenta centrally covers the os

Internal os

Cause

Unknownit is associated with:

– previous caeserean section– previous history of placenta praevia– previous h/o spontaneous abortion whereby

evacuation of uterus was performed– multiparity– multiple pregnancy

How do they present?

Classical presentation:– fetal malpresentation in late pregnancy– painless pervaginal bleeding

An unengaged head at term especially in a primigravida

Asymptomatic– diagnosis via ultrasound scan

History

Bleeding– usually painless– unprovoked e.g.. Trauma– the amount varies– fresh bleeding

Fetal movement unchanged

Physical examination

Usually vital signs stable i.e.. Not in shock (the vital signs reflect the amount of bleeding)

Abdomen is non tender and softUterus is soft and corresponding to dateFetus could be in an abnormal presentationFetal heart sound present

NO VE TO BE DONE

Until placenta praevia is ruled out

Investigation

Ultrasound scan via the abdomen – full bladder is required for better visualization– able to tell anterior or posterior– type of placenta– presentation of the fetus

Haemoglobin levelBlood group

Other methods

X-ray of the pelvis (lateral)– will show a excessive distance between the

fetal head and sacrum or symphisis pubisRadioisotope imagingMagnetic Resonance Imaging (MRI)

– expensive– not invasive

Examination under anaesthesia

Ultrasound equipment or expertise is not at hand

Patient is bleeding to a degree whereby the delay to arrange for ultrasound would be dangerous

Uncertainty between a normally situated placenta and a praevia minor

How to do it?

Preparation as if the patient is going for caesarean section

In operation theatreNot necessarily under general anaesthesiaScrub nurse and assistant fully scrubbed

and gownedInstruments for CS are laid out

EUA - how to do it?

The surgeon scrubbed and fully gowned– patient in dorsal position– vulva and vagina are inspected for active bleeding– speculum introduced to look at the os for bleeding or

placenta– finger introduced to feel for fornices– introduced into the os and feel for placenta– If no placenta, amniotomy is performed

Principle of management of APH

ResuscitationAdmit to a center with adequate facilities

such as operation theatre, blood bank and neonatal backup

After patient is stabilized, get brief history and physical examination to assess patient’s condition

Perform several investigations to look for cause and assess patient’s condition

Planned for further treatment ( to deliver or not and mode of delivery)

Management

Resuscitation of patient– 2 large bore branulas (at least 18G)– IV fluid replacement, preferably crystalloids– blood for GXM and Hb level– CBD for measuring urine output

Macafee Regime

Patient must be in a hospital with facilities for immediate CS

Blood at least 4 units must be available at all time

Anaemia must be correctedMonitoring of maternal and fetal wellbeing

– including dexamethasone for lung maturity

Delivery

Try to bring to 38 weeks POA as possibleMajor PP - CSMinor PP- vaginal delivery is possible

especially the anterior typeHowever, if the bleeding is profuse ,

delivery must be done at any gestation in order to save the maternal life.

Complications of Placenta praevia

Postpartum haemorrhage:– placenta accreta– uterine atony– poor haemostasis because lower segment has

less smooth muscle therefore contraction is poor.

Recurrence of Placenta praevia in next pregnancy

ABRUPTIO PLACENTA

DEFINITION

Premature separation of a normally situated placenta

Blood clotplacenta

Maternal surface of placenta

Blood clots

Causes

UnknownAssociated with:

– elderly and multipara– hypertension– poor placentation (diminished adhesiveness to

the uterine wall)– trauma (to abdominal wall,external cephalic

version or cordocentesis)

Causes

– Smoking cocaine– sudden decompression of uterus i.e. in

polyhydramnios– fibroids– multiple pregnancy– ? Folate deficiency

HOW DO THEY PRESENT?

History of painful PV bleedingLoss of consciousness/syncopal attackReduced or no fetal movementMaybe history of trauma before

Physical examination

Pale not appropriate with amount of bleeding seen

Hypovolumic shockBP high or normal if it is associated with

hypertensionUterus is tender and rigidUterus can be larger or equal to date

Physical examination-cont...

Fetal parts not felt wellFetal heart absentAmniotomy noted blood stained liquor

How to diagnose?

Basically on clinical judgementUltrasound plays a small role in achieving

diagnosisIt is only confirmed by demonstrating a

retroplacental clot after delivery of placenta

Management

ResuscitationCorrect coagulopathyEarly deliveryClose monitoring of maternal vital signAdequate analgesiaAssessment of fetal condition

Delivery

C S / S V D

A live +N o D IV C

correc t D IV C +C S / S V D

A live +D IV C

C orrec t D IV C +S V D

D ead +D IV C

M od e o fd e live ry

Complications

Fetal demiseAcute renal tubular or cortical necrosisRecurrenceSevere DIVCPostpartum haemorrhage

– uterine atony– couvelaire uterus (insufficient contraction )

Indeterminate APH

Undetermined cause of bleeding Usually originating from placentaFrequently associated with circumvallate

placenta

Vasa praevia

RareUsually intrapartum rather than antepartumFetal exsanguination is rapidVelamentous insertion of cord

PlacentaCord

Vasa praevia_ cont…..

Fetal distressDelivery via CSDiagnosis is confirmed by Kleihaeur test

THAT’S ALL FOLKS!

The rest you read on your own

That’s all,the rest please read on your own