haemorrhage during late pregnancy

PRESENTED BY KRIPA SUSAN KURIEN

2 ND YEAR MSC NURSING

Haemorrhage during late pregnancy : Placenta previa,

Abruptio placenta

Meaning of Antepartum haemorrahge

Any bleeding that occurs during the late period of pregnancy is termed as Antepartum hemorrhage

Definition

Haemorrhage from the genital tract in late pregnancy after the 24 week of gestation and before the onset of labour is referred to Antepartum haemorrhage

orIt is defined as the bleeding from or into the

genital tract after the 28th week of pregnancy but before the birth of the baby(the first and the second stage of labour)

CONTD DEFINITION...

“bleeding into or from the genital tract after 24 weeks of gestation”

“ Bleeding from the female genital tract anytime after fetal viability but before delivery”

WHO

INCIDENCES

It affects 4% of all pregnancies.

It is associated with increased risks of fetal and maternal morbidity and mortality

CAUSES AND CLASSIFICATION

UNEXPLAINED (25% ) EXTRAPLACENTAL

OR (5%)

INDETERMINATE LOCAL CERVICO VAGINAL LESION

trauma, cervical polyp, carcinoma

cervix, genital varicosities, vasa pravia

vulvo vaginal infections , cervicitis

APH

PLACENTAL BLEEDING (70%)

PLACENTA ABRUPTIO PRAEVIA PLACENTAE

Causes Placenta praevia Abruptio placentae Distal genital tract / gynaecological bleeding Unclassified bleeding Abnormal placentation Abnormal placental shape Vasa praevia (south australian prenatal pratice

guidelines)

Causes and incidence

Abruptio placenta (1 in 100 pregnancies) 40%

Placenta previa (1 in 200 pregnancies) 20% Unclassified 35% Lower genital tract lesion 5%

PLACENTA PRAEVIA

DEFINTIONWhen the placenta is implanted partially or

completely over the lower uterine segment orOccurs when the implantation of the

trophoblast takes place in the lower uterine segment

Incidences

80% in multiparous mothers Age greater than 35Presence of uterine scar Prior placenta praeviaMultiple pregnanciesDevelopment of abnormal large placenta

(multi fetal pregnancies)

Etiology

Exact cause is not knownFollowing theories is proposed DROPPING DOWN THEORY- Fertilized ovum drops down and implanted in

the lower segment Poor decidual reaction in upper uterine

segmentFailure of zona pellucida to disappear in timeThoery explains the development of central

placenta praevia

Persistence of choronic activity: in the decidua capsularis and its subsequent development into the capsular placenta which comes in contact with decidua vera of the lower segment – explain formation of lesser degree of placenta praevia

Defective decidua Results in spreading of the chorionic villi over

a wide area into the uterine wall to get nourishment

During process , placenta gets membraneous and may invade the underlying decidua and they also encroach into the lower uterine segment

Explains the cause for development of placenta accreta

Big placenta in case of twins

Predisposing factors of placenta praevie

Multi parity Increased maternal ageh/o of previous caesarean section or scars in

uterusPlacental size and abnormality Smoking

Pathological anatomy

Placenta- may be large and thin, often tongue shaped extension from the main placental mass, extensive areas of degeneration with infarcation and calcification , placenta may be morbidly adherent( due to poor decidua formation)

Contd.....Umbilical cordCord may be attached to margin( battledore)

or into the membranes( velamentous)Insertion of cord close to the internal os or

fetal vessel may run across the internal os in velamentous insertion leads to vasa praevia

Contd......

Lower uterine segmentbecome soft and and more friable , due to

increased vascularity

Types or degrees Type- 1( low lying)- major part of the placenta

is attached to the upper segment and only the lower margin encroaches onto to the lower segment but not upto the os

Type 2 ( marginal ) placenta reaches the margin of the internal os but doesnot cover it

depending on position: type 2 a anterior & type 2b posterior

Typr 2b posterior or dangerous placentabecause of the curved birth cannel, major

thickness of placenta overlies the sacral promontory ,thus reducing antero posterior diameter of inlet , prevent engagement of presenting part

TYPE 3- ( Incomplete or partial central) – the placenta covers the internal os partially ( covers the internal os when closed , but doesnot when fully dilated )

Type 4- ( central or total) placenta completely covers the internal os even after it is fully dilated

Also, classified , clinical purposeMild degree- type 1,and 2Major degree- type 2 posterior , 3 and 4

Pathophysiology or cause for bleeding

Placental growth slows down in later months

Lower segment progressively dilates Inelastic placenta sheared off wall of

lowersegment

Opening up of utero placental vessels

Clinical featuresSYMPTOMSVaginal bleeding – features sudden onset,painless,

causeless and recurrent SIGNSAbdominal examinationsize of uterus is proportionate to period of gestationUterus feel relaxed , soft, elastic without tendernessPresence of malpresentation is frequent Head is floating in contrast to period of gestationFHS is usually present , unless major separation is

seen

Contd..

