APH APH

DR.HEMANT DESHPANDE.DR.HEMANT DESHPANDE.PROF. & HODPROF. & HODDEPT. OF OBST & GYNDEPT. OF OBST & GYNDR D Y PATIL MEDICAL COLLEGEDR D Y PATIL MEDICAL COLLEGEPUNE.PUNE.

DEFINE APH?

DEF:-

BLEEDING FROM OR INTO THE GENITAL TRACT

AFTER 28 WEEKS OF PREGNANCY,

BUT BEFORE THE DELIVERY OF FETUS

CAUSES OF APH ?

CAUSES:

PLACENTAL BLEEDING: LOW LYING PLACENTA < 28 WEEKS PLACENTA PRAEVIA ABRUPTIO PLACENTA

LOCAL CAUSES: POLYP CA.CERVIX VARICOSE VEINS IN VAGINA VASA PRAEVIA

UNKNOWN:

DEFINE PLACENTA PRAEVIA?

PLACENTA PRAEVIA

PARTIALLY OR TOTALLY IN LUS

LOW LYING 10-30% AT 20 WEEKS BUT > 90% OF THEM MIGRATES

TYPES OF PLACENTA PRAEVIA?

TYPES JAUNIAUX & CAMPBELL CLASSIFICATION

I LOWER MARGIN WITHIN 5 CMS OF INT. OS.- LATERAL

II MARGINAL,LOWER MARGIN UPTO INT. OS.-MARGINAL

III COVER OS IN UNDILATED CONDITION. - INCOMPLETE CENTRAL

IV COVER DILATED OS. COMPLETE CENTRAL

PLACENTA PRAEVIA

RISK FACTORS?

INCIDENCE : 1 IN 200 PREG.

RISK FACTORS:-

ELDERLY MULTIPARA ,AGE > 35, PARITY > 4

PREV. LSCS RISK INCREASES WITH NUMBER

PREV. HYSTEROTOMY

LARGE PLACENTA: MULTIPLE PREG

MEMBRANEOUS PLACENTA

ETIOLOGY THEORIES?

DROPING DOWN THEORY

DEFECTIVE DECIDUA

MEMBRANEOUS PLACENTA

PERSISTANT CHORIONIC ACTIVITY

TYPICAL CHARACTERISTICS ?

DIAGNOSIS:

PAINLESSCAUSELESSRECURRENTVARIBLE AMOUNTT.

What is warning hemorrhage?

WARNING HAEMORRHAGE : 20-24 WEEKS, SLIGHT BLEED

AMOUNT 10-30 ML : NO MATERNAL / FETAL PROBLEM

FRESH BLEEDING 2 - 4 DAYS, AMT DECREASES

STOPS TOTALLY 5-7 DAYS

RECURRENT BOUTS :MORE IN AMOUNT

How the bleed stops?

AMOUNT MORE THAN WARNING FRESH BLEED 1- 4 DAYS DECREASES & DARKENS BLEEDING STOPS WITHIN 5-7 DAYS BY

THROMBOSIS OF SINUSES

EVERTION & INFARCTION OF SEPARATED PLACENTA

PRESSURE ???

How many episodes of bleed ? When?

SOME PATIENTS – H/O THREATENED ABORTION ( 5%)

EPISODES OF BLEEDING : 2 – 5 MAX

COMMONLY DURING 32 -36 WEEKS

TYPE 4 CENTRAL BLEEDS FIRST TIME AFTER 36 WEEKS IN LABOUR

What is the clinical picture?

ON EXAMINATION :

HT OF UTERUS ~ PERIOD OF AMENO. UTERUS RELAXED, SOFT, NON TENDER PRESENTING PART : FLOATING MALPRESENTATIONS ++ MATERNAL VITALS ~ AMT OF BLEEDING FHS ~ AMT OF BLEEDING

What is stallworthys sign?

STALLWORTHYS SIGN : DROP IN FHS ON PRESSING HEAD

IN PELVIS ,RECOVERY ON RELEASE IN TYPE II PP

Investigations ?

NO PV EXAM.

USG : SITE , TYPE , FETAL CONDITION ,

98-99% ACCU. (CLOT,LOCALIZED MYOMET. CONTRACTION)

COLOR DOPPLER --SITE, ACCRETA

MRI?? IN PREV. LSCS WITH PRAEVIA ACCRETA

Management ??

