Seminar aph
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Transcript of Seminar aph
At the end of this tutorial the student will be able to:
Define APH Discuss the etiology and differential
diagnosis of APH Describe the assessment and
management of a woman with APH
Definition and Classification
Definition bleeding from or in to the genital tract, occurring from 22 weeks (>500g) of pregnancy and prior to the birth of the baby.
Classification Placenta praevia
Abruptio placenta
CAUSES OF 763 PREGNANCY-RELATED DEATHS
DUE TO HEMORRHAGE
CAUSES OF HEMORRHAGE NUMBER (%)
Placental abruption 141 (19)
Laceration/uterine rupture 125 (16)
Uterine atony 115 (15)
Coagulopathies 108 (14)
Placenta previa 50 (7)
Uterine bleeding 47 (6)
Placenta accreta/increta/percreta
44 (6)
Retained placenta 32 (4)
Placental: - Placenta praevia - Placenta abruption - Vasa praevia
Local cause: - Cervical polyps - Cervicitis, Vaginitis - Cervical cancer.
(Should be taken after the mother is stable.) Severity of the bleeding
-associated pain with the haemorrhage?
-Continuous pain : Placental abruption.
-Intermittent pain : Labour. Time of onset Triggering factors A/w pain or uterine contractions? Fetal movement
-If it reduced and associated with spontaneous or iatrogenic rupture of the fetal membranes : ruptured vasa praevia
Hx of ruptured membranes Hx cervical smear (date/normal or abnormal)
-Previous cervical smear history possibility of Ca cervix. Symptomatic pregnant women usually present with APH (mostly postcoital) or vaginal discharge.
Previous ultrasound report Risk factors for abruption and placenta praevia should be identified.
General: PULSE & BP Abdomen: The tense, tender or ‘woody’ feel to the
uterus indicates a significant abruption. Painless bleeding, high fetal presenting part –
Placenta praevia - soft, non-tender uterus may suggest a
lower genital tract cause or bleeding from placenta or vasa praevia.
Speculum : -identify cervical dilatation or visualise a
lower genital tract cause.
Digital vaginal examination - Should NOT be done until Placenta
Praevia has been excluded by USG.
Blood test - FBC - Coagulation profile - Cross-match blood Ultrasound Colour doppler Kleihauer test
Fetal monitoring: CTG monitoring
Conservative Management
Admit ( according to RCOG is 28weeks)
Monitor BP & Pulse rate Pad chart - to monitor progress of
the leaking liquor Minimize the abdominal examination
Monitor fetal well being - Fetal kick chart(daily) - CTG (weekly) - U/S (fortnightly)
Steroid injection (> 24w, <36w) ‐ IM dexamethasone 12mg stat and repeat the second dose after 12 hours.
Any symptoms or signs of labour �
Maternal complications Fetal complications
Anaemia Fetal hypoxia
Infection Small for gestational age and fetal growth restriction
Maternal shock Prematurity (iatrogenic and spontaneous)
Renal tubular necrosis Fetal death
Consumptive coagulopathy
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Complications of blood transfusion
Definition The condition that the placenta is wholly or partly attached to the lower uterine segmentClassification (GRADING/CLINICAL)
Type IV The placenta completely covers the cervical os.
Type IV The placenta completely covers the cervical os.
Type III The placenta covers the os but not at full dilatation.
Type III The placenta covers the os but not at full dilatation.
TYPE II The placenta reaches the margin of cervical os
TYPE II The placenta reaches the margin of cervical os
TYPE 1 The placenta enroaches into lower segment
A PLACENTA WHICH HAS IMPLANTED OVER THE OS
Placenta
Cervix
Uterus
Minor : Type 1 (anterior/posterior) Type 2 anterior
Major: Type 2 posterior (dangerous type) Type 3 Type 4
Deliver vaginallyType 1 Posterior > likelihood of fetal distress
Caesarean sectionType 2 posterior > chance of fetal distressType 3 & 4 anterior –cut through placenta to deliver. Hence need to be fast and efficient.
ETIOLOGY
Advancing maternal age Multiparity Prior cesarean section ,manual
removal of placenta and dilatation and curettage(D&C)
Multiple gestation Smoking History of PP
PATHOLOGY
Maternal influence
Haemorrhage Shock Anemia
Fetal influence Distress or
death IUGR Premature Neonatal death
The incidence of placenta praevia is 0.5%, bleeding from a placenta praevia is about 20% of all cases of antepartum hemorrhage.
The incidence of placenta praevia is 0.5%, bleeding from a placenta praevia is about 20% of all cases of antepartum hemorrhage.
PATHOPHYSIOLOGY
During the trimester of pregnancy Slight or severe bleeding from the vagina without evident cause and without any pain on the abdomen.
During delivery Severe haemorrhage is inevitable as the cervix dilates, especially in type I and type II.
During the third stage of labour Postpartum haemorrhage
•Intermittent painless PV bleeding
•Minimal/spotting
•Bleeding mainly from mother
•Abdomen is soft and nontender
•CTG usually normal
•a/w with abnormal lies and presentation
Maternal:1)FBC2)BUSE/RP3)GSHFetal1)CTG2)U/S
Low Lying Placenta PraeviaImage shows (Transvaginal Ultrasound, 33 weeks gestation): On transvaginal scan, the placenta is situated on the posterior uterine wall (arrow) and extends to 15mm of the internal cervical os. The cervix is long and closed through its entire length and measures 38mm. Normal fetal measurements and activity are noted which are not illustrated.
Partial Placenta PraeviaImage by (Transvaginal Ultrasound): The placenta partially overlies the internal cervical os (arrow).
Complete Placenta PraeviaImage by (Transvaginal Ultrasound): The placental completely covers the top of the internal cervical os (arrow).
Type I,II(ant) Type II( post), III,IV
ARM +/- oxytocin
Satisfactory progress without bleeding
Vaginal delivery
Bleeding continues
Caesarean section
Caesarean section