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ANTEPARTUM HAEMORRHAGE R.G.Kar Medical College and Hospital Department of Gynecology and Obstetrics

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Definition : It is defined as bleeding from or into the genital tract after the 28 th week of pregnancy but before the birth of the baby (the 1 st and 2 nd stages of labour are thus included). Causes: APH

Placental Bleeding:

Placental Bleeding APH

Placenta Praevia:

Placenta Praevia When the placenta is implanted partially or completely over the lower uterine segment it is called placenta praevia. About 1/3 rd cases of APH belong to Placenta Praevia. The incidence of Placenta Praevia ranges from 0.5-1% amongst hospital deliveries. In 80% cases, it is found to multiparous women. The incidence is increased beyond the age of 35yrs, with high birth order pregnancies and multiple pregnancy. APH

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Etiology: The exact cause of implantation of the placenta in the lower segment is not known. However some theories are postulated regarding this. They are as follows.. DROPPING DOWN THEORY PERSISTENCE OF CHORIONIC ACTIVITY DEFECTIVE DECIDUA BIG SURFACE AREA OF THE PLACENTA

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The high risk factors : Multiparity Increased Maternal Age Previous caesarean section Placental size and abnormality Scarring of the uterus Smoking Prior Curettage

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Types of Placenta Praevia: There are four types of placenta praevia depending upon the degree of extension of placenta to the lower segment. TYPE-I: (low lying) The major part of the placenta is attached to the upper segment and only the lower margin encroaches onto the lower segment but not up to the internal os. TYPE-II: (marginal) The placenta reaches the margin of the internal os but does not cover it. TYPE-III: (partial central) The placenta covers the internal os when it is closed, but does not cover it when the os is open. TYPE-IV: (total) The placenta completely covers the internal os, even when the os is open. APH

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Each of the types are again subdivided into “A” and “B” depending upon the implantation of the placenta on the anterior or the posterior wall of the uterus respectively. TYPE-IA, IB, and IIA are termed as MINOR DEGREE PLACENTA PRAEVIA. TYPE-IIB, IIIA, IIIB, and IV are termed as MAJOR DEGREE PLACENTA PRAEVIA. Dangerous placenta praevia is the name given to TYPE-IIB i.e. TYPE-II posterior placenta praevia. APH

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Because: 1. Due to the curved birth canal, major thickness of the placenta overlies the sacral promontory, thereby diminishing the anteroposterior diameter of the inlet and prevents the engagement of the presenting part. 2. Placenta is more likely to be compressed, if vaginal delivery is allowed. 3. More chances of cord compression or cord prolapse. APH

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Clinical Features: Symptoms- 1. Painless and apparently causeless recurrent vaginal bleeding. 2. The blood is usually bright red in colour. 3. Subsequent bouts of bleeding may be alarming. 4. Earlier bleeding is more likely to occur in major degrees. Signs- 1 . General condition and anemia are proportionate to the visible blood loss APH

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Examination: General Examination- 1. Present with features of shock, which is proportional to the amount of blood loss. 2. Degree of anemia is also proportional to the amount of blood loss. 3. Pulse, Blood pressure are recorded. Hypotension and tachycardia are present, if the patient is in shock. Hypertension and gross edema is absent. APH

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Abdominal Examination- 1. Height of the fundus usually corresponds to the period of gestation. 2. Uterus feels relaxed, soft, and elastic without any localized area of tenderness. 3. Persistence of malpresentation like breech or transverse or unstable lie. 4. The presenting part is high up. 5. The Fetal Heart Sound is usually present, unless there is major separation of the placenta with the patient in exsanguinated condition. APH

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Vulval Inspection: Only inspection is done to note whether bleeding id still occurring or has ceased, character of the blood. Confirmation of diagnosis : Localization of placenta Clinical MRI By internal examination by double set up examination Transabdominal ultrasound Direct visualization during caesarean section Transvaginal ultrasound Examination of the placenta following vaginal delivery Transperineal ultrasound Colour Doppler flow study APH

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Transabdominal Ultrasound Colour Doppler Flow Study APH

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Transvaginal Ultrasound Transabdominal Ultrasound APH

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Complications of Placenta Praevia: Maternal complication: During pregnancy: Shock Malpresentation Premature Labour During labour: Early rupture of the membrane Cord prolapse Slow dilatation Intrapartum Haemmorrhage Increased incidence of operative interference Postpartum haemorrhage Retained placenta APH

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Puerperium: Sepsis is increased due to- 1. Increased operative interference 2. Placental site near to the vagina 3. Anemia and devitalized state of the patient Sub involution Embolism Fetal complication: Low birth weight Asphyxia Intrauterine death Birth injuries Congenital malformation APH

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Management: Prevention: 1.Adequate antenatal care to improve the health status of women and correction of anemia. 2.Antenatal diagnosis of low lying placenta at 20 weeks with routine ultrasound, and repeat the ultrasound examination at 34 weeks to confirm the diagnosis. 3.Significance of Warning haemorrhage should not be ignored. 4.Colour flow Doppler USG in placenta praevia is indicated to detect any placenta accreta.( Placenta accreta is a severe obstetric complication involving an abnormally deep attachment of the placenta, through the endometrium and into the myometrium) APH