VULVAL INSPECTIONTo note for bleeding presences, and character

of bleed – bright red or dark cloured , and amount

Placental praevia bleeding – bright red

Vaginal examination not to be done outside ot

DIAGNOSIS

LOCALISATION OF PLACENTA

( PLACENTOGRAPHY)

MAGNATIC

RESONANCE

IMAGING

CLINICAL

INTERNAL EXAMINATION

DIRECT VISUALISATION

EXAMINATION OF PLACENTA

Differential diagnosis

Confused with other causes of bleeding in later months

Vasa praevia- unsupported umbilical vessels in vilamentous placenta , lie below the presenting part and run across the cervical os

Vessels are torn either spontaneous OR during rupture of membranes

Colour flow doppler helps in the diagnosis

Contd...

Local cervical lesions -Differentiated using speculum examination

Circumvallate placenta : bleeding is slight and diagnosis made after

examination the placen ta after delivery

ComplicationsMaternal FetalMATERNAL 1. during pregnancy : antepartum

haemorrhage with varying degree of shock, malpresentation , premature labour

2. During labour : early rupture of membranes, cord prolapse, slow dilation of cervix, intrapartum haemorrhage, increased incidence of operative interference, postpartum haemorrhage , retained placenta

Contd.....

3. during puerperium: SEPSIS( operative interfernce , placenta site near to vagina , subinvolution, embolism

FETAL low birth weight babies , asphyxia ,

intrauterine death birth injuries , congenital malformations

MANAGEMENT

PREVENTIONTo minimize risk , following guidelines are

followed Adequate antenatal care Antenatal diagnosis – using USG .and

periodic examinations Warning haemorrhage – not to be ignored Family planning and limitation of births

Contd...

1.AT HOMEImmediately put to bed, assess the blood

loss , gentle abdominal examination to note the height of the uterus ,to ausculate FHS , VAGINAL EXAMINATION NOT DONE

2. TRANSFER TO HOSPITALArrangement to be made to shift to the

nearest hospital as quick as possible( equipped with facility for emergency cs)

3. TREATMENT ON ADMISSION

IMMEDIATE ATTENTION FORMULATION OF LINE OF

Amount of blood loss treatment

Blood samples to be taken Infusion of normal saline, crossed matched blood Gentle abdominal palpation &auscultation(note FHS) Inspection of vulva ( to note presence of bleeding)

EXPECTANT ACTIVE

Expectant treatment 1.Policy advocated – macafee nd johnson 19452.Vital prequites- availability of blood

transfusion, facilities for c section to be avaliable for 24 hours

3.Selection of cases – mother in good health status , duration of pregnancy less than 37 weeks , active vaginal bleeding is absent , fetal well being is assured

4. conduct of expectant treatmenta) Bed rest with bathroom privilages b) Investigation like hb, blood grouping , urine

for proteinurea ,c) Periodic examination of vulval pads and fetal

surveillance with usg at intervals of 2-3 weeks

d) Supplementary heamatintics – blood loss to be replaced by cross matched blood

e) Gentle speculum( cusco’s) examination made – rule out local cervical and vaginal lesions

TERMINATION OF EXPECTANT TREATMENT

Treatment carried upto 37 weeks followed by termination

Premature termination done: recurrence for brisk haemorrhage , fetus is dead, fetus congentially malformed

Steriod therapy – indicated if pregn is less than 34 weeks

ACTIVE INTERFERENCE

Indications : 1. bleeding occurs at or after 37 wk of

gestation2. pt is in labour3. pt is in exsanguished state 4.Bedding is continuous5. baby is dead Also the contraindication for putting pt to

expectant treatment

DEFINITVE TREATMENTInstituted soon following hospitalisation or

following expectant managementInvolves 1. vaginal examination : followed by low

rupture of membranes or caesarean section2. caesarean section without internal

examination

1.VAGINAL EXAMINATION

Double set up examination done in ot, following everything ready in ot

Contraindications:Pt in exsanguished state Diagnosed of major degree of placenta

praevia (usg)Associated complication factors and previous

history of caesarean section

A.low rupture of membranes :Aim – induce labour by low rupture

membranes using kochers forceps ( in lesser degree type 1 and typr 2 anterior)

Finger inserted to exclude cord prolapse Oxytocin drip may be started , if not

contraindications Aminiotomy – if fails to stop bleeding or

initiate labour, then caesarean section to be done

Percautions during vaginal birth:Active step be to be taken to restore blood

volumeMethergin 0.2mg given following delivery ant

shoulder Proper examination of the cervix following

delivery Baby’s blood hb to be checked

B.CAESAREAN SECTIONIndicationSevere degree of placenta praevia Lesser degree of placenta praeviaComplication of factors are associated with

lesser degree of placenta praevia where vaginal delivery is unsafe

2. Caseraen section without internal examination

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

PROGNOSIS

MATERNAL: reduction of maternal deaths in placenta preavia due to 1. early diagnosis

2. omission of internal examination 3.free availability of blood transfusionPotent antibioticsWider use of caesarean section

FETAL: Reduction in death due to judicious extention of expectant treatment

ABRUPTIO PLACENTA

DEFINITIONForm of antepartum haemorrhage where

bleeding occurs due to premature separation of normally situated placenta

Types

1.Revealed : following seperation of placenta , the blood insinuates downwards between the membranes and the decidua, blood seen out of the cervical cannal

Common type

2. concealed : blood collected behind the separated placenta or between the membranes and decidua

Collected blood prevented from coming out of cervix by presenting part which presses on lower segment

Blood percolates into amniotic sac after rupturing themembrane

Blood not visible

3. MIXED : part of blood collected inside (concealed) and a part is expelled out ( revealed)

INCIDENCES AND SIGNIFICANCES

1 in 200 deliveries Significant cause of perinatal mortality( 15-

20%) and maternal mortality( 2- 5%)

RISK FACTORS

Increased age & parity. Hypertensive disorders. Preterm ruptured membranes. Multiple gestation. Polyhydramnios.