MANAGEMENT DEPENDS UPON

AMT. OF BLEEDING PERIOD OF GESTATION FACILITY OF BT, LSCS

EXPECTANT MANAGEMENT MACAFEE & JOHNSONS ---

WHEN??

EXPECTANT MANAGEMENT MACAFEE & JOHNSONS --- WHEN??

LESS BLEEDING

NO MATERNAL, FETAL COMPLICATION

POG < 37 WEEKS

FETUS ALIVE NO CONG. ABN.

FACILITIES OF BT, MONITORING , LSCS

EXPECTANT MANAGEMENT—MACAFEE & JOHNSONS BED REST--SEDATION– INVESTIGATIONS-LAB + USG

Fe & Ca, FOLIC ACID BT(KEEP READY)

NO PV EXAM- - PS– 5-7 DAYS AFTER

DEXAMETHAZONE 12 MG IM 12 HOURLY 2 DOSES/ REPEAT 10 DAY

100 mcg ANTI-D IF Rh – VE

OS TIGHTENING ???LOVESET

AT 37 WEEKS

IF MINOR DEGREE PP- I ,II ANT

HEAD LIES BELOW PLACENTA

ARM + OXYTOCIN

VAGINAL DELIVERY

CAN PLACENTAL EXAMINATION SHOWS S/O PP?

EXAMINE PLACENTA: TOUNGE SHAPED

EXTENTION,EVERTED MARGINS,

MEMBRANE RENT NEAR PLACENTA

MAJOR DEGREE & TYPE II POST. ACTIVE BLEEDING:- PALLOR +++ , HYPOTENSION TACHYCARDIA HAEMORRHAGIC HYPOVOLEMIC SHOCK FETAL DISTRESS OR DEATH

ACTIVE MANAGEMENT :- RESUCITATION IV FLUIDS OXYGEN BT LSCS

LSCS

ANTERIOR PLACENTA III, IV - LUS OPEN ,SEPARATE PLACENTA

RUPTURE MEMB.,DELIVER BABY

CUTTING OF PLACENTA – FETAL BLOD LOSS , AREA OF DELIVERY)

USE 1 NO./ 2 NO. CATGUT TO AVOID CUT THROUGH STITCHES

DIFFICULTIES ? RARE

BLEEDING : BED BOX STITCHES , UTERINE LIGATION, IIL, HYSTERECTOMY

ACCRETA ! FOCAL ! PIECEMEAL! – ACCRETA TOTAL : LIGATE CORD NEAR INSERTION GIVE MTX + ANTIBIOTICS : MONITER VITALS/USG AUTOLYSIS :4-8 WEEKS

PV IN OT UNDER ANAESTHESIA ??? ONLY IF DEAD, PREMATURE BABY

CX DILATED,PATIENT IN LABOUR

ARM + WILLETS SCALP TRACTION

COMPRESS SEPARATED PLACENTA &

VAGINAL DELIVERY(AVOID LSCS)

PPH IN APH !

LUS NON RETRACTILE SINUSES WIDE OPEN LUS VASCULAR ,SOFT,STITCH CUT THROUGH COMPRESSION + LOCAL UTEROTONICS INJECTIONS + BOX STITCHES + DEVASCULARISATION HYSTERECTOMY SOS

PROGNOSIS:

MATERNAL : ANAEMIA, RENAL FAILURE,DIC, SEPSIS,SHEEHANS SYND.

MORBIDITY & MORTALITY

FOETAL: PREMATURITY,ANOXIA, IUD,, RDS, NEONATAL DEATH

PLACENTA IN THE LOWER SEGMENTLYING DOWN THEREWHEN THE LUS FORMINGIT BLEEDS AND SHEER

AH! SAID MOTHERI MAY HAVE HAEMORRHAGIC SHOCKFOETAL DISTRESS & DEMISE MAY FINALLY ROCK

IF THE BLEED IS LESSMACAFEE & JOHNSON WILL BACK IF THE BLEED IS MORE OPEN IMMIDIETLY THE SAC

ABRUPTIO PLACENTA:

Definition :

PREMATURE SEPARATON OF NORMALLY SITUATED PLACENTA

ACCIDENTAL HAEMORRHAGE –RIGBY 1776

What are risk factors for abruption?

ELDERLY PRIMI PIH ,CHR.HT ,CHR RENAL DISEASE DM FOLIC ACID DEFICIENCY PREV. H/O ABRUPTION 10% RISK TRAUMA ARM,AMNIOCENTESIS ECV CIRCUMVALLATE PLACENTA-

DETACHABLE PERIPHERAL TISSUE SUBMUCUS FIBROID SUPINE HYPOT. SYNDR. APLA SYNDR.