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At Home: 1.Patient immediately put to bed. 2.Assess the blood loss by inspection of clothing soaked with blood and measuring pulse blood pressure and degree of anemia. 3.Quick but gentle abdominal examination. 4.Vaginal examination is not done ,only the inspection is done. Transfer to Hospital: Arrangement is made to shift the patient to an equipped hospital having facilities of blood transfusion, emergency caesarean section and neonatal intensive care unit. APH

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Admission to Hospital: All Cases of APH should be admitted in hospital. Treatment on Admission: Immediate Attention: 1.Amount of the blood loss 2.Blood samples are taken for group, cross matching and estimation of hemoglobin. 3.A large-bore IV cannula is sited and an infusion of normal saline is stated and compatible cross matched blood transfusion should be arranged. 4.Gentle abdominal palpation. 5.Inspection of the vulva. Formulation of the line of treatment: Depends upon the duration of pregnancy, fetal and maternal status and the extent of the haemorrhage APH

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Expectant management: Prerequisites: 1. Availability of blood for transfusion whenever required. 2. Facilities for caesarean section should be available throughout 24 hrs. Selections of Cases : 1. Mother is in good health status, i.e. Hb>= 10 gm%, Haematocrit >30% 2. Duration of pregnancy is less than 37wks. 3. Active vaginal bleeding is absent. 4. Fetal well being is assured by USG. APH

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Conduct of expectant treatment: 1. Bed rest. 2. Routine blood investigation. 3. Periodic inspection of the vulval pads and fetal surveillance with USG at interval of 2-3 wks. 4. Supplementary haematinics should be given and the blood loss is replaced by adequate cross matched blood transfusion. if patient is anemic. 5.When the patient is allowed out of bed(2-3days after the bleeding stops), a gentle Cusco’s speculum examination is made to exclude local cervical and vaginal lesions for bleeding. However, their presence does not negate placenta praevia. APH

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6. Use of tocoloysis (magnesium sulphate) can be done if vaginal bleeding is associated with uterine contractions. 7. Use of cervical circlage to reduce bleeding and to prolong pregnancy is not helpful. 8. Rh immunoglobulin should be given to all Rh negative( unsensitised ) women. Expectant management is ideal in hospital, but considering the cost of prolonged hospitalization and psychological morbidity, home care may be allowed is some. They are- Patient living close to hospital. 24 hrs transportation is available. Bed rest assured and patient is well motivated to understand the risks. APH

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Definitive management: Indications : 1. Bleeding occurs at or after 37 wks of pregnancy. 2. Patients is in labour. 3. Patient is in exsanguinated state on admission. 4. Bleeding is continuing and of moderate degree. 5. Baby is dead or known to be congenitally deformed. Management: Caesarean section: It is done for all woman with sonographic evidence of placenta praevia where placental edge is within 2cm from the internal os. Vaginal delivery: Its may be considered where placental edge is clearly 2-3cm away from the internal cervical os. APH

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SCHEME OF MANAGEMENT OF PLACENTA PRAEVIA IN HOSPITAL All APH patients are to be admitted Expectant Treatment Active Interference No active bleeding bleeding continues Pregnancy <37 wks Ultra sonography pregnancy >37wks Placental edge is clearly 2-3 cm placental edge within 2cm of Away from the internal os. the internal os or placenta praevia. Vaginal delivery Caesarean delivery Caesarean delivery APH

Abruptio Placentae:

Abruptio Placentae Definition: It is a form of ante partum haemorrhage where the bleeding occurs due to premature separation of normally situated placenta. Etiology: The exact cause of separation of normally situated placenta remains obscure in majority of cases. 1. Trauma 2. Sudden uterine decompression 3. Short cord 4. Supine hypotension syndrome 5. Placental anomaly 6. Sick placenta APH

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6. Folic acid deficiency 7. Uterine factor 8. Torsion of uterus 9. Cocaine abuse 10. Thrombophilias 11. Prior abruption High risk factors: 1. High birth order 2. advancing age of the mother 3. malnutrition, poor economic condition, smoking APH

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Types of Abruptio Placentae: Clinical manifestation of haemorrhage Ultrasonographic localization of haemorrhage The bleeding remains confined inside the uterus without any evidence of external bleeding. It is a severe form.— Concealed type. Retro placental —Between placenta and myometrium. The bleeding appears as vaginal bleeding. It is a mild form.— Revealed type . Sub chorionic —Between the placenta and the membranes. Both concealed and revealed type— Mixed type. Pre placental —Between placenta and the amniotic fluid. Blood may percolate through the layers of myometrium upto serous coat– Couvelaire uterus. APH

