Antepartum Hemorrhage

1. بسم الله الرحمن الرحیم Lecturer: Dr O.M.O ANTEPARTUM HEMORRHAGE Prepared By Group A

2. Group Members • Abdilahi Hassan Abdi • Deeqa Aden Ismail • FarhanIidan Aden • Abdilahi Mohamed Abdilahi • Abdicasisaliibrahim • Ayaan Hassan Siciid • Bilan Abdurrahman Huseyn • Fadxiyaabdifataxmohamed • Israaliibrahim

3. Definition APH • Bleeding from the genital tract in pregnancy between 20 to 24 week’s gestation and the onset of labour. • It affects 4% of all pregnancies. • It is associated with increased risks of fetal and maternal morbidity and mortality.

4. Causes • Placental: • Abruptio placenta. • Placenta previa. • Non-placental: • Vasa previa. • Bloody show. • Trauma. • Uterine rupture. • Cervicitis. • Carcinoma. • Idiopathic.

5. ABRUPTIO PLACENTA

6. Introduction Definition: It is the separation of the placenta from its site of implantation before delivery of the fetus. • Incidence: • 1 in 200 deliveries.

7. Types of Placental Abruption • Revealed placental abruption: causes vaginal bleeding. • Concealed placental abruption: internal bleeding

8. Risk Factors • Increased age & parity. • Hypertensive disorders. • Preterm ruptured membranes. • Multiple gestation. • Polyhydramnios. • Smoking. • Cocaine use. • Uterine fibroid. • Trauma

9. ClinicalPresentation • Vaginal bleeding. • Uterine tenderness or back pain. • Fetal distress. • High frequency contractions. • Uterine hyper tonus. • IUFD. • Nausea and vomiting

10. Classification Grade 0 Grade 1 • Asymptomatic, • External vaginal bleeding • Uterine tetany and tenderness may be present • No signs of maternal shock • No evidence of fetal distress

11. Cont. Grade 2. Grade 3. • External vaginal bleeding may or may not be present • Uterine tender and tentany • No signs of maternal shock • Signs of fetal distress present • External bleeding may or may not be present • Marked uterine tetany • Maternal shock • Fetal death or distress • Coagulopathy in 30% of the cases

12. Diagnosis • Physical examination to determine the uterine rigidity or tenderness. • Abdominal Ultrasound • CBC • Fetal Monitoring • Pelvic Exam • Vaginal Ultrasound

13. Management • Fetal Monitoring for the fetal heart rate • Blood Transfusion if its need • Administer Rh immune globulin if the patient is Rh- • Vaginal Delivery • Blood plasma replacement to maintain fibrinogen level • Cesarean Delivery is often necessary for fetal and maternal stabilization

14. Prevention • Do not drink any alcohol such as beer and wine • Do not smoke or use recreational drugs during pregnancy • Get early and regular prenatal care • Early recognizing and managing conditions in the mother such as diabetes and high blood pressure also decrease the risk of placental abruption

15. Complications Maternal Fetal • Hypovolemic shock • DIC (Disseminated intravascular coagulation) • Renal failure. • Death. • Uterine rupture • Hypoxia. • Brain Damage • IUGR. • stillbirth • Anemia

16. PLACENTA PREVIA

17. Introduction Definition: • The presence of placental tissue overlying or proximate to the internal cervical os after viability. Incidence: • Complicates approximately 1 in 300 pregnancies.

18. Predisposing factors • Multiparty • Increased maternal age • Previous placenta previa, recurrence rate 4-8% • Multiple gestation • Previous cesarean section • Uterine anomalies • Maternal smoking

19. Placenta praevia Grades: • Grade 1: the placental edge is in the lower uterine segment but does not reach the internal os (low implantation). • Grade 2: the placental edge reaches the internal os but does not cover it. • Grade 3: the placenta covers the internal os when it is close and is asymmetrically situated (partial). • Grade 4: the placenta covers the internal os and is centrally situated (complete)

20. Clinical presentation • Bright red vaginal bleeding without pain • Premature contractions • Baby is breech in transverse position

21. Diagnosis • History taking • Abdominal examination • Leopold's Maneuvers • Fetal Heart Monitoring • Vaginal Examination is avoiding

22. Management • Admit to hospital • Corticosteroids • Blood volume replacement to maintain blood pressure • Avoiding intercourse

23. Complications of Placenta praevia Maternal Fetal • APH • PPH • Increase risk of puerperal sepsis • Malpresentation; breech, oblique, transverse. • IUGR • Premature delivery • Death

24. VASA PREVIA

25. Introduction • Is a complication of pregnancy in which babies blood vessels cross or run near the internal opening of the uterus • These vessels are at risk of rupture when the supporting membranes rupture. • The term of Vasa previa is derived from the Latin word • Vasa means Vessel • Pre means Before • Via means Way • The incidence is 1 in 2000 – 3000 deliveries.

26. Associated Conditions • Low-lying placenta. • Bilobed placenta. • Multi-lobed placenta. • Succenturiate-lobed placenta. • Multiple pregnancies. • IVF.

27. Clinical Presentations • Painless vaginal bleeding • Rupture of membranes • Fetal bradycardia

28. Diagnosis • The diagnosis of vasaprevia is considered if vaginal bleeding occurs upon rupture of the membranes. • Fetal hemoglobin test • Concomitant fetal heart rate abnormalities. • Ultrasound

29. Antenatal Management • Consider hospitalization in the third trimester to provide proximity to facilities for emergency cesarean delivery. • Fetal surveillance to detect compression of vessels. • Antenatal corticosteroids to promote lung maturity.

30. Antepartum Management • Immediate C/S. • Avoid amniotomy as the risk of fetal mortality is 60-70% with rupture of the membranes.

31. UTERINE RUPTURE

32. Reported in 0.03-0.08% of all delivering women, but 0.3-1.7% among women with a history of a uterine scar (from a C/S for example) • 13% of all uterine ruptures occur outside the hospital • The most common maternal morbidity is hemorrhage • Fetal morbidity is more common with extrusion

33. Cont. • Classic presentation includes vaginal bleeding, pain, cessation of contractions, absence/ deterioration of fetal heart rate, loss of station of the fetal head from the birth canal, easily palpable fetal parts, and profound maternal tachycardia and hypotension. • Patients with a prior uterine scar should be advised to come to the hospital for evaluation of new onset contractions, abdominal pain, or vaginal bleeding.

34. Risk Factors • The most common risk factor is a previous C/S or uterine surgery. • Placenta previa • Plastentaaccreta. • Trauma.

35. Presentation • Sudden severe fetal heart decelerations. • Abdominal pain ( <10%). • Excessive vaginal bleeding • Rapid heart rate of mother • Lowe blood pressure • Cessation of uterine contractions.

36. Prognosis • Fetal death 50-75%. • Maternal mortality is high if not diagnosed & managed promptly. • Maternal morbidity: hemorrhage & infection.

37. Management • stabilization of maternal hemodynamics. • Blood transfusion • Prompt C/S with either repair of the uterine defect or hysterectomy. • Antibiotics.

38. Complications Labor complications: Delivery complications: • CPD. • Abnormal presentation. • Unusual fetal enlargement (hydrocephalus). • Difficult forceps. • Breech extraction. • Internal podalic version.

39. Reference • https://en.wikipedia.org/wiki/Antepartum_haemorrhage • https://www.glowm.com/pdf/AIP%20Chap5%20APH.pdf