Antepartum Haemorrhage BATCH - 2007

• ASHISH KUMAWAT

BHMS III YEAR

DR M P K

HOMOEOPATHIC

MEDICAL COLLEGE,

HOSPITAL AND

RESEARCH CENTRE,

JAIPUR

Massive Obstetric Haemorrhage

• Second most common cause

• Maternal Death

8.5 / million pregnancies

Also includes post-partum haemorrhage

Antepartum Haemorrhage- Definition

Bleeding in pregnancy after 28 weeks gestation

Antepartum Haemorrhage - Types

1. Simple

2. Complicated

Antepartum Haemorrhage -Simple

1.Local causes• Vaginal• Trauma

2.Cervical• Erosion

• Tumour – Pap Smear

3.Blood Dyscrasia• Thrombocytopenia

• Anticoagulants

Antepartum Haemorrhage - Complicated

Placenta Praevia

• (Inevitable APH)

Abruptio Placentae

• (Accidental APH)

Placenta Praevia - Definition

Placenta which has implanted partially or

wholly in the lower uterine segment

Placenta Praevia - Types

Old Classification

Grade 1 – Just enters lower segment

Grade 2 – Enters LUS but does not reach os

Grade 3 – Partially covers os but not

completely

Grade 4 – Completely covers os

Placenta Praevia – Old Classification

Placenta Praevia – Types

Major – Enters LUS but does not cover os

Minor – Covers internal os completely

Placenta Praevia – New classification

Placenta Praevia- aetiology

• Unclear

• Any damage to endometrium or myometrium

• Scar tissue impedes migration away from os

• Increased placental mass

Placenta Praevia – Increased Mass

• Multiple pregnancy- large surface area

• Cigarette smoking- vasoconstriction

• Cocaine Use – Vasoconstrictionhypertrophy

Placenta Praevia –Endo/Myometrial Damage

• Previous C/S

•Spontaneous Abortion

•Uterine abnormalities

Placenta Praevia – Other Factors

• Previous Placenta Praevia

• Maternal Age – reduced uterine blood flow

needs greater surface area

• Parity - 3 previous deliveries 2.6 fold Vessels at site of previous placenta reduced flow-

discourage implantation

Placenta Praevia – Associated Complications

• Congenital Abnormality - 6.7% /3.2% ?• Small for Dates(SGA)

19% - decreased placental perfusionReduced nutrient transfer

• Malpresentation – 3 fold increaseBreechTransverse lie

• Abnormal Placentation – Accreta/PercretaUnscarred uterus 5% 1 previous C/S 24% 4 C/S 67%

• Pregnancy Induced Hypertension – reduced½ normal incidence

Placenta Praevia - Presentation

• Antepartum Haemorrhage

Late pregnancy

Painless bleeding

• Malpresentation

Breech/High Head/Unstable lie in 3rd

trimester

• Asymptomatic –found at routine U/S scan

Placenta Praevia – Diagnosis

Ultrasound

Transabdominal

Transvaginal

Placenta Praevia – Abdominal U/S

Placenta Praevia – Transvaginal U/S

Placenta Praevia - Management

• Antenatal

Inpatient vs Outpatient

Major vs minor

Anaemia

Regular Hb

X-match/Transfuse

Placenta Praevia - Management• Delivery

Timing – Mahady’s equationUsually 38/52

• Mode of DeliveryMinor praevia – 2cm from os Examination in theatre/ARM/Vaginal delivery

• Major praeviaCaesarean SectionNB Senior Obstetrician

Abruptio Placentae - Types

Revealed APH

Pain + Vaginal bleeding

Concealed

Pain/Shock

No vaginal bleeding

Abruptio Placentae - Types

• Placental Site - Upper Uterine Segment

Abruptio Placentae – Associated risk factors

• Hypertension/Pre-eclampsia - 44% of all cases

• Maternal Trauma - RTA /Pelvic # - 1.5-9.4%C

• Smoking – 40% increase for each year smoked

• Cocaine – hypertension/catecholamine release• Thrombophilia• Cord complications

• Raised alpha feto-protein• Amniocentesis• Maternal Age• Alcohol

Abruptio Placentae - Symptoms

• Vaginal Bleeding ( Revealed) 80%

• Abdominal /Back Pain (Severe) 70%

• Fetal Distress 60%

• Contractions (Hypertonic) 35%

• Preterm Labour 25%

• Fetal Death in utero 15%

Abruptio Placentae - Complications

Maternal• Haemorrhagic /Hypovolaemic SHOCK

• Coagulopathy DIC/Hypofibrinogenaemia

• Couvelaire Uterus / Uterine rupture

• Renal Failure

• Ischaemic Necrosis distal organs (Liver,Adrenals,Pituitary)

Abruptio Placentae - Complications

Fetal• Hypoxia - Fetal distress - CTG

• Anaemia

• Growth Retardation - if treated conservatively and survives

• CNS Abnormalities

• Intra Uterine Death

Abruptio Placentae - Investigations

• Blood Group - X matchRh – anti D

• Haemoglobin/FBC – Platelets

• Clotting Time / Fibrinogen /FDP /PTT

• Urea /Creatinine

• Ultrasound - exclude Praevia• CTG - Non Stress Test• Biophysical Profile - NB <6

Abruptio Placentae - Management

• Correct SHOCKI V access – 2 large bore cannulae

• Crystalloids IV – emergencyBLOOD as soon as possible

• Correct DIC - ? Heparin• Catheterise - hourly urine output chart• Assess for delivery

FH absent - induce – IV oxytocinFH present- ? C/S ?Induce

Treatment

IPECACUANHA

Uterine hæmorrhage, profuse, bright, gushing, with nausea. Vomiting during pregnancy. Pain from navel to uterus. Menses too early and too profuse.

MILLEFOLIUM

Menses early, profuse, protracted.

Hæmorrhage from uterus; bright red,

fluid. Painful varices during pregnancy.

TRILLIUM PENDULUM

Uterine hæmorrhages, with sensation as though hips and back were falling to pieces; better tight bandages. Gushing of bright blood on least movement. Hæmorrhage from fibroids (Calc; Nitr ac; Phos; Sulph ac). Prolapse, with great bearing-down. Leucorrhœa copious, yellow, stringy (Hydras; Kali b; Sabin). Metrorrhagia at climacteric. Lochia suddenly becomes sanguinous. Dribbling of urine after labor.

CHINA OFFICINALIS

Menses too early. Dark clots and abdominal distention. Profuse menses with pain. Desire too strong. Bloody leucorrhœa. Seems to take the place of the usual menstrual discharge. Painful heaviness in pelvis

BELLADONNA

Sensitive forcing downwards, as if all the viscera would protrude at genitals. Dryness and heat of vagina. Dragging around loins. Pain in sacrum. Menses increased; bright red, too early, too profuse. Hæmorrhage hot. Cutting pain from hip to hip. Menses and lochia very offensive and hot. Labor-pains come and go suddenly. Mastitis pain, throbbing, redness, streaks radiate from nipple. Breasts feel heavy; are hard and red. Tumors of breast, pain worse lying down. Badly smelling hæmorrhages, hot gushes of blood. Diminished lochia.

HYOSCYAMUS NIGER

Before menses, hysterical spasms. Excited sexual desire. During menses, convulsive movements, urinary flux and sweat. Lochia suppressed. Spasms of pregnant women. Puerperal mania.

I Would like to give the thanks to Resp. mam Mrs. PUNIT Who gave me good suggestion & motivation to prepare this project & thanks to all my friends who helped me.