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Depending upon the degree of placental abruption .. Grade 0- clinical features absent. Grade 1- a) Vaginal bleeding is slight, b) Uterus is irritable tenderness may be minimal or absent, c) Maternal BP and fibrinogen levels unaffected, d) FHS is good Grade 2- a) Vaginal bleeding mild to moderate, b) Uterine tenderness is always present, c) Maternal pulse ,BP is maintained, d) Fibrinogen , e) Shock absen , f) Fetal distress or fetal death occurs Grade 3- a) Bleeding is moderate to severe or may be concealed, b) Uterine tenderness is marked, c) Shock is pronounced, d) Fetal death is the rule, e) Associated coagulation defect or anuria may complicate. APH

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Clinical Features: Symptoms Revealed type Concealed type Character of bleeding Abdominal discomfort and vaginal bleeding ( dark ). Continuous abdominal pain and slight bleeding. General condition Proportionate to visible blood loss, shock is absent. Shock may be pronounced which is out of proportion to visible blood loss. Pallor Related to blood loss. Severe pallor. Features of pre- eclampsia May be absent. Frequent association. Uterine height Proportionate to period of gestation. Disproportionately enlarged and globular. Fetal parts & FHS Present . Absent . Urine output Normal . Usually diminished. APH

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Laboratory Investigation: Investigation Revealed type Concealed type Blood: Hb% Low value proportionate to the blood loss. Markedly lower, out of proportion to the visible blood loss. Coagulation Profile Usually unchanged. Clotting time increased Fibrinogen level low Platelet count low. Urine for protein May be absent. Usually present. Confusion in Diagnosis With placenta praevia. With acute obstetrical gynecological surgical complication. APH

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Complications of Abruptio Placentae: Maternal: 1. Revealed type: Maternal death is rare. 2. Concealed type: Haemorrhage Blood coagulation disorder Shock Oliguria and anuria Puerperal sepsis Postpartum haemorrhage due to atony of the uterus. Fetal: 1. Revealed type : Fetal death is to extent of 25-30% 2. Concealed type : Fetal death is high( 50-100%) due to prematurity and anoxia due to placental separation. APH

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Management of Abruptio Placentae: Assessment of the case is to be done as regards: a) amount of blood loss, b) maturity of the fetus, c) whether the patient is in labour or not, d) presence of any complication, e) type and grade of placental abruption. Emergency measures: a) Routine blood test, b) Ringer’s solution drip arrangement for blood transfusion. Management options are: a) immediate delivery, b) Management of complication if any, c) Expectant management. APH

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Definitive Treatment: The patient is in labour The patient is not in labour The labour is accelerated by Low Rupture of the Membranes. Vaginal delivery is favoured in cases with: i ) Limited placental Abruption, ii) FHR tracing, iii) Continuous fetal monitoring is available, iv) placental abruption with a dead fetus. Induction of labour is done by low rupture of membranes: Oxytocin may be added to expedite delivery. Inj.Oxytocin 10 IU IV(slow) is given with delivery of baby to minimize postpartum blood loss. Caesarean Section APH

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Abruptio Placentae Resuscitation Revealed Concealed Pt. in labour Pt. not in labour Delivery ARM+Oxytocin Delivery ARM+Oxytocin Caesarean Sec. Vaginal delivery ARM+ Caesarean Vaginal delivery Oxytocin delivery Vaginal delivery Oxytocics is continued to improve uterine tone along blood transfusion. APH

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Difference between placenta praevia & Abruptio placentae: APH Points of discussion Placenta praevia Abruptio placentae Nature of bleeding & character of blood Painless, causeless and recurrent & bright red. Painful, continuous and dark coloured General condition and anemia Proportionate to visible blood loss. Out of proportion to the visible blood loss. Features of pre- eclampsia Not relevant. Present in 1/3 rd of cases. Height of uterus Proportionate to the gestational age. Enlarged and disproportionate. Feel of uterus Soft and relaxed. Tense, tender, rigid. Malpresentation It is common. Head is high. Unrelated as head is engaged. FHS Present. Absent.

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Points of discussion Placenta praevia Abruptio placentae Placentography (USG) Placenta in lower segment. Placenta in upper segment. Vaginal examination Placenta is felt on the lower segment. Placenta is not felt in lower segment. APH A, Partial abruption with concealed hemorrhage. B, Partial abruption with apparent hemorrhage. C, Complete abruption with apparent hemorrhage.

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An extra placental cause of APH is suspected when placental praevia and abruptio placentae are excluded from history, clinical examination and USG. A gentle speculum examination of the cervix and vagina helps to settle the diagnosis of local causes of bleeding in such cases. Benign conditions like cervical ectropion , cervical polyp are not treated during the pregnancy. A cervical polyp can however be removed, if recurrent bleeding persists. Cervical carcinoma in pregnancy requires special attention. If diagnosis is made in early 2 nd half of pregnancy, the carcinoma is treated with usual management thus sacrificing the pregnancy. In the late pregnancy, often treatment is started after delivery. Caesarean section is necessary in such case. APH Extra placental bleeding

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APH Thank you