Antepartum Hemorrhage 1

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Antepartum Haemorrhage (APH) : 

Antepartum Haemorrhage (APH) Dr Mayuramana

Contents : 

Contents Definition Importance Causes Management of APH Prognosis

Slide 3: 

Bleeding In Pregnancy Bleeding in early Pregnancy Antepartum haemorrhage (APH) Post partum Haemorrhage (PPH)

Antepartum Haemorrhage : 

Antepartum Haemorrhage Antepartum haemorrhage (APH,prepartum hemorrhage) is bleeding from the vagina during pregnancy from twenty four weeks of gestational age to term. Epidemiology Affects 3-5% of all pregnancies 3 times more common in multiparous than primiparous women

Importance : 

Importance Obstetric emergency Attention should be sought immediately If left untreated can lead to death of the mother and/or foetus Can leads to DVT Management reduce the risk of premature delivery and maternal/perinatal morbidity/mortality

Causes : 

Causes Blood stained show (benign) - Most common cause of APH Placental abruption - Most common pathological cause (1/100) Placenta praevia - Second most common pathological cause (1/200) Vasa praevia- Often difficult to diagnose, frequently leads to foetal demise (1/2000-3000) Uterine rupture - (<1% in scarred uterus)

Causes ctd… : 

Causes ctd… Bleeding from the lower genital tract Cervical bleeding – Cervicitis , cervical neoplasm, cervical polyp, Cervical ectropion Vagina bleeding - Trauma, neoplasm, Vulval varices , infection Inherited bleeding problems - Very rare, 1 in 10,000 women Unexplained - No definite cause is diagnosed in about 40% of APH

Bleeding that may be confused with vaginal bleeding : 

Bleeding that may be confused with vaginal bleeding GI bleed - Hemorrhoids, inflammatory bowel disease Urinary tract bleed - UTI

Placenta praevia : 

Placenta praevia Definition Insertion of the placenta, partially or fully, in the lower segment of the uterus

Etiology : 

Etiology No definitive cause Endometrial factors: A scarred endometrium Curettage for several times Abnormal uterus Placental factors Large plcenta Abnormal formation of the placenta Development retardation of fertilized egg

Risk factors for Placenta praevia : 

Risk factors for Placenta praevia Multiparity Advanced maternal age Prior LSCS or other uterine surgery Prior placenta praevia Uterine structural anomaly Assisted conception

Degrees of Placenta praevia : 

Degrees of Placenta praevia

Classification of degrees of Placenta praevia : 

Classification of degrees of Placenta praevia Four grades: Grade I: Placenta encroaches lower segment but does not reach the cervical os Grade II: Reaches cervical os but does not cover it Grade III: Covers part of the cervical os Grade IV: Completely covers the os, even when the cervix is dilated

Placenta praevia- Clinical Features : 

Placenta praevia- Clinical Features Recurrent painless vaginal bleeding (not always) Abdominal findings Uterus is soft, relaxed and non tender Contraction may be palpated Presenting part is usually high Abnormal presentations Maternal cardiovascular compromise Foetal condition satisfactory until severe maternal compromise Vaginal examination- should not be done

Investigation : 

Investigation Diagnosis by ultrasound scan showing that the placenta coming in to the lower segment Transvaginal ultrasound is safe and is more accurate than transabdominal ultrasound in locating the placenta Leading edge within the 2 cm from internal os or completely covering the internal os is incompatible with normal vaginal delivery

Placenta praevia-Complications : 

Placenta praevia-Complications Maternal Major hemorrhage, shock, and death Renal tubular necrosis and acute renal failure Post partum haemorrhage Morbid adherence of Placenta : placenta accreta complicates approximately 10% of placenta praevia cases Anaemia in chronic haemorrhage Sensitization of mother for foetal blood in Rh (-) patients Disseminated intravascular coagulopathy (DIC)

Placenta praevia-Complications cont…. : 

Placenta praevia-Complications cont…. Foetal IUD Hypoxic ischemic encephalopathy Cerebral paulsy Placental abruption Premature labour

Placental abruption : 

Placental abruption Definition Premature separation of a normally situated placenta in a viable foetus Placental abruption should be considered in any pregnant woman with abdominal pain with or without PV bleeding, as mild cases may not be clinically obvious

Placental abruption : 

Placental abruption Concealed haemorrhage Retro placental blood clot

Etiology : 

