anterpartum haemorrhage

8/9/2019 Anterpartum Haemorrhage

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Clinical cases Case 1 I am 38 wee s pregnant and bleeding

!aginall" #A 2$ "ear old woman attendsthe midwi%e at 38 wee s gestation # &hehad pre!ious uncomplicated deli!eriesand she is concerned that o!er the past%ew da"s she has been ha!ing a smallamount o% %resh !aginal bleedingintermittentl"# &he has no abdominal painand the bab" is acti!e#


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Diferential diagnosis

'lacenta prae!ia 'lacental abruption Cer!ical lesions ( erosion)pol"p)cancer*

History to supportdiagnosis 'ainless small bleeds

supports diagnosis o%placenta prae!ia#

Additional patient+ssmear histor" shouldbe obtained# ,hereport o% an" pre!ious

-&&s in this pregnanc"should be chec ed inorder to identi%" thelocation o% placenta#


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Clinical examination

Abdominal palpation

.etal heart sound

auscultated &peculum e/amination o digital e/amination

Reasons o clinicalexamination &upport '' palpation) with

a so%t non tender uterus mhigh presenting part and anabnormal lie

to e/clude %etal distress( ass placenta abruption*

I% placenta is not low b"-&&) to !isuali e the cer!i/indicated#

,orrential bleeding can bepro!o ed i% '' has been%alsel" e/cluded as a cause


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In!estigations

.BC Blood group and cross

match 4leihaur test i%rhesus negati!e

-&& C,5

,o detect anemia In case bleeding increases

and a trans%usion is re6uired# ,he patient should be gi!enanti 7 i% her blood group isrhesus negati!e to pre!entisoimmunisation

,o locali e the placenta and

determine whether it is lowl"ing )as well as to assess%etal growth and well being#

,o identi%" suspected %etalcompromise


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Management Admit patient to an obstetric unit# At term gestation with a histor" o%

A' )deli!er" is indicated to ensure a sa%e deli!er" o% a mature %etus# Caesarean section should be pre%ormed in cases o% ma9or placenta prae!ia Consider e/amination without anesthesia and arti:cial rupture o%

membranes in cases with minor degrees o% ''# ,his procedure should be

per%ormed in an operating theater with a senior anesthetist present andread" to administer a general anesthesia to e/pedite deli!er" i% bleeding ispro!o ed on !aginal e/amination#

Cross matched blood should be a!ailable in ;, and can per%orm animmediate C sec i% indicated

I% diagnosis o% placental abruption is suspected ( based on the low l"ingplacenta on scan )normal appearance o% the cer!i/ on speculum< Andthere is no e!idence o% %etal compromise) an arti:cial ruptures o%membrane should be per%ormed and an o/"tocin ( &"ntocinon* in%usioncommended with continuous monitoring o% the %etal heart because o% theincreased ris o% %etal h"po/ia#


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=is s o% Antepartumhaemorrhage

emorrhage and shoc =enal %ailure

7isseminated intra!ascularcoagulation(7IC* .etal h"po/ia

Intrauterine death


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Case 2 I am 32 wee s pregnant and ha!ing contractions A 2> "ear old nulliparous woman at 32 wee s

gestation presents with abdominal pain associatedwith uterine contractions# .etal mo!ements aresatis%actor"# er boo ing ultrasound scan (-&&*showed singleton pregnanc" consistent withmenstrual dated and her anomal" scan at 20 wee sgestation was normal# er screening %or 7own+s

&"ndrome was reported ad low ris # &he had beena smo er but stopped in mid trimester# &he had anappendectom" as a child# &he was assessed to be alow ris pregnanc" at boo ing


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7i?erential diagnosis

Obstetric causes

're term labor Chorioamnionitis Concealed abruptio

placenta .ibroid degeneration

( usuall" at midtrimester*

Non obstetric causes

-rinar" tract in%ection)p"elonephritis ( canprecipitate pre termlabor*

Irritable bowels"ndrome)constipation

;!arian c"st( hemorrhage) torsion*


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A , 'A=,-M

M;== A5


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7 .I I,I;

Antepartum haemorrage Bleeding %rom the genital

tract %rom 22 nd wee o%pregnanc" or

%oetal weight is more than>00 grams


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CA-& &

Diagnosis Clinical ndings

Placenta previa Bleeding P ! painless

"bruptio placenta #revealed$ Bleeding P ! Pain abdomen!tender abdomen

"bruptio placenta#concealed$

Bleeding P ! pain abdomen!tender abdomen! %&H mig'tbe more t'an PO( #approx)*+cm$

asa previa Bleeding P ! painless

,xcessive s'o- Bleedin P ! .abor pain #/0*$!cervical os dilated1


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' AC ,A '= IA

'lacenta which issituated wholl" orpartiall" within thelower segment ator a%ter 28 wee s o%gestation#