What are the types of abruption?

TYPES REVEALED CONCEALED - RPC MIXED

What is the pathology of abruption?

DECIDUAL HAEMATOMA DECI. NECROSIS SEPARATION OF PLACENTA FROM DECI. BASALIS R P BLEED BLOOD PLOUGHS MYOMETRIUM COUVELAIR UTERUS BLOOD AF STAINED BLOOD REVEALED OUT > 35% PLACENTAL SEPARATION :FETAL DISTRESS/IUD

what is Ernest Pages classification?

GRADES: ERNEST PAGES CLASSIFICATION

0) ASYMPTOMATIC DIAGNOSED ONLY AFTER DELIVERY,SMALL RPC

1) REVEALED BLEEDING ,WITH OR C UTERINE TENDERNESS, MAT & FETAL CONDITION GOOD

2) UTERINE TENDERNESS,FETAL DISTRESS MAY/MAYNOT, NO MATERNAL SHOCK

3) MATERAL SHOCK,UTERINE TENDERNESS, FETAL DEATH , DIC,RENAL FAILURE

SHER’S CLASSIFICATION – SHER’S CLASSIFICATION –

GRADE I :GRADE I :MILD, OFTEN RETROPLACENTAL CLOT IDENTIFIED AT DELIVERY

GRADE II :GRADE II :TENSE, TENDER ABDOMEN AND LIVE FETUS

GRADE III WITH FETAL DEMISEGRADE III WITH FETAL DEMISEIII A(2/3)III A(2/3) - WITHOUT COAGULOPATHY - WITHOUT COAGULOPATHY III B(1/3)III B(1/3) - WITH COAGULOPATHY - WITH COAGULOPATHY

0 ASYMPTOMATIC POST DELIVERY

1 MILD (48% CASES)

2 MILD –MOD (27% CASES)

3 SEVERE (24%CASES)

Investigations role of USG ?

ULTRASOUND

DIAGNOSTIC

HELPFUL IN RULING-OUT OTHER CAUSES

LOCATION: PROGNOSTIC INDICATOR OF FETAL OUTCOME

SUBCHORIONIC: PLACENTA-MEMBRANES

RETROPLACENTAL: PLACENTA-MYOMETRIUM

PREPLACENTAL: PLACENTA-AMNIOTIC FLUID

ULTRASOUND SIGNS

RETROPLACENTAL ECHOLUCENCY

THICKENING OF THE PLACENTA

ABNORMALLY ROUND “TORN EDGE”

RETROPLACENTAL BLOOD CLOT > 500 Grams ASSOCIATED WITH 50% FETAL MORTALITY

SUBCHORIONIC BLEED ASSOCIATED WITH 10% FETAL MORTALITY IN EARLY PREG.

Clinical diagnosis

DIAGNOSIS:

POG >30 WEEKS ( MAJORITY 34 WEEKS)

SEVERE ABDOMINAL PAIN , BLEEDING FRESH OR DARK

PALLOR +++EDEMA ++BP- HTFHR + / - HEAD FIXEDUTERINE TENDERNESS, TENSE ,HYPER TONICITY (BOARD LIKE RIGIDITY)

HT OF UTERUS MAY BE MORE IN CONCEALED

BISHOP SCORE < 5

What is the clinical presentation ?

CLINICAL PRESENTATION

VAGINAL BLEEDING - 80%ABDOMINAL / BACK PAIN& UTERINE TENDERNESS - 70%FETAL DISTRESS - 60%HYPERTONIC UTERUS- 35%PREMATURE LABOR - 25%FETAL DEATH - 15%

TRIAD

UTERINE BLEEDING

UT. HYPERTONICITY / HYPERACTIVITY

FETAL DISTRESS / DEATH

PLACENTAL ABRUPTION

RP BLEED WHERE IT GOES ??

RP BLEED WHERE IT GOES ??

