Case study 29Case study 29

ANTEPARTUME HAEMORRHAGE

Zarul naim Mohd Tamizi

APH

• Definition: vaginal bleeding from 24 weeks to delivery of baby.• Common causes:

Placenta praevia Placenta abruptio Local causes (cervicitis, cervical ca, cervical ectropian, vagina

trauma,vagina infection) Unexplained APH

Placenta Praevia

• Placenta which has implanted partially or wholly in the lower uterine segmentGrade 1 – Just enters lower segment(3-5cm from OS)

Grade 2 – Enters LUS but does not reach os (<3cm from OS) Grade 3 – Partially covers os but not completely Grade 4 – Completely covers os

• Risk factors:Uterine scar (Caesarian, myomectomy, curretage)MultiparityMultiple gestationsUterine structure anomalyAssisted conception

Placenta Abruptio

• The premature separation of the placenta-before delivery of the fetus.

• Occur in 1% of pregnancy

• Types:Revealed - Pain + Vaginal bleeding-80%Concealed - pain/shock + no vaginal bleeding-20%

Risk factors:

PolyhydramniosTrauma to abdomenSmokingCrack cocaine usageThrombophilia Anticoagulant therapy

Previous abruptioHypertensionPre-eclampsiaIUGRMultiple gestation

Placenta Praevia Placenta Abruptio

Features of bleeding Painless, recurrent, always revealed

Painful, revealed, concealed or mixed

General condition Proportional to blood loss Out of proportion in concealed type

Abdomen Soft, relaxed, malpresentation is common,

Tense, tender & woody, head maybe enganged

Fetal heart sound Usually present Usually absent particularly in concealed type

U/S Low lying placenta Normal lying placenta, retroplacenta clot

Diagnosis U/S Clinically

CASE

• 30 year old woman, Para 1+0• Previous spontaneous vaginal delivery and appropriately

grown fetus• Admitted at term with fresh vaginal bleeding and abd pain• On examination: in pain, pale, pulse is 100bpm, BP is

110/80mmHg and tender uterus which is contracting 3 minutely

• Blood stains on her feet between her toes

Q1: what is the most likely diagnosis and why is this the case?

Placenta abruptio(revealed) because of antepartum bleeding associated with abdominal pain and tenderness of the uterus.

Symptoms: Vaginal Bleeding ( Revealed) 80% Abdominal /Back Pain (Severe) 70% Fetal Distress 60% Contractions (Hypertonic) 35% Preterm Labour 25% Fetal Death in utero 15%

Q2: what are the risk to the mother

and fetus?

• Mother: Hypovolaemic shock Acute renal failure DIC PPH – uterine

atony(Couvelaire uterus)

Maternal mortality Operative delivery Recurrence

Fetus: Hypoxia - Fetal distress Anaemia Growth Retardation - if

treated conservatively and survives

CNS Abnormalities Intra Uterine Death

Q3: how should you assess and manage this situation?

• Call for help• Resuscitation

– Admit labour room– Estimated amount of blood loss

• Mild : 2 pads soaked / < 200ml• Severe : > 2 pads soaked / > 200 ml

– Mild : 1 IV line & GXM 2 units blood– Severe : 3 IV lines & GXM 4 units blood– Use branula size 16 and below and transfuse immediately

• Blood InvestigationsFBC (low Hb, low platelet), BUSE + Creat (Acute renal failure),

Coagulation profile (PT,APTT,INR), GXM

• U/S scan (Retroplacental clot, exclude placenta praevia, check fetal viability etc)

Hx and P/E

• Hx: vaginal bleeding, painful or not, abdominal pain, risk factors (previous abruptio,trauma)

• P/E: vital sign (BP,pulse,temperature), colour (pale),sign of

anemia Abdomen(tense,tender and woody, uterus larger than date VE – avoid before exluded placenta praevia

Investigations

• For fetal: CTG

• For maternal: FBC Coagulation screen GXM 4 units Catheterization (monitor urine output) Urea and creatinine (renal failure)

• In this patient because she is already at term, delivery is indicated

1. Vaginal delivery – cervix favourable or foetal death - ARM + oxytocin augmentation

2. LSCS – usually indicated for foetal distress - use prophylactic oxytocin infusion routinely in

these cases

• Before LSCS or Vaginal delivery, always correct Hypovolaemia DIVC Ensure urine output >30ml/hr Other causes

Q4:One hour later : Maternal condition unchanged from admission. borderline tachycardia, BP satisfactory, uterus contract

3:10 min and remains tender.

CTG: appropriate beat to beat variability, no decelerations.

Coagulation screens:

Hb - 8.4 g/dl, platelets - 105x109 /l, fibrinogen - 2.2 g/l,APTT - 48 s, PT - 14 s, Fibrin degradation product - 2.1 mg/ml

Comment on these result and discuss further

managementResults Interpretation Impression

Hb 8.4g/dl(11-16g/dl)

Low Anaemia

Platelets 105x109 /l(150-400x109/l)

Low

Disseminated Intravascular

Coagulation(DIVC)

Fibrinogen 2.2 g/l(2-4 g/dl)

Borderline low

aPTT 48s(35-45s)

Prolonged

pT 14s(12-15s)

normal

Fibrin degradation products

2.1mg/ml(<1mg/ml)

Raised

DIC Secondary phenomenon following trigger of

generalised coagulation activity

Why?• Retroplacenta blood clot

– Consumptive coagulopathy– Hypofibrinogenemia

• Increase pressure within uterus (bp)• Release of thromboplastin from circulation

/retroplacenta clot

management

1. Involve support services (anaesthethist, blood bank, etc) early

2. Replace blood constituents and coagulation factors in addition to blood transfusion, start giving Cryoprecipitate (6 units) followed by FFP (2 units) and platelet concentrate (4 units)

3. Repeat tx if necessary and check coagulation profile 2 hourly.

4. Plan for delivery (treat the cause)

Q5: cervix is found to be 5 cm dilated and fully effaced with no placental palpable.

The fetal head is at the level of ischial spines and is in left

occipito-anterior position, should you perform

amniotomy?

Artificial rupture of membrane (ARM) Enhanced labor Using Hollister amniohook Stimulates release of endogenous prostaglandin Assessment based on Bishop’s score to determine

favourable cervix

What is amniotomy?

YES

• Term

• Favourable cervix

• No fetal distress

After ARM

Assess liquor : for blood stained or meconium stained

Monitor progress of labour, maternal and fetal condition

If prolonged labour, fetal distress, and uncontrolled haemorrhage -Emergency Caesarian section

Indication for LSCS• Bishop score <7• Fetal distress• Severe abruption with alive fetus• Other obstetric complication• No uterine contraction with oxytocin &

prostaglandin• Uncontrolled bleeding

• Q6: amniotomy is performed and she delivers a live male infant less than 1 hour later. The infant is healthy with Apgar score of 9 at 5 min. Placenta is rapidly delivered and has approximately 500ml of clot adherent to about 25% of its surface area. She recovers uneventfully.

• What is the risk of having a similar event in subsequent pregnancy?

Risk of recurrence :

5-15%% after one abruption25% after two abruption

Advice patient :• Get early and continuous prenatal care.

• Early recognition and proper management of conditions in the mother such as diabetes and high blood pressure

• If pregnant, don't engage in activity more vigorous than what you were accustomed to before pregnancy.

• Avoid risk factors when possible. Maintain a positive lifestyle free of smoking, alcohol and recreational drug use (e.g., cocaine use).

• Proper and adequate nutrition prior to becoming pregnant and during pregnancy

THANK YOU