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C A&&I.ICA,I;

2ype 3lo- lying placenta*

implanted in lo-er uterinesegment1 ,dge o placentais near t'e internal os but

not reac' it

2ype )marginal placenta*located

at t'e margin o t'einternal os

2ype +partial placenta previa!-'en placenta partially

covering t'e internal os

2ype 4*

total placenta

previa!placentacom letel coverin t'e


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P."C,N2" PR", 5"


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'= 7I&';&I 5 .AC,;=&

"bnormal placental implantation "dvanced maternal age #6+7years are + times

more li8ely to 'ave placenta previa$ 9ultiparity : 7; in grand multiparous patients 9ultiple gestation Previous abortion Previous caesarean section %mo8ing Prior placenta previa #4*


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M C A I&M ;. B 7I 5

(ro-t' o placenta slo-sdo-n cause t'e dilatation o

lo-er segment and inelasticplacenta is s'ared of t'elo-er segment -all1 2'is

leads to opening o utero*placental vessels and causest'e episode o bleeding


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7IA5 ;&I& I&,;= aginal bleeding occurs suddenly

during t'e t'ird trimester Bleeding is usually brig't red

and painless 5nitial bleeding is not usually

pro use but it is 8no-n to recur 2'e rst bleed usually occurs at

)=*+) -ee8s o gestation Contraction may or may not

occur simultaneously -it' t'e


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AB;=A,;= &,-7I & &ull blood count : 'emoglobin

estimation (roup! screen and 'old or at least 4

units o blood &ibrin split products #&%P$ and

brinogen level Prot'rombin time #P2$0 activated

partial t'romboplastin time #aP22$ "P2 test to determine etal origin o

blood #as in t'ecase o vasa previa$


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IMA5I 5 &,-7I & 2rans abdominal sonograp'y

" simple! precise and sa e met'od to visuali>e t'eplacenta

Have an accuracy o ?7; &alse positive can occur secondary to ocal uterine

contractions or bladder distension1

2rans vaginal sonograp'y %a er and more accurate t'an trans abdominal met'od ,specially -'en it comes to t'e diagnosing type 3 and )

placenta previa

9R5 @se ul in determining placenta accreta1 But is not a cost

efective diagnostic tools


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C;M' ICA,I; & PPH 5ntrauterine gro-t' retardation

#5@(R$ Congenital anomalies &etal anemia and R'

isoimmuni>ation 9aternal mortality due to

'emorr'age


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MA A5 M , If the Pregnancy less t'an +=-ee8s

No active bleeding 9ot'er -it' Hb is 63Agm; &etal -ell being assured* &H% by

C2(! @%(, P,C2"N2 9"N"(,9,N2#9aca ee Conservative

9anagement$


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C; & = A,I MA A5 M ,(McCa%ee+s =egime*

itals are monitored in t'e -ard @%( monitoring or locali>ation o

placenta is done every ) -ee8s toloo8 or placental migration -'ic' isa possibility prior to +4- since t'elo-er segment ormation is in t'eprocess o completion

&etal monitoring by C2( andbiop'ysical pro ling s'ould be doneto ensure etal -ell being1

Eeep a daily etal movement countc'art

) doses o Dexamet'asone #3)mg$


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CA &A= A & C,I; If the Bleeding occurs at or a ter

+=-ee8s o pregnancy Pt is in labour Bleeding persists #pro use

'emorr'age and pt 'as'ypotension and ot'er eatureso s'oc8$

5mmediately delivery t'e etusby C%


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Cont 5 pro use bleeding occur!

'emodynamic stability o t'e patients'ould be addressed rst1

,stablis'ment o ) large* bore 5access lines -it' 5 crystalloids orblood products

@rinary cat'eteri>ation is done -it'&oley s Cat'eter

Blood is ta8en or investigation "nemia treated -it' blood

trans usion


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2GP, 3 #"N2,R5OR PO%2,R5OR$

Can deliver vaginally9ore li8eli'ood o etaldistressin post type -'en t'elo-est edge o t'e placenta isalmost reac'ing t'e internalos margin

2GP, 55 "N2,R5OR Can deliver vaginally

2GP, 55 PO%2,R5OR C*section I as -'en t'e 'eadenters t'e pelvis! it impactson t'e placenta -'ic' islocated posteriorly againstsacrum1.ead to uteroplacentalinsuJciency and etal'ypoxia and distress