RPC

PLOUGHS MYOMETRIUM –REACH BENEATH SEROSA

BLUISH PURPLE , MULTIPLE ECCHYMOSIS OVER PLACENTAL SITE –COUVELAIRE UTERUS (1920)START AT CORNUE –SPREAD TO--- FUNDUS – TO POSTERO LAT --- THEN TO ANT WALL

PORTWINE STAINING –IRREGULAR LINES –BLOOD PLOUGHS MYOMETRIUM---CLOT BETWEEN MUSCLE BUNDLES—BENEATH SEROSA : TONE AFFECTED

SEROSAL RUPTURE –INTRAPERITONEAL BLEED

INTRA AMNIOTIC BLEED—BLOOD STAINED AF

BROAD LIGAMENT HAEMATOMA

D/DBLUNT ABDOMINAL TRAUMAACUTE APPENDICITISOVARIAN CYST TORSIONPLACENTA PRAEVIAEXCESS SHOW IN LABOUR ECTOPIC PREGNANCY

Investigations ?

INVESTIGATIONS:

HAEMOGRAM OBST. USG:RPC + URINE-R ( ALB. + VE),C/S BLOOD GROUPING Rh TYPING RFT,LFT. HIV, VDRL.

BT, CT, PT,PPT ,PLATLETS FIBRINOGEN < 100 mg% FDP > 10 mcg/ml

CLOT OBSERVATION TEST:

2 ML BLOOD IN TUBE --NO CLOT IN 8 MIN.– HYPOFIBRINOGENEMIA

IF CLOT BUT NO RETRACTION IN 1 HOUR -THROMBOCYTOPENIA

IF DISSOLVES IN 1 HOUR—SUSPECT FIBRINOLYSIS

Management

MANAGEMENT:

I.V. FLUIDS

CVP LINE > 10 CM WATER ~ GOOD PERFUSION

MONITORING

OXYGEN

FOLEYS CATH.

LAB. INV.

ARRANGE FRESH BLOOD

INDUCTION / LSCS

What is role of crystalloids?

VOLUME EXPANSION

CRYSTALLOID: RINGER LACTATE, NS RL SIMILAR TO PLASMA ONLY 20% RETAINED IN CIRCULATION GIVE 2- 3 TIMES VOLUME OF BLOOD LOST

DEXTROSE: ONLY 10% RETAINED, INTERFERES WITH X MATCHING

NS : AVOID IN PRE-ECLAMPTIC PATIENT

BLOOD VOLUME CHANGES LAST FOR 40 MINUTES ONLY

GIVE COLLOIDS AFTER 2 L OF CRYSTALLOIDS GIVEN

What is role of colloids?

COLLOIDS

GELATIN POLYMERS

HEMACCEL-:

RAPID URINARY EXCRETIONANAPHYLAXIS

HYDROXYETHYL STARCH :- HETASTARCH, PENTASTARCH

INCREASES PLASMA VOLUME BY 70 – 230%DOSE 20 ML/KG = 1 TO 1.5 LNO ANAPHYLACTIC REACTIONS WELL TOLERATEDLASTS FOR 4 HOURS IN CIRCULATION

Labour management ?

DELIVERY MANAGEMENT:

LABOUR: INDUCTION ARM + OXYTOCIN / PG

WEIGHT OF RPC ,PLACENTAL EXAM.

LSCS: FETAL DISTRESS, FAILED INDUCTION (6 HOURS)

Role of amniotomy?

AMNIOTOMY –

DECREASE INTRAUTERINE PRESSURE,

EXTRAVASATION OF BLOOD IN THE MYOMETRIUM, ENTRY OF THROMBOPLASTIN IN CIRCULATION.

Maternal complications?

MATERNAL COMPLICATIONS

HEMORRHAGIC SHOCKCOAGULOPATHY/DICUTERINE RUPTURERENAL FAILURE - CORTICAL NECROSISISCHEMIC NECROSIS OF DISTAL ORGANS (EG, HEPATIC, ADRENAL, PITUITARY)ARDS

SOME COAGULOPATHY : 30% SEVERE ABRUPTION.

BEST TREATMENT FOR DIC AS A COMPLICATION OF PLACENTAL ABRUPTION IS IMMEDIATE DELIVERY. 

Fetal complications?

FETAL COMPLICATIONS

HYPOXIA ANEMIAGROWTH RETARDATION CNS ANOMALIESFETAL DEATH

T/ T OF COMPLICATIONS

Rx COAGULOPATHY

FRESH BLOOD, FFP,PCV

CRYOPRECIPITATE FOR -- FIBRINOGEN < 100 MG/DL PLATELETS TRANSFUSION-- IF PLATELETS < 50,000

FIBRINOGEN: 4 GRAM IV RAISES LEVEL BY 100 Mg% ACTIVATED RECOMBINANT FACTOR VIIA.- (20- 120 MCG/KG.)

RENAL FAILURE: HAEMODIALYSIS