ANTEPARTUM HEMORRHAGE

ANTEPARTUM HEMORRHAGE UCHENNA OSANAKPO

INTRODUCTION • It is one of the most ominous complications of pregnancy. • It is one of the three leading causes of maternal death and a major cause of perinatal morbidity and mortality in the U.S. • Differentiation must be made between obstetric and non–obstetrics causes of bleeding.

PREMATURE SEPARATION OF THE PLACENTA • Separation from the site of uterine implantation before delivery of the fetus. • Two types (a) concealed (b) external • 30% antepartumhemorrhage is due to placental separation usually the first hemorrhage is seen after the 26th week • 50% occur before the onset of labour and 10-15% are not diagnosed before the second stage of labour

ETIOLOGY Predisposing factors: previous placental separation, hypertensive states of pregnancy, advanced maternal age, multiparity, uterine distension, vascular disease, thrombophilias, uterine anomalies or tumors, cigarette smoking, alcohol consumption (>14 drinks per week), cocaine use and possibly maternal type O blood.

ETIOLOGY • Precipitating factors: circumvallate placenta, trauma, sudden reduction of uterine volume, abnormally short cord, increase venous pressure

PATHOPHYSIOLOGY AND PATHOLOGY • Local vascular injury that results in vascular rupture into the deciduabasalis, bleeding and hematoma formation, the hematoma shears off adjacent denuded vessels, producing further bleeding and enlargement of the area of separation • Due to an abrupt rise in uterine venous pressure transmitted to the intervillous space leads to engorgement of the venous bed and separation of all or part of the placenta

CLINICAL FINDINGS • Larger separations are accompanied by abdominal pain, uterine irritability, hemorrhage may be visible or concealed. If the process is extensive, evidence of fetal distress, uterine tetany, DIC, hypovolemic shock may be seen. Increased uterine tonus and frequency of contractions may provide early clues of abruption, most times patients present with vaginal bleeding

LABORATORY • anaemia • Peripheral blood smear shows reduced platelet counts, presence of schistocytes, fibrinogen depletion with release of fibrin split products • Prothrombin time, PTT, platelet count, fibrinogen and fibrin split products- help determine coagulation status

IMAGING • U/S may be helpful in diagnosing placental abruption but it is inconclusive. • Possible findings are hyperechoeic foci posterior to the placenta suggests fresh blood or a hpoechoeic area suggests a formed clot

TREATMENT • Expectant management in placental abruption is the exception and not the rule. Appropriate when the mother is stable, fetus immature and fetal heart tracing is reassuring. Continousfetal and uterine monitoring should be done. • Emergency measures, most cases are diagnosed during labour or delivery. Hemorrhage, fetal distress and uterine spasm. Blood should be collected and @ least 4 units of PRBC typed and crossed. Two large bore IV cannulas SHOULD BE PLACED AND CRYSTALLOIDS ADMINISTERED.

TREATMENT • Vaginal delivery is indicated if the degree of separation appears to be limited and if continuous FHR is reassuring. When the separation is extensive but the fetus is dead, vaginal delivery is indicated. It is contraindicated when there is massive hemorrhage and operative delivery is necessary to save mother or fetus

TREATMENT • Cesarean section is done when vaginal delivery is not imminent for a fetus with a reasonable chance of survival with persistent evidence of distress. It is also indicated when the fetus is in good condition but the situation is not favourable for rapid delivery in d face of progression or severe placental separation • Maternal indications are uncontrollable hemorrhage, rapidly expanding uterus with concealed hemorrhage with or without live fetus

COMPLICATIONS • DIC • Renal and cortical necrosis • Uterine atony

PROGNOSIS • External or concealed hemorrhage, excessive blood loss, shock, nulliparity, closed cervix, absence of labor and delayed diagnosis and treatment are unfavourable • Maternal mortality ranges from 0.5-5%, most die from hemorrhage(immediate or delayed), cardiac or renal failure • Perinatal mortality rate is approx 5%, liveborn infants have a high morbidity rate due to predeliveryhypoxia,birth trauma and hazards of prematurity

