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Antepartum haemorrhage : 

Antepartum haemorrhage Dr. Mohammed Abdalla

WHO Estimates 515 000 Maternal Deaths Each Year : 

WHO Estimates 515 000 Maternal Deaths Each Year MORE THAN ONE WOMAN DIES EVERY MINUTE from pregnancy-related causes

What Do Women Die Of? : 

What Do Women Die Of? They Die Of Obstetric Complications That Need Not Be Fatal

OBSTETRIC COMPLICATIONS : 

OBSTETRIC COMPLICATIONS Hemorrhage 21% Unsafe Abortion 14% Eclampsia 13% Obstructed Labor 8% Infection 8% Other 11% Account for about 3/4 of Maternal Deaths DIRECT

OBSTETRIC COMPLICATIONS : 

OBSTETRIC COMPLICATIONS Are Due to Pre-existing Conditions, including Malaria, Anemia and Hepatitis And Increasingly HIV / AIDS Account for about 1/4 of Maternal Deaths INDIRECT

Most Obstetric Complications Occur Suddenly : 

Most Obstetric Complications Occur Suddenly If women do not receive medical treatment on time, they will probably suffer disability… Or Die Without Warning

The Three Delays : 

The Three Delays First Delay: Recognizing that there is a problem. Second Delay: Reaching the appropriate level of care once the problem is identified. Third Delay: Receiving appropriate care once reaching the referral institution.

Most Obstetric Complications : 

Most Obstetric Complications Can Neither Be Predicted Nor Prevented… But If Women Receive Effective Treatment In Time, …Almost All Can Be Saved

How Much Time Do We Have? : 

How Much Time Do We Have? It is estimated that, if untreated, death occurs on average in: 2 hours from Postpartum Hemorrhage 12 hours from Antepartum Hemorrhage 2 days from Obstructed Labor 6 days from Infection

How Do We Know Which Women Will Experience Complications? : 

How Do We Know Which Women Will Experience Complications? WE DON’T

Slide 11: 

…But we do know that of any population of pregnant women at least 15% will experience an obstetric complication …This is as true of pregnant women in the US and Europe as of women in Africa, Asia and Latin America Nobody Knows Why This Happens. It Is a Fact of Life

what is an antepartum haemorrhage? : 

what is an antepartum haemorrhage? An antepartum haemorrhage is any vaginal bleeding which occurs at or after 28 weeks and before the birth of the infant.

the initial, emergency management of antepartum haemorrhage : 

the initial, emergency management of antepartum haemorrhage 1. Assess the condition of the patient. 2. Assess the condition of the fetus. 3. If the patient stable Diagnose the cause of the bleeding.

what symptoms and signs indicate that the patient is shocked due to blood loss? : 

what symptoms and signs indicate that the patient is shocked due to blood loss? 1. Dizziness , irritability. 2. sweating, pallor, and cold , clammy skin. 3. low BL.P and tachycardia.

how should you manage a patient with an antepartum haemorrhage? : 

how should you manage a patient with an antepartum haemorrhage?

Slide 16: 

Insert 2 I.V. lines at least gauge 18.

Slide 17: 

give 1000 ml. crystalloid while waiting blood.

Slide 18: 

Insert a Foley's catheter.

Slide 19: 

take blood for cross-matching , and order 2 or more units of blood and 2 units of plasma urgently.

Slide 20: 

Call 7

CALL 7 : 

CALL 7 Nursing staff. Senior specialist. Senior anethsiest. Neonatologest Blood bank. Lab. O.R

Slide 22: 

Listen to the fetal heart

Slide 23: 

If she is severly shocked PREPARE FOR URGENT DELIVERY BY CS

If she is in mild or moderate shock : 

If she is in mild or moderate shock then more attention can be given to the history and examination of the patient in order to make a diagnosis of the cause of the bleeding and assessment of fetal condition.

can you rely on clinical findings to determine the cause of a haemorrhage? : 

can you rely on clinical findings to determine the cause of a haemorrhage? Yes! Abruptio placentae OR Placenta praevia.

Slide 26: 

An antepartum haemorrhage with fetal distress or fetal death is almost always due to abruptio placentae

Maternal risk assessment of abruptio placentae? : 

Maternal risk assessment of abruptio placentae? 1. history . 2.Ut. anomalies or s.m fibroid. 3. Pre-eclampsia (gestational proteinuric hypertension). 4. Intra-uterine growth restriction. 5-abdominal trauma .

what do you expect to find on general and abdominal examination of the patient? : 

what do you expect to find on general and abdominal examination of the patient? 1- shock often out of proportion to the amount of visible blood loss. 2. pain. 3. The abdominal examination shows the following : (i) The uterus is topically contracted, hard and tender, so much so that the whole abdomen may be rigid. (ii) Fetal parts cannot be palpated. (iii) The uterus is bigger than the patient's dates suggest. (iv) The haemoglobin concentration is low, indicating severe blood loss. 4. The fetal heart beat is almost always absent in a severe abruptio placentae.