Smoking. Cocaine use. Prior abruption. Uterine fibroid. Trauma

ETIOLOGYA. Hypertension in pregnancy B. Trauma – attempted external cephalic

version, road traffic accident or blow on abdomen, needle puncture of aminocentesis

C. Sudden uterine decompression – lead to decreased SA of uterus hence in placental seperation

D. Short cordE. Supine hypotension syndromeF. Placental anomalyG. Folic acid deficiency

Contd...

Torsion of uterus Cocaine abuse Thrombophilias Prior abruption

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

CONVELAIRE UTERUS described by convelaireSevere form of concealed haemorrahge Massive intravasation of blood into the

uterine musculature upto the serous coat

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

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

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 increasedFibrinogen level lowPlatelet count low.

• Urine for protein May be absent. Usually present.

• Confusion in Diagnosis

With placenta praevia.

With acute obstetrical gynecological surgical complication.

APH

DIFFERENTIAL DIAGNOSIS

A. REVEALED TYPE : confused with placenta praveia

B. MIXED OR CONCEALED:rupture uterusrectus sheath hematomaappendicular or instentinal perforationtwisted ovarian tumorvolvulusacute hydraminoustonic uterine contraction

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

Management

1. PREVENTION2. TREATMENT 1. PREVENTION – aims at eliminating

known factors that cause risks, correction of anaemia, prompt detection and institution of treatment

2. TREATMENT1. AT HOME : Arrangement to be made for

shift the patient to the hospital 2. IN HOSPITAL: A. REVEALED TYPEa) Assessment of case : amt of blood loss,

maturity of fetus b) Preliminaries:1. Blood for hb

estimation,haemotocrit estimation, coagulation profile , ABO and rh grouping , urine for detection of protein, 2. ringer solution drip is started

C. DEFINITIVE TREATMENT : I. Pt in labour :labour accelerated by low

rupture of membranes , oxytocin drips to be started to accelerate labour

II. Pt not in labour: a. preg 37 weeks or more then induction of

labour is done by low ruptue of membranes b.Indication for caesarean section: fetal distress

, amniotomy could not be done or failed, associated complicating factors, confusion in diagnosis

Preg less than37 weeks : bleeding moderate to severe( low rupture of mebrane , oxytocin drip is started), bleeding slight or stopped( put on conservative mx)

B. MIXED OR CONCEALED TYPE Defentive treatment: i. Blood samples are takenii. To correct hypovolemiaiii. Artificial rupture of membranesiv. Vaginal deliveryv. Caesarean section – indicated in two

extreme cases 1. early – unfavourable cervix, whr speedy delivery is not possible

vi. 2.late – progress of labour delayed in spite of amniotony and oxytocin

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

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 1/3rd 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.

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. 

Unexplained or indetreminate bleeding

Collective group of entities where a confident diagnosis of placenta praevia or abruptio placenta cannot be made , nor is there any local lesions to account for the cause of bleeding

Marginal sinus haemorrahgeCircumvallate placenta or excessive show

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.

APH

EXTRA PLACENTAL BLEEDING

Broadly divided into LOCAL CAUSES OF BLEEDING

And OTHER CAUSES LOCAL CAUSES – includes vulvar vein

varicosities, cervical erosions, cervical polyps , cervical carcinomas , cervical lesions

OTHER CAUSES – Execess show, coagulopathies, uterine ruptures

A. Local causes Vulvar vein varicosities Condition of

varicose vein occuring in vulva during pregnancy

Cervical erosions- raw looking granular appearance of cervix, occurs when the inner linning of the cervical cannal comes out onto the part whr cervix can be visualised

Cervical cancers- cancers arising from the cervix , also cause vaginal bleeding

Cervicitis : Inflammtion of the cervix , caused due to infection of the endo cervix

B. OTHER CAUSES 1. clotting problems : DIC OR disseminated

intravascular coagulation Is pathological form of clotting factors that

consumes large amount of clotting factors that is diffuse causing widepread external bleeding , internal bleeding or both

Is a over activation of clotting cascade and fibrinolytic sytem , resulting in depletion of plaletes and clotting factors

Management : correcting the underlying cause and replacement of essential factors and fluid volume

2. CORD INSERTIONS AND PLACENTAL VARIATION:

Velamentous insertion of cord :traction on the cord may tear , one or more of fetal vessels, as a result fetus bleed to death

Battledore insertion of the cord- increases the risk for fetal haemorrhage

Thank you