ANTEPARTUM HAEMORHHAGE(APH)

MAJ SAMIA NASREEN CLASSIFIED GYNAECOLOGIST CMH OBJECTIVES OF PRESENTATION

• Identify serious causes of vaginal bleeding in the second half of • Describe a systematic approach to identify the cause of bleeding • Describe specific treatment options based on diagnosis

DEFINITION

• Vaginal bleeding after 24weeks and before the delivery of the . • It complicates (3-4%) of all . • It is an obstetric emergency because it endanger the life of both the mother and fetus. • Hemorrhage remain the most frequent cause of maternal . • Mild= <50 mL loss of blood, Major= 50-1000mL loss, Massive= >1000mL loss. • Bleeding >1 occasion regarded as recurrent APH.

Causes of Late Pregnancy Bleeding

• previa • • Uterine scar disruption Life Threatening • Ruptured vasa previa • Cervical polyp • /cervical change • or • Vaginal trauma • INITIAL MANAGEMENT

• Same initial steps regardless of etiology in all cases of APH

• Assess vital signs, circulatory stability

• Secure intravenous access, administer fluids HISTORY & EXAMINATION

• Targeted history and physical • Abdominal examination for estimated fetal weight (EFW), estimated (EGA), and fetal presentation  Localize tenderness  Palpate for uterine contractions • Gentle speculum examination is safe • NO digital vaginal exam unless placental location is known DIAGNOSTIC EVALUATION

• Continuous electronic fetal monitoring (CTG) and tocodynamometry • Ultrasound for placental location, presence of clots, and fetal presentation • Obtain baseline laboratory tests Complete count Blood type and antibody screen Consider: coagulation studies, blood urea nitrogen (BUN), creatinine, liver function testing, and type and cross • Prepare for possible emergent cesarean delivery

PLACENTA PREVIA Grading of placenta previa

Grade .1 (lateral placenta): The placenta implanted in the lower uterine segment but not reach the internal os. Grade .2.(marginal placenta): The edge of the placenta reaches the internal os but not cover it. Grade.3.(partial placenta previa): The placenta partially covering the internal os. Grade.4.(complete placenta previa): The placenta completely cover the internal os completely. Grade (1&2) called minor P.P. grade (3&4) major P.P.

Prevalence Of Placenta Previa Risk Factors

• Common finding on second • Advanced maternal age trimester ultrasound,most regress • Chronic hypertension Previa found on 4% of • Multiparity ultrasounds at 20 to 25 weeks, only 0.5% by term • Multiple gestation • More likely to persist with • Previous cesarean previous cesarean delivery, delivery complete previa • • No benefit to routine Previous placenta previa screening ultrasound in late • Previous uterine curettage pregnancy • Smoking COMPLICATIONS OF PLACENTA PREVIA • Maternal Hemorrhage Blood transfusion Cesarean delivery Hysterectomy Invasive placenta (accreta, increta, or percreta) • Fetal Prematurity CLINICAL PRESENTATION OF PLACENTA PREVIA • presentation is painless bleeding late second or third trimester provoked by intercourse may be accompanied by preterm contractions • Suspect previa with persistent malpresentation • Diagnosis confirmed with ultrasound localization of placenta • Confirm with transvaginal ultrasound Ob-Gyn key TRIADS Placenta Previa Late trimester bleeding Low segment plac. implaNnot USG SHOWING COMPLETE PREVIA USG SHOWING MARGINAL PREVIA MANAGEMENT OF PLACENTA PREVIA

