antepartum hemorrhage

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					Antepartum Hemorrhage
Hemorrhage has been identified as the single
most important cause of maternal death
worldwide, accounting for almost half of all
maternal deaths in developing countries
      Ante partum hemorrhage

Any bleeding from genital tract after 22 wks of
pregnancy & before delivery of the foetus.

4% of all pregnancy
                Causes of APH

• Placental causes ( 50 -70%) (obstetric causes)

  –   Placenta previa
  –   Placental abruption
  –   Velamentous insertion of cord /Vasa previa ( rare)
  –   Marginal sinus rupture
  –   Circumvellate placenta
  –   Rarely rupture uterus
•       Excessive show

• Local causes ( non obstetric causes)

    –   Cervical polyp
    –   Cervical ectopy ( erosion)
    –   Carcinoma cervix
    –   Vaginal / vulval varicosities
    –   Cervicitis/ vaginitis

    – Indeterminate Bleeding
Abruptio placentae / accidental hemorrhage
 • Types:

     Revealed / External hemorrhage

     Concealed hemorrhage – carries worse risk ,
     increased risk of consumptive coagulopathy / extent
     of hemorrhage not appreciated


 • Total / partial
 • Incidence : 0.5%
       Etiology of abruptio placentae

• Advancing maternal age / High parity

• Race - more common among African American as
  compared to Asians

• Hypertension – chronic HTN / pre eclampsia

• Uterine over distension / Sudden uterine decompression
  e.g.: polyhydramnios & multiple pregnancy
•   Previous abruption

• Abnormal placentation /Retroplacental location of fibroid
  / short cord

• Cigarette smoking / cocaine

• Congenital / acquired thrombophilias

• Trauma

• Iatrogenic – following external cephalic version
        Pathophysiology of abruption

• Vascular injury ( e.g)       vascular rupture into
  decidua basalis        hematoma formation
  further separation of placenta
• Abrupt rise in uterine venous pressure
  engorgement of intervillous space
  separation of placenta
               Clinical features

• Symptoms & signs may not correlate with the severity
  of abruption

• Symptoms:

  – Bleeding ( may be altered / fresh blood)
  – Abdominal pain - continuous pain
  – Too frequent contractions
  – Back pain
                  Clinical features
• Signs:

  – Signs of hemodynamic compromise
  –  Anemia & oliguria may be present
  – Tense & tender uterus
  –  Uterus may feel doughy / woody hard due to persistent
  – Frequent uterine contractions
    (It may be difficult to appreciate uterine contractions due to
    persistent hypertonus)
  – About 10% is ass with clinically significant coagulopathy
         Grading of abrupion
• Grade o: An asymptomatic , RPC seen after
• Grade 1: Vaginal bleeding & uterine tenderness;
  visible RPC after delivery
• Grade 2: Abruption severe enough to cause fetal
  distress & RPC visible after delivery
• Grade 3: Significant maternal signs- uterine
  tetany, abdominal pain, hypovolemia; IUD, DIC

• Abruption is mostly a clinical diagnosis
  based on history & physical findings.

• Ultrasound may / may not reveal evidence
  of abruption. The main usefulness of USG
  is in excluding placenta previa &
  confirming fetal viability
         Diagnosis of Abruptio placentae

• USG – retroplacental
  sonolucent area

• Negative findings with
  ultrasound examination do not
  exclude placental abruption

• No collection in revealed type
        Differential diagnosis
Bleeding with pain abdomen
• Painful bleeding : abruption
 (Note: revealed abruption not painful)

• Painless bleeding : placenta previa
  (Note:1. placenta previa with labour pains
  will be painful
  2. 10% of placenta previa may be
  associated with abruption)
  Other differential diagnosis for pain
  abdomen in later half of pregnancy

• Preterm labour / premature contractions
• Imminent eclampsia ( R U Q tenderness /
  epigastric pain)
• chorioamnionitis
• Red degeneration fibroid
• Other surgical / medical illness
      Complications of abruption
 Fetal :
• Prematurity , fetal distress , fetal Death
 Maternal :
• Anemia / shock /oliguria ( rarely ARF)
• Consumptive coagulopathy
• Couvelaire uterus
• Maternal Death

• Blood gping / Rh typing

• Coagulation Profile



• Severe cases – Fibrinogen & FDP

• USG : may not help in excluding abruption, but can
  exclude p. previa, confirm viability & well being & AFI
• With a live and mature fetus, and if vaginal
  delivery is not imminent, emergency caesarean
  delivery is the choice

• Role of vaginal delivery

  – Advanced labor + no evidence of fetal distress

  – Perform ARM + augment with syntocinon
    once vaginal delivery is planned

• In severe abruption with IUD, adequate
  resuscitation of mother with fluid & blood
  replacement should be carried out to prevent
  ARF & to correct the coagulopathy & if cervix not
  favourable - to proceed with LSCS
             Placenta previa

Incidence of low lying placenta – 5% at 18-28
Incidence of placenta previa at term - 0.5%
         Placenta previa - Types

• Total placenta previa. The internal os is covered
  completely by placenta

• Partial placenta previa. The internal os is partially
  covered by placenta

• Marginal placenta previa. The edge of the placenta is at
  the margin of the internal os.

• Lateral placenta praevia . Just dipping into lower uterine
  segment ( within 5 cm from the internal os)
         Placenta Previa


Endometrial damage :
  Previous pregnancies, scar
  Defective decidual vascularisation
          RISK FACTORS
• Advancing maternal age / multiparity
• Previous Lscs / Myomectomy scar /
  induced abortion
• H/o placenta previa in the previous
• Multiple pregnancy
• smoking
Vaginal bleeding

 – Sudden in onset
 – Bleeding is bright red and painless.
 – Occasional mild irritable uterus (about 20%)
 – Initial bleeding is usually not profuse
   Spontaneously ceases, may recur later.
 ( Warning Haemorrhage)
                    Physical signs

Profuse hemorrhage : signs of Hypovolaemia
(eg) Tachycardia, Hypotension, anaemia

Soft and non tender uterus

Normal fetal heart sound (usually)

Unengaged presenting part at term / mal presentations like
  breech or transverse in 30%

Fetal condition remains good until there is maternal
  hemodynamic compromise
• Vaginal & rectal examinations: Do not
  perform because they may provoke
  uncontrolled bleeding
        Cause of bleeding
Mechanism of bleeding
Formation of lower segment – tear of
placental attachments + inability of lower
segment to contract as effectively

Other causes of hemorrhage in placenta
 praevia include digital examination and
 sexual intercourse.

• Fetal abnormality - rate of abnormality
  doubled with placenta praevia
• IUGR – 15%
• 10% of women with placenta praevia will
  have coexisting abruption
   Complications :maternal

Hemorrhage & consequences of hemorrhage,
 DIC less as compared to abruption.
Operative intervention including risk of
 hysterectomy is high

PPH: adherent placenta like
accreta,increta percreta
        Neonatal complications
Foetal:Perinatal morbidity & mortality increased
  Preterm labor
  Congenital anomalies
  Respiratory distress syndrome
Major cause of perinatal mortality. Prematurity
 accounts to 50%
                 Diagnosis - TAS

• Transabdominal
• 96-98 % accuracy

  – Congenital anomalies,
    mal presentation, and
    intrauterine growth
  – Identify umbilical cord
    insertion and to exclude
    a vela mentous
    Transvaginal ultrasonography

• Better accuracy
• Particularly useful in
  posterior placenta
• Found to be safe
• Magnetic
  Imaging- not widely
• Identification of placenta accreta, placenta
  increta, and placenta percreta with any
  placenta previa.

