APH

By: Huzaifa Hamid

Definition

is defined as vaginal bleeding from 24 weeks to delivery of the baby.

Or any bleeding occurring in the antenatal period after 20 weeks gestation.

It complicates 2–5% of pregnancies. It is associated with increased risks of

fetal and maternal morbidity and mortality

Causes

• Erosion• Polyps• Cancer

• Varicosities

• Lacerations

• Abraptio p.

• Placenta p.

• Vasa previa

Initial steps in management of late pregnancy bleeding:

initial management: patient’s vitals FHM IV fluids

Order lab tests: CBC DIC workup (platelets, PT,

PTT, fibrinogen, and D-dimer)

Type and cross-match Ultrasound “The most

accurate”

further steps in management: Give blood transfusion for

large volume loss. Place Foley catheter and

measure urine output. Perform vaginal exam to

rule out lacerations. Schedule delivery if fetus is

in jeopardy or gestational age is ≥ 36 weeks.Never perform a digital or speculum examination in a patient

with late vaginal bleeding until a vaginal ultrasound first rules out placenta previa.

Apt, Kleihauer-Betke, and Wright’s stain tests determine if blood is fetal,

maternal, or both.

ABRUPTIO PLACENTA

Introduction

Definition:It is the separation of the placenta from its site of implantation before delivery of the fetus.

Varieties:- Total or partial- Revealed or Concealed

Incidence:1 in 200 deliveries

Placental Abruption

Pathophysiology

Initiated by bleeding into the decidua basalis, the bleeding splits the decidua, and a decidual hematoma forms. The hematoma leads to separation, compression, and destruction of the placenta adjacent to it.

a. The process may be self-limited, with no further complication to the pregnancy or may continue to become catastrophic.

b. Bleeding insinuates between the fetal membranes and uterus which may extravasate or may remain concealed. Concealed abruptions can often be more compromising to maternal hemodynamic status since they are generally underappreciated.

Risk Factors

Increased age & parity.

Hypertension. Preterm ruptured

membranes. Multiple gestation. Polyhydramnios.

Smoking. Cocaine use. Prior abruption. Uterine fibroid. Trauma

Clinical presentation

Vaginal bleeding. Constant and severe abdominal pain. Irritable, tender, and typically hypertonic

uterus. Evidence of fetal distress (if severe). Maternal shock. Disseminated intravascular coagulation.Up to 20% of placental abruptions can present without vaginal bleeding because

bleeding is concealed.

U|S for Abruptio placenta

Abratio Placenta

Diagnosis:Clinically: Late trimester painful bleeding Normal placental implantation Disseminated intravascular coagulopathy

(DIC)

Ultrasonography:

Management

Emergency CS

Vaginal Delivery

Conservative

Management

Emergency cesarean delivery: if maternal or fetal jeopardy is present as soon as the mother is stabilized.

Vaginal delivery: if bleeding is heavy but controlled or pregnancy is >36 weeks. Perform amniotomy and induce labor. Place external monitors to assess fetal heart rate pattern and contractions. Avoid cesarean delivery if the fetus is dead.

Conservative in-hospital observation: if mother and fetus are stable and remote from term, bleeding is minimal or decreasing, and contractions are subsiding. Confirm normal placental implantation with sonogram and replace blood loss with crystalloid and blood products as needed.

Complications

Maternal : Hypovolemia. DIC. Renal failure. Death. Uterine rupture

Fetal : Hypoxia. IUGR. IUFD. Anemia

PLACENTA PREVIA

Introduction

Definition:the placenta is implanted in the lower uterine segment.

Classification: Complete placenta previa: The placenta covers the

entire internal cervical os. Partial placenta previa: The placenta partially covers the

internal cervical os. Marginal placenta previa: One edge of the placenta

extends to the edge of the internal cervical os. Low-lying placenta: Within 2 cm of the internal cervical

os.Incidence: Complicates approximately 1 in 300 pregnancies.

Placenta Previa

Ultrasound performed in the second trimester may show a placenta previa in 5% to 15% of cases. However, as the lower uterine segment develops, over 90% of these previas will resolve. A repeat ultrasound

should be performed at 28 weeks to confi rm the presence of a placenta previa.

Placental migration

At 16 weeks 20% At 40 weeks 0.5% Why the difference?

TrophoTropism Placental migration

Next Slide …

Mechanism of migration

Pathophysiology of bleeding

Avulsion of villi, stretching of lower uterine segment

Risk Factors

Multiparty Increased maternal

age Previous placenta

previa Multiple gestation Previous C/S Uterine anomalies Maternal smoking

ART!!!

Presentation & Diagnosis

Late trimester bleeding Lower segment placental

implantation No pain MRI or Double set-up

Transabdominal US(95% accurate)

U|S Placenta Previa

Management

Emergency cesarean delivery

Conservative in-hospital observation

Vaginal delivery

Scheduled cesarean delivery

Management

Emergency cesarean delivery: if maternal or fetal jeopardy is present after stabilization of the mother.

Conservative in-hospital observation: Conservative management of bed rest is performed in preterm gestations if mother and fetus are stable and remote from term. The initial bleed is rarely severe. Confirm abnormal placental implantation with sonogram and replace blood loss with crystalloid and blood products as needed.

Vaginal delivery: This may be attempted if the lower placental edge is >2 cm from the internal cervical os.

Scheduled cesarean delivery: if the mother has been stable after fetal lung maturity has been confirmed by amniocentesis, usually at 36 weeks’ gestation.

Complications of Placenta praevia

Preterm delivery. PPROM. IUGR Malpresentation Fetal abnormalities ↑ number of C/S. morbidly adherent placenta Postpartum haemorrhage

morbidly adherent placenta

Placenta accreta: The placenta is abnormally attached directly to the myometrium.Placenta increta: The placenta invades the myometrium.Placenta percreta: The placenta penetrates completely through the myometrium.

If placenta previa occurs over a previous uterine scar the villi may invade beyond Nitabuch layer resulting in PLACETNA ACRETA

Summary

Abruptio Placenta Placenta Previa

Pain Yes No

Risk factors PreviousabruptionHypertensionTraumaCocaine abuse

Previous previaMultiparityStructuralabnormalities(e.g., fibroids)Advanced maternalage

Diagnosis:Sonogram

Placenta innormalposition ±retroplacentalhematoma

Placenta implantedover the loweruterine segment

Summary

Abruptio Placenta Placenta Previa

Management 1. Emergent c-section: Best choice for placenta previa or if patient/fetus is deteriorating.2. Vaginal delivery if ≥ 36 weeks or continued bleeding. May be attempted in placenta previa if placenta is > 2 cmfrom internal os.3. Admit and observe if bleeding has stopped, vitals and fetal heart rate (FHR) stable, or < 34 weeks.

Complication Disseminatedintravascularcoagulation

Placenta accreta/increta/percreta→ hysterectomy

Any question?