PLACENTA PREVIA • The placenta is implanted in the lower uterine segment within the zone of effacement and dilatation of cervix leads to an obstruction to the descent of the presenting part • Classified into (a) marginal (b) complete (c) incomplete

ETIOLOGY • Multiparity, advancing age, previous C/S, scarred or poorly vascularizedendometrium in the corpus, large placenta, succenturiate lobe, multiple gestation. • Bleeding in placenta previa is due to (a)mechanical separation from its implantation site during formation of the lower uterine segment or during effacement and cervical dilatation (b)placentitis (c) rupture of poorly supported venous lakes in d deciduabasalis that have been engorged with venous blood

DIAGNOSIS • Every patient suspected to have placenta previa should be hospitalized and cross match blood @ hand. • Vaginal and rectal examination should not be performed to avoid hemorrhage • 95% are diagnosed via U/S

SYMPTOMS AND SIGNS • Painless, sudden and profuse bleeding , bright red clotted blood. Bleeding rarely produces shock. • Uterus is soft, relaxed and non-tender • High presenting cannot be pressed into the pelvic inlet • Infant will pressent in a transverse or oblique in approx 15%

DIFFERENTIAL DIAGNOSIS • PLACENTA ABRUPTION • CIRCUMVALLATE PLACENTA

TREATMENT • Depends on the amount of uterine bleeding, duration of pregnancy and viability of fetus, degree of placenta previa, presentation, position and station of fetus, gravidity and parity of the patient, status of the cervix and whether or not labour has begun • Patient should be admitted and blood should be readily available for transfusion

TREATMENT • Expectant therapy because hemorrhage may occur early in pregnancy before pulmonary maturity, transfusions to replace blood loss, use of tocolytic agents to prevent premature labour and prolong pregnancy to about 32-34 weeks • C/S is the delivery of choice. Vaginal delivery is usually indicated for marginal placenta previa and when the presentation is cephalic plus there should be constant FHR monitoring any signs of distress do C/S

COMPLICATIONS • Maternal: hemorrhage, shock, death, operative trauma, infection and embolism, placenta previa accreta • Fetal: prematurity, fetal hemorrhage due to tearing of the placenta occurs with vaginal manipulation and upon entry into the uterine cavity as C/S is done

PROGNOSIS • Maternal: due to rapid recourse to C/S, use of banked blood and expertly administered anaesthesia the mortality has fallen to less than 1 in 1000 • fetal: perinatal mortality has reduced to approx 1%. Premature labour, placenta abruption, cord accidents and uncontrollable hemorrhage cannot be avoided, can be reduced with ideal obsteric and newborn care

UTERINE RUPTURE • Major cause of maternal death • Two types(a) complete: traumatic and spontaneous (b) incomplete

RISK FACTORS • Hysterotomy • Trauma • Uterine overdistension • Uterine anomalies • Placenta percreta • Invasive mole • Choriocarcinoma • Neglected obstructed labour • Improper use of oxytocin

CLINICAL FINDINGS • Fetal heart rate abnormalities • Increased suprapubic pain and tenderness with labour • Sudden cessation of uterine contractions with a tearing sensation • Vaginal bleeding or bloody urine • Recession of the fetal presenting part

TREATMENT • Prepare the patient for URGENT C/S

PREVENTION • Identify patients @ risk of uterine rupture • Early diagnosis of abnormal presentation • Correct administering of oxytocin during labour • Good obstetric assessment and technique • Correct use of partograph

COMPLICATIONS • HEMORRHAGE • SHOCK • POSTOPERATIVE INFECTION • BLADDER OR URETERAL DAMAGE • THROMBOPHLEBITIS • AMNIOTIC FLUID EMBOLUS • DIC • PITUITARY FAILURE • DEATH

PROGNOSIS • Maternal mortality rate is 4.2% • Perinatal mortality rate is 46%

THANK YOU

ANTEPARTUM HEMORRHAGE