   – Associated with very high morbidity and
     mortality rates and may need for a
     scheduled caesarean hysterectomy.
   – Counselling all patients with placenta previa
     about the possible eventuality of an
     emergent caesarean hysterectomy.
         Placental ‘Migration’
• Placenta that lie close to the internal os, but not
  over it, during the second trimester, or even
  early in the third trimester, are unlikely to persist
  as previa by term.

• Those covering the os, about 40 percent
  persisted as a previa

• Once low lying placenta diagnosed @
  20wks , Rpt scan @ 30 - 32 wks is a must
  TRO placenta previa
 Morbidly adherent placenta previa
• Risk factor- uterine scarring
• The incidence is on the rise due to increasing
  cesarean section rate
  – Accreta ( 80%)
  – Increta
  – Percreta
• Most of the time diagnosis made in third
• Small % - diagnosis made antenatally

 Women with a placenta previa may be
 considered as follows:

• Those in whom the fetus is preterm / minimal
  bleeding and there is no indication for delivery.

• Those in whom hemorrhage is so severe as to
  mandate delivery despite fetal immaturity

• Major degree / minor degree ( vaginal Vs C.S)
     Other issues in management
• Home Vs Hospital
• Home management
   – Should have an adult with her / conveyance /
• Hospital :
   – long term hospitalization – financial & psychological

• Inpatient management for patients for women
  who have had episodes of bleeding

• Complete assessment @36weeks. Major degree
  unlikely to move after 36 wks, but a minority may
  do so
     Caesarean section for placenta previa

• Planned C.S @ 38weeks ( if C.S required
  prior to that , administer steroids)
• X-match adequate amount of blood
• Senior team / regional anesthesia
• Technique : Pfannensteil , lower segment
• Delivery : cut through / go round the margin
  of placenta
• Third stage- Oxytocics. If accreta
  encountered proceed with hysterectomy
     Bleeding from placental bed

• Over sewing ( figure of 8) individual bleeding
• Extra Oxytocics ( as in management of atonic
• Packing the cavity
• Uterine artery ligation / internal iliac artery
  ligation / embolisation techniques
• Hysterectomy
• Post delivery – in HDU
• Postnatal counselling
             Vasa previa
• An aberrant Feto placental vessels
  running in the membranes which may
  Cross over the internal os
• Rupture of vasa occurs during Labour,
• Can cause Acute Fetal distress & Death
• Treatment is delivery usually immediate
• Fetal mortality is > 50%
Management of women presenting with APH

• Rapid assessment of both mother & fetus
• Quick clinical history
• LMP / previous scan report
• Amount of bleeding / clots / abdominal
  pain/ previous episodes of bleeding
• Trauma / coitus / liquor loss
• Previous uterine surgery
• Fetal movements / blood group
Management of women presenting with APH

• Maternal assessment : vital signs / pallor /
• Obstetric – size, tenderness & presenting
• No P/ V
• Establish fetal viability & fetal well being /
  commence monitoring
Management of women presenting with APH

• Group 1 : bleeding minimal ; both mother
  & fetus stable

• Group 2 : bleeding heavy & continuing,
  either compromised / likely to be
    Management of women presenting with APH

    Group 1 : if placenta previa for expectant
    management ( Johnson & Macafee regime)
•   Bed rest / make sure Hb ok / steroids / pad chart/
•   Tocolysis : in women who exhibit uterine activity
•   Severe : proceed with LSCS + simultaneous
    resuscitation ( regardless of gestational age)
•   Investigations: FBC, X-match, clotting screen,
General principles in the management of APH
• Patient with APH should always be managed in a set up
  which is capable of dealing with maternal hemorrhage &
  premature baby

• Never perform a vaginal examination before the placental
  position is confirmed

• Perform quick evaluation of blood loss & hemodynamic
  status (Note: symptoms & signs of hypovolemia in a
  pregnant woman occurs only after about 25% of volume is

• Perform quick lab evaluation

• Follow ABC of resuscitation in an unstable patient

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