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Antepartum haemorrhage

This is bleeding from the genital tract of a pregnant woman at any time from the 28th week of gestation to the birth of the baby (end of the second stage of labour) It is one of the major causes of maternal and fetal morbidity and mortality

Causes of antepartum haemorrhage


Classification Obstetric Non-obstetric causes Obstetric causes Placenta praevia Haemorrhage from separation of a placenta that is attached in an abnormal position on the lower uterine segment Abruptio placenta Haemorrhage from separation of a placenta that is attached in a normal position on the upper uterine segment Indeterminate causes Haemorrhge from the marginal sinus Placenta vera

Placenta previa (types and classification)


Types (just descriptive) Type 1: placenta attached onto upper segment but its lower margins encroach onto the lower segment (Lateral) Type 2: Placenta attached onto lower segment but lower margins do not reach the internal cervical os (Marginal) Type 3: (Central, acentric) Placenta extends to partially cover the internal cervical os (does not cover os when cervix is fully dilated Type 4: (Total, centric) Placenta covers the internal os when cervix is fully dilated Type 1 and 2 are referred to as minor: Type 3 and 4 are major

Placenta previa: associated factors and clinical presentation


Associated factors High parity and Grand-multiparity Multiple gestations Prior caesarian section or uterine operations Clinical presentation Recurrent painless bleeding, may be post-coital Initial episodes of haemorrhage usually minor May have history of recurrent threatened abortion Unstable lie Malpresentations (especially breech) Abnormal lie , (Transverse or oblique lie)

Placenta previa (diagnosis)


Diagnosis High index of suspicion from history of recurrent painless haemorrhage; often subtle or spotting; rarely heavy. Signs of : -Malpresentations; abnormal lie -Unstable lie, -Lateral displacement of the fetal head (or pole) -Persistent failure of the fetal head to engage (stays high) - Abdomen may be difficult to palpate due to anterior placenta previa. Investigations : ultrasound scan for placental localization Vaginal examination is absolutely contraindicated

Placenta previa (management)


Management depends on: amount of blood lost, gestation age, Grade of placenta previa At any gestation age, with severe haemorrhage: resuscitate the patient Check BP, Pulse; correct anaemia; transfuse Terminate the pregnancy by caesarean section Close to term, with severe haehorrhage: (Resuscitate patient) Do EUAMajor previa present, do emergency C/S No or minor previa, ARM in theatre, augment labour, Monitor labour.

Placenta previa (management)


Minor haemorrhage before term: Aim at Conservative management of pt ADMIT Patient with 24-hr available facilities for t/fusion and surgery Confirm diagnosis Resuscitate Correct anaemia and Book blood - Do speculum exam to rule out local lesions once bleeding has stopped,

Placenta previa (management)


Be on the look out for any hemorrhage If minor previa confirmed, no further bleed: Do EUA at 37 weeks. If minor previa diagnosed, rupture membranes, (ARM), Augment labor, - aim at vaginal delivery for type 1 and 2 anterior placenta; - Active Management of the 3rd stage of labor. If major previa is confirmed, no further bleed, Do elective C/S at (term) 37 completed weeks If severe haemorrhage occurs at any time, stop conservative mngt, Do emergency C/S

Placenta previa: complications


Anaemia Post-partum haemorrhage Lower segment does not contract effectively Morbidly-adherent placenta May be partial, local or diffuse Fetal complications

Abruptio placenta
Associated factors Smoking excessively Folic acid deficiency Pre-eclampsia Trauma Sudden decompression of the uterus after fetal membrane rupture High parity

Abruptio placenta (clinical features)


Clinical features Sudden onset Severe abdominal pain, may be associated with labor Fetal distress, fetal death Inaudible fetal heart due to uterine muscle spasm Fainting, collapse; patient be very sick or even toxic in appearance Usually associated pre-eclampsia or hypertension Haemorrhage may be concealed, revealed or mixed in type Tends to recur in subsequent pregnancy

Abruptio placenta-Diagnosis
History: A high index of suspicion from history of sudden onset of abdominal pain (severe, diffuse, constant) with variable amount of haemorrhage Clinical signs: pt may be in shock in severe cases, or may be apparently normal. Signs: Look for pallor, hypotension (severe cases), hypertension, uterus tense and tender, abdominal tenderness; fetal demise Confirm diagnosis by : Ultrasound scan: 1 to rule out placenta praevia 2 for retroplacental clot

Abruptio placenta- mngt


Depends on fetal viability and whether bleeding continues Fetus viable, any gestation age: emergency c/s Fetal death confirmed on ultrasonography, no continuing bleeding: do EUA to rule out placenta previa. If no previa, do ARM, augment labour, AIM for vaginal delivery

Abruptio placenta- mngt (contd)


Any gestation age, fetus dead, continuing severe bleeding: Resuscitate pt, correct volume deficit , aim for CVP of 10 cm of water Correct anaemia, preferably with fresh blood products check for and correct coagulopathy, (Do full blood count, assay fibrinogen levels, do clot retraction tests) deliver by c/s if coagulopathy corrected or absent Vaginal delivery is a much safer and preferred option for delivery in case fetus is dead (not viable) Confirm fetal death by ultrasonography, not fetoscope (due to uterine spasm which may make fetal heart inaudible)

Abruptio placenta- complications

Hypovolaemic shock. This may lead to acute renal failure and renal shut down (both cortical and tubular necrosis) Fetal distress and fetal death Postpartum haemorrhage DIC

Indeterminate causes of APH


May be due to: 1 Bleeding from margins of the placenta (from the marginal sinus) 2 Placenta vera (bleeding from the rupture of fetal vessels as they course thru the membranes Associated with Placental abnormalities like: succenturate lobe, velamentous insertion of the cord, placenta membranaceaous

Indeterminate causes of APH


Bleeding usually mild Blood loss is fetal in origin so fetal demise is very common Diagnosis can be made by ultrasound in a few cases, where the position of the cord may be localized. When in doubt, manage as placenta previa Confirm fetal origin of blood loss with the KleihauerBetke test (to test for fetal blood cells) If fetus is alive, manage as placenta previa. If fetus is dead, manage as abruptio placenta When in doubt, manage as placenta previa

Antepartum haemorrhage: Non-obstetric causes


Local lesions in the genital tract Cervical - cervical cancer - Cervical erosions - Cervical ectropion - Trichomoniasis - Vulvovaginitis of any cause

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