Slide 29: 

why is it important to remember that many patients with abruptio placentae have underlying pre-eclampsia?

placenta praevia : 

Placenta previa is less frequently diagnosed as gestational age advances due to the so-called "placental migration" phenomenon. A diagnosis of placenta previa is unlikely to change after 32 weeks' gestation, placenta praevia

placenta praevia : 

incidence of placenta praevia fell with advancing gestational age : 76% at 17 weeks' gestation . 3% at term. placenta praevia

placenta praevia : 

If it encroaches on the cervical os it is considered a major or complete praevia if not then minor or partial praevia exists. placenta praevia

placenta praevia : 

1. the amount of bleeding corresponds to the degree of shock. 2. (i) The uterus is soft and not tender to palpation. (ii) The uterus is not bigger than it should be for the patient's dates. (iii) The fetal parts can be easily palpated, and the fetal heart is present. . placenta praevia

placenta praevia : 

If there is 2/5 or less of the fetal head palpable above the pelvic brim on abdominal examination, then placenta praevia can be excluded and a digital vaginal examination can be done safely. The first vaginal examination must always be done carefully, placenta praevia

what is the further management after making the diagnosis of placenta praevia? : 

what is the further management after making the diagnosis of placenta praevia? 1. If the patient is not bleeding actively, further management depends on the gestational age: 2.A patient who is actively bleeding must be delivered irrespective of the gestational age,

placenta praevia : 

The mode of delivery should be based on clinical judgement in each situation…. complete or major placenta praevia, should be delivered by c.s Evidence level III , grade B recommendation RCOG placenta praevia

Slide 37: 

but in partial praevias a placenta encroaching within 2cm of the internal os is a contraindication to attempting vaginal delivery. Evidence level III , grade B recommendation RCOG

Higher risk : 

Higher risk The association between placenta praevia and placenta accreta is strong, with a relative risk of 2,065 compared to women with a normally sited placenta. Am J Obstet Gynecol 1997;177:210-4.

Highest risk : 

Placenta praevia itself raises the risk for accreta due to implantation over a highly vascular, poorly contractile lower uterine segment; an existing scar in this same area, as well, obviously compounds the risk. Highest risk

Risk association : 

Risk association Source: Modified from Clark SL, et al., , the American College of Obstetricians and Gynecologists.

Slide 41: 

bladder Uterine body tube

Slide 42: 

Ut. incision

CASE PROBLEMS : 

CASE PROBLEMS

CASE 1A patient who is 35 weeks pregnant, presents with vaginal bleeding. : 

CASE 1A patient who is 35 weeks pregnant, presents with vaginal bleeding.

Slide 45: 

1. Why does this patient need to be assessed urgently? 2. What is the first step in the management of a patient with an antepartum haemorrhage? 3. What is the next step in the management of a patient with an antepartum haemorrhage? 4. What should be done once the condition of the patient and her fetus have been assessed, and the patient resuscitated, if necessary?

Slide 46: 

CASE 2 A patient who is 32 weeks pregnant, according to her antenatal card, presents with a history of severe vaginal bleeding and abdominal pain. The blood contains dark clots. Since the haemorrhage, the patient has not felt her fetus move. The patient's blood pressure is 100/50 mm Hg and the pulse rate 120 beats per minute.

Slide 47: 

1. What is your clinical diagnosis? 2. If the clinical examination confirms the diagnosis, what should be the first step in the management of this patient? 3. What is the next step in the management of the patient, that requires urgent attention? 4. How should you manage the patient, if a fetal heart beat is heard? 5. Should the above patient be transferred to a level 2 or 3 hospital for delivery, if the fetus is still alive? 6. How should you manage this patient if a fetal heart beat is not heard?

Slide 48: 

CASE 3 A patient is seen at the antenatal clinic at 35 weeks gestation with a breech presentation. The patient is referred to see the doctor the following week, for an external cephalic version. That evening she has a painless, bright red vaginal bleed.

Slide 49: 

1. What is your diagnosis? 2. What should be the initial management of the patient? 3. How should the patient be managed, if she should have a severe bleed? 4. What investigations should be done, if the patient is not bleeding actively during your initial clinical examination? 5. How should the patient be managed, if she has had no further severe bleeding after the initial bleed?

THANK YOU : 

THANK YOU Dr. Mohammed Abdalla