2GP, 555 #"N2,R5OR PO%2,R5OR$

C*section"nterior is more dangeroussince obstetrician 'as to cutt'roug' t'e placenta todeliver baby and it 'as to be

ast and eJciently done

2GP, 5 "bsolutely C*section


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AB=-',I; ' AC ,A

Prematureseparation o normallyplaced placenta a ter)A -ee8s o gestationand prior to t'e birt'o t'e in ant1


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'= 7I&';&I 5 .AC,;=& 9aternal H2N 9aternal trauma #motor ve'icle accident!

asault! alls$ Cigarette smo8ing "lco'ol consumption Cocaine use %'ort umbilical cord

%udden decompression o t'e uterus Retroplacental broid "dvanced maternal age 5diopat'ic


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"BR@P25O P."C,N2"

'remature separation o% the normally implanted

placenta


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C A&&I.ICA,I; C."%% A

"symptomatic &inding an organi>ed blood clot and depressed

area on a delivered placenta

C."%% 3 @pto mild vaginal bleeding 2ender uterus

Normal maternal BP and 'eart rate No coagulopat'y No etal distress


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C."%% ) @pto moderate vaginal bleeding %evere uterine tenderness -it' possible tetanic

contractions 9aternal tac'ycardia -it' ort'ostatic c'anges in BP

and 'eart rate &etal distress Hypo brinogenemia

C."%% + @pto 'eavy vaginal bleeding ery pain ul tetanic uterus 9aternal s'oc8 Hypo brinogenemia Coagulopat'y &etal deat'


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'A, ;' &I; ;5 Presence o blood in t'e decidua basalis

lead to separation o placenta Hematoma ormed causes urt'er

separation o placenta .eading to compression o placenta andcompromise t'e uteroplacental per usion

Retroplacental blood later penetrate

t'roug' t'e t'ic8ness o t'e uterine -allinto t'e peritoneal cavity 2'is p'enomenon is 8no-n as Couvelaire


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9yometrium in t'is area become-ea8ened

9ay give a-ay and rupture -it'increased intrauterine pressureduring contraction

Can cause etal 'ypoxia


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& M',;M& aginal bleeding "bdominal or bac8

pain &etal distress "bnormal uterine

contractions

Preterm labor &etal deat'


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C;M' ICA,I; & 9O2H,R

Hemorr'agics'oc8

Coagulopat'y0D5C

@terine

rupture Renal ailure 5sc'aemic

necrosis odistal organs

&,2@% Hypoxia "nemia (ro-t'

restriction

CN% anomalies &etal deat'


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AB;=A,;= &,-7I & Hemoglobin! 'ematocrit! platelets Prot'rombin time 0 activated partial

t'romboplastin time &ibrinogen! brin0 brinogen

degeneration products D*dimer


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7I.. = ,IA 7IA5 ;&I& Blunt abdominal trauma "cute appendicitis Disseminated intravascular

coagulation Ovarian torsion

Placenta previa ,ctopic pregnancy Hemorr'agic s'oc8


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,= A,M ,&

"ssess : Blood .oss 9aturity o &etus

K'et'er s'e is in labor %end 5nvestigations %ecure 5 line 9onitor maternal etal

condition


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A&A '= IA

2'e etal blood vessels traverse t'e

.@% in advance o presenting part in

close proximity to t'e inner cervical os 2'ese vessels traverses -it'in t'e

membrane Not supported by umbilical cord or

placental tissue putting t'em at ris8 orupture -'en t'e supportingmembrane rupture


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'A, ;' &I; ;5 2'e vessels may arise rom a

velamentous insertion o t'eumbilical cord or may be Loiningan accessory placental lobe tot'e placenta

Occur -'en t'ese etal vesselsrupture and t'e bleeding is rom

etoplacental circulation .ead to etal exsanguination and

deat'


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7IA5 ;&I& Clinically Present o painless vaginal bleeding at t'e

time o spontaneous rupture o membraneor amniotomy1

&etal bradycardia depend on rapidity o t'e'emorr'age

Can lead to etal s'oc8 or deat'

9ost o ten t'e etus is already dead -'ent'e diagnosis is made because t'e bloodloss constitutes a maor bul8 o bloodvolume o t'e etus1


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MA A5 M , A 7 ,= A,M ,&

Obstetrician must be vigilant -'eneveramniotomy is per ormed!as all cases o vasaprevia cannot be identi ed antenatally

5mmediate delivery s'ould be consideredand aggressive resuscitation o t'e neonate

Necessary to avoid etal s'oc8 or demise-'en vaginal bleeding occur during labour1

,mergency caesarean section stronglyconsidered or t'e rst sign o bleeding

ollo-ing amniotomy associated -it' etaldistress


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anterpartum haemorrhage

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