• When active bleeding is assessed in the hospital If preterm, consider maternal transfer to appropriate level of care  Consider antenatal corticosteroids and tocolysis  Full dose of Rho (D) immune globulin if Rh negative • Absence of active bleeding can be managed expectantly • No intercourse or tampons in the third trimester • Avoid digital examinations • Confirm unresolved previa with ultrasound at 32 weeks • Ultrasound at 36 weeks can help determine mode of delivery ONGOING MANAGEMENT OF PLACENTA PREVIA • If bleeding stops, can consider outpatient management if Assurance of current maternal and fetal well‐being Patient lives in close proximity to hospital Immediate evaluation can occur if new bleeding episode starts or with onset of labor • Need for emergency cesarean delivery increases with Three or more episodes of antepartum bleeding Initial episode of bleeding occurring at <29 weeks Shortened cervical length on serial ultrasounds DECISION OF DELIVERY IN PLACENTA PREVIA • For known low‐lying placenta or marginal previa with no bleeding, perform ultrasound at 36 weeks If placenta is located ≥2 cm from internal os, expect vaginal delivery If 1 to 2 cm from os, may attempt vaginal delivery in setting with immediate surgical backup • Perform cesarean delivery if Ultrasound indicates complete previa Fetal head is not engaged Concerning fetal heart rate tracing Brisk or persistent bleeding • Regional anesthesia is safe and results in less blood loss NEONATAL COMPLICATIONS OF PLACENTA PREVIA • Greatest morbidity and mortality is related to prematurity • Tocolysis can increase the duration of pregnancy and birth weight without increased maternal/fetal complications • Antenatal steroids should be administered to patients with symptomatic previa between 24 and 34 weeks gestation PLACENTAL ABRUPTION

• Premature separation of placenta from uterine wall Partial or complete abruption can occur • Occurs in 1% of pregnancies • Apparent increase in incidence Increased diagnosis (ultrasound) vs Increased risk factors (hypertension)

TYPES OF ABRUPTION

• It could be of two types: • Revealed (Overt) and External Bleeding: there is obvious external vaginal bleeding (2/3 of cases)

• Concealed or Internal Bleeding: bleeding in the with no external bleeding. (1/3 of cases).

RISK FACTORS OF PLACENTAL ABRUPTION • Hypertensive disorders of pregnancy Treating preeclampsia with magnesium sulfate (MgSO4) decreases risk • • Tobacco, cocaine, stimulants • Thrombophilias • • with PROM • History of abruption in a previous pregnancy CLINICAL PRESENTATION OF PLACENTAL ABRUPTION • Abdominal pain is the hallmark symptom Varies from mild cramping to severe pain With back pain – think posterior abruption • Vaginal bleeding or bloody amniotic fluid Differentiate from exuberant bloody show •Concealed bleeding occurs in 20% to 63% of cases Visible bleeding may not accurately reflect blood loss Ob-Gyn key TRIADS Abruptio placenta Late trimester painful bleNeodrimnagl placental implantaDtioICn EVALUATION - ABRUPTION

• Check vital signs to assess for circulatory instability • Palpate maternal abdomen to assess for Location of tenderness Tetanic contractions • Monitor fetal heart rate (FHR) and contractions Continuous fetal electrocardiogram Consider amniotomy and intrauterine pressure catheter • Ultrasound to determine Estimated fetal weight, fetal lie, and presentation Evaluate the placenta DIAGNOSIS OF PLACENTAL ABRUPTION • Diagnosis of placental abruption is highly dependent upon clinical assessment • Do not delay definitive management to obtain an ultrasound • Ultrasound may show characteristic features, but has low sensitivity for detecting placental abruption SEVERITY OF ABRUPTION

• Mild Often identified at delivery with retroplacental clot present upon inspection of placenta • Severe Symptomatic, tender abdomen • Severe with fetal demise without coagulopathy (two‐thirds) with coagulopathy (one‐third) MANAGEMENT OF SEVERE ABRUPTION • Expeditious operative or vaginal delivery Decision‐to‐delivery interval >20 minutes increases incidence of fetal mortality or cerebral palsy • Maintain maternal circulation Urine output >30 mL/hour Hematocrit >30% • Prepare for neonatal resuscitation • If fetal demise Vaginal delivery preferred, unless severely bleeding Check for coagulopathy Coagulopathy with Abruption

• Occurs in one‐third of fetal demises • Usually not seen with delivery of live fetus • Etiologies: consumption, disseminated intravascular coagulation (DIC) • Administer platelets, fresh frozen plasma (FFP) before operative delivery

VASA Previa 1 in 3000 pregnancies VASA PREVIA

• Fetal vessels run in membranes between and presenting part • Rarest cause of hemorrhage • Can result in fetal blood loss • Rapid intervention is essential for fetal survival VASA PREVIA ASSOCIATED CONDITIONS • In vitro fertilization • Low‐lying placenta or previa present in second or third trimester • Bilobed and succenturiate lobed • Velamentous insertion of the CLINICAL PRESENTATION OF VASA PREVIA • Can be detected antenatