Antepartumhaemorrhage Dr. Lubna F. Maghur MRCOG
introduction • One of the commonest obstetric complains. • Can present as an obstetric emergency. • Common question in the exam !!!!!!
Objectives • Able to define APH. • List the causes of APH. • Define abruptio-placenta and placenta previa. • Understand the risk factors, presentation, diagnosis and management of placenta previa. • Understand the risk factors, presentation, diagnosis and management of placenta previa.
Definition Vaginal bleeding following 24 weeks gestation until the delivery of the baby. Effects 3% of pregnancies
Causes • Abruptio placenta. • Placenta previa. • Vasaprevia • unexplained Obstetric causes All patients with bleeding in pregnancy should have speculum examination Local causes Cervical polyp. Cervical erosion. Cervical cancer.
Placental abruption Premature separation of a normally situated placenta 0.5-2% of pregnancies. More common than placenta previa
A etiology and risk factors • Hypertension. • Pre-eclampsia. • IUGR • High parity. • Previous abruption. • Hyperdestension of the uterus. • Smoking and drug abuse. • Low social class • Unknown (defective rophoblastic invasion) • trauma
Types of abruption • Revealed. • concealed
Clinical presentation • Symptoms: Pain , bleeding+/_, decrease fetal movement • Signs: May be in shock, abdomen tense, tender, fetal hart difficult to here,
Diagnosis • Abruption is mainly a clinical diagnosis. • Ultrasound may show a retroplacentalhematome
Complications • Couvelaire uterus. • Post partum haemorrhage. • Intrauterine fetal death. • DIC. • Maternal hypovolemia.
Placenta previa Abnormal implantation of the placenta in the lower uterine segment
incidance • 0.5% of pregnancies. • Incidence is higher in early gestation Migration of placenta
Aetiology and risk factors • Advanced maternal age. • Multiparity. • Previous cesarean section. • Previous placenta previa
Types • Type: I: in the lower segment. • Type II; reaching the os. • Type III; partially covering the os. • Type IV; completely covering the os (centralis. Ultrasound classification Clinical classification Major Minor
Clinical presentation • Usually presented during ante natal follow up. • Symptoms; Asymptomatic, bleeding (painless, causeless, recurrent) • Signs; Soft abdomen, unengaged head, +/_ malpresentation. Vaginal examination is absolutely contraindicated
Diagnosis Placenta previa is an ultrasound diagnosis
Why does PP cause APH? Uterine contraction pulling up of lower segment separation of the placenta which is implanted in lower segment bleeding. Life threatening if in labour.
complication • Severe bleeding and hypovolemia. • Post partum haemorrhage. • Morbidly adherent placenta
Why does placenta previa cause PPH? • Placenta inserted in lower segment. • Not enough muscle fibers in lower segment to prevent bleeding from placental bed.
Morbidly adherent placenta • Placenta invading the myometrium. • 1:2500 pregnancy • Increase risk with placenta previa and previous cesarean. • Types: • Accreta. • Increta. • percrita
Management of APH History: • Bleeding duration, amount, color, clots, previous attacks. • Pain. • Predisposing factor. • Antenatal ultrasound scan • Hypertension. • Past obstetric history
Examination: • Vital signs. • Abdominal examination. • speculum Investigation: • Ultrasound. • CBC Never never never perform Vagina examination unless PP is excluded
Management of massive obtetrichaemorrhage • Insert 2 large canula. • Blood for CBC, Blood group, coagulation screen. • Cross match at least 4-6 units blood. • Start I/V fluid. crystalloid Vs colloid • Blood if low hemoglobin. • Urinary catheter. • Treat the cause.
Management of a patient with abruption Mild – moderate: • Admission. • Observation of vital signs and vaginal bleeding. • Observation of fetal heart. • If term deliver. • If progressing deliver. • If any sign of fetal or maternal compromise deliver. • May be role for conservative management !!!!! Severe: • Resuscitate and deliver
Management of placenta previa Asymptomatic: • Admission. • Prepare blood. • Cross match 6 units blood. • Deliver at term by cesarean section. • May require early delivery if she has bleeding
Presented with bleeding: • Resuscitate. • Deliver if severe. • Conservative if self limiting
Cesarean section in pacentaprevia • Complications. • Counseling. • When should we perform it? • Who should perform it?
Management of adherent placenta • Hysterectomy. • If no bleeding leave placenta in, consider methotrexate and antibiotic.
Vasaprevia Occurs following rupture of membranes in a patient with valementous insertion of the cord
Characteristically there is mild vaginal bleeding associated with sudden fetal bradycardia. • The blood is fetal in origin. • Requires emergency cesarean section.