Etiology Risk factors Increased age and parity Vascular diseases: preeclampsia, maternal hypertension, renal disease,SLE and APS Mechanical factors: Trauma, intercourse Sudden decopression of uterus Polyhydroamnios Multiple pregnancy 4. Smoking, cocaine use, 5. Uterine myoma 6. Premature rupture of membranes 7. Supine hypotensive syndrome

Pathology : 

Pathology Main changes Hemorrhage into the decidua basalis → decidua splits → decidural hematoma → separation, compression, destruction of the placenta adjacent to it Types of abruption 1. Revealed abruption 2. Concealed abruption 3. Mixed type

Slide 22: 

Revealed abruption Concealed abruption

Diagnosis-Clinical Features : 

Diagnosis-Clinical Features Painful vaginal bleeding Pain is usually continuous 1.Mild type Abruption≤ 1/3 Vaginal bleeding may be present or absent

Diagnosis-Clinical Features ctd : 

Diagnosis-Clinical Features ctd 2.Severe type Abruption > 1/3 Large retroplacental haematoma Vaginal bleeding associate with persistent abdominal pain Tenderness on the uterus “Woody” hard uterus Change of foetal heart rate –CTG changers Features of hypovolemic shock

Complication of Placental abruption : 

Complication of Placental abruption Maternal Disseminated intravascular coagulopathy Hypovolemic shock Amnionic fluid embolism Renal tubular necrosis and acute renal failure Post partum haemorrhage Sensitization of Rh(-) mother for foetal blood Sheehan’s syndrome Maternal death

Complication of Placental abruption : 

Complication of Placental abruption Feotal Premature labour IUGR in chronic abruption Hypoxic ischemic encepalopathy and cerebral paulsy Foetal death

Investigations : 

Investigations Ultrasonography Mainly to exclude placenta praevia Can detect Retroplacental hematoma Feotal viability Most of the time findings will be negative Negative findings do not exclude placental abruption CTG – Sinosoidal pattern,Feotal tachycardia or bradycardia Laboratory investigations Investigation for Consumptive coagulopathy – Platelet count/BT/CT/PT/INR & APTT Liver and Renal function tests

Vasa praevia : 

Vasa praevia Foetal blood vessels from the placenta or umbilical cord cross the internal os beneath the baby Rupture of membranes leads to damage of the foetal vesseles leading to exsanguination and death High foetal mortality (50-75%)

Vasa praevia : 

Vasa praevia

Risk factors : 

Risk factors Eccentric (velamentous) cord insertion Bilobed or succenturiate lobe of placenta Multiple gestation Placenta praevia In vitro fertilization (IVF) pregnancies History of uterine surgery or D & C

Slide 31: 

Succenturiate lobe Bilobate placenta Eccentric (velamentous) cord insertion

Diagnosis - Vasa praevia : 

Diagnosis - Vasa praevia 1.Moderate vaginal bleeding + feotal distress 2.Vessels may be palpable through dilated cervix 3.Vessels may be visible on ultrasound (Transvaginal colour Doppler ultrasound) Difficult to distinguish from abruption Can look for feotal Hb (Kleihauer-Betke test) or nucleated RBC’s in shed blood Tachycardia or bradycardia in CTG

Rupture of Uterus : 

Rupture of Uterus Uterine scar dehiscence: Foetal membranes remain intact, foetus is not extruded intraperitoneally, separation limited to old scar, peritoneum overlying is intact Usually no foetal distress / maternal Hemorrhage Uterine rupture: Separation of scar  extension, rupture of foetal membranes with extrusion Results in foetal distress / maternal hemorrhage Maternal mortality Foetal mortality = 35%

Rupture of Uterus : 

Rupture of Uterus

Rupture of Uterus : 

Rupture of Uterus High Index of clinical suspicion In all cases of antepartum and intra partum haemorrhage uterine rupture must be excluded

Risk factors : 

Risk factors Scarred uteri –Previous caesarian section & other uterine surgeries Grand multiparous Inadvertent use of oxytocin & prostaglandins Shoulder dystocia Forceps deliveries Trauma Uterine abnormalities

Rupture of Uterus-Clinical features : 

Rupture of Uterus-Clinical features Maternal Pain in between contractions Scar tenderness Vaginal bleeding Profound maternal tachycardia and Hypotension Loss of uterine contractions Haematurea Postpartum haemorrhage may be a sign

Rupture of Uterus-Clinical features cont.. : 

Rupture of Uterus-Clinical features cont.. Foetal Foetal distress-CTG changers Loss of station Absence of FHS Palpable foetal parts through maternal abdomen

Complications : 

Complications Maternal Hemorrhage Bladder rupture Maternal death PPH DIC Foetal Respiratory distress Hypoxia and cerebral paulsy Acidemia Death

Comparison of Presentation of Abruption v. Previa v. Rupture : 

Comparison of Presentation of Abruption v. Previa v. Rupture Abruption Praevia Rupture Abd. pain present absent variable Vag. blood old or fresh fresh fresh DIC common rare rare Acute foetal common rare common distress

Slide 41: 

Management of APH

Management of APH : 

Management of APH Admit to hospital for assessment and management May need resuscitation measures if shocked or severe bleeding Airway, breathing and circulation Senior staff must be involved –Consultant obstetrician and consultant anaesthetist, neonatalogist Two wide bore canula Take blood for Grouping & DT,FBC , coagulation profile,Liver & renal function Severe bleeding or fetal distress: urgent delivery of baby irrespective of gestational age

Management of APH : 

Management of APH Volume should be replaced by Crystalloid / colloid until blood is available Severe bleeding or feotal distress: Urgent delivery of baby irrespective of gestational age

Management of APH cont… : 

Management of APH cont… History Obtain a history if patient’s condition including: Colour and consistency of bleeding Quantity and rate of blood loss Precipitating factors i.e. Sexual intercourse, Vaginal examination Degree of pain, site and type Placental location-review ultrasound report if available Ascertain foetal movements Ascertain blood group

Management of APH cont… : 

Management of APH cont… Examination Assess maternal and foetal well-being Pallor, record temperature, pulse and BP Perform abdominal examination Note areas of tenderness and hypertonicity Determine gestational age of foetus, presentation and position, auscultate foetal heart No vaginal examination should be attempted at least until a placenta praevia is excluded Do speculum examination to assess cervix / bleeding and exclude local lesions

Management of APH cont… : 

Management of APH cont… Investigations Arrange urgent ultrasound scan Foetal monitoring Continuos electronic foetal monitoring is indicated

Management of APH cont… : 

Management of APH cont… Rhesus negative woman should have a klihaver test and be given prophylactic anti-D immunoglobulin (Rhogum) For pre-term delivery when immediate delivery is not necessary, maternal steroids - to promote feotal lung maturity Betamethasone Dexamethasone

Further management of APH : 

Further management of APH Further management will depend on Cause of the APH Extent of bleeding Presence of feotal distress Gestational age and feotal maturity

Placenta praevia - Management : 

Placenta praevia - Management 1.Near term / Term Delivery is considered Grades I and II - May be able to deliver vaginally Grades III and IV - Will require caesarean section by senior obstetrician Should anticipate PPH

Placenta praevia – Management cont… : 

Placenta praevia – Management cont… 2.Early in pregnancy Continuation of pregnancy better if possible Need bed rest Educate patient regarding condition and risk 3 pint of crossed matched blood should be available till delivery Foetal well being and growth should be monitored –KCC,CTG,USS Medications may be given to prevent premature labour- Nifidipine, Atosiban

Placental abruption – Management ctd : 

Placental abruption – Management ctd Small abruption Conservative management depending on gestational age Careful monitoring of feotal condition

Placental abruption - management : 

Placental abruption - management Moderate or severe placental abruption: Restore blood loss Ideally measure central venous pressure (CVP) and adjust transfusion accordingly Prevent coagulopathy Monitor urinary output Delivery 1.Caesarean section 2.Vaginal If coagulopathy present If feotus is not compromised If feotus is dead

Rupture of Uterus Management : 

Rupture of Uterus Management Emergency laparotomy Deliver the baby Uterine repair if possible specially in primi gravida PPH haemostasis sequence Caesarian hysterectomy (may be preferred)

Vasa Previa management : 

Vasa Previa management Urgent delivery Most of the time urgent LSCS Neonatologist involvement Aggressive resuscitation of the baby with blood transfusion following delivery

Prognosis of APH : 

Prognosis of APH Feotus may die from hypoxia during heavy bleeding Perinatal mortality more than 50 per 1000 even with tertiary care facilities High rates of maternal mortality

Slide 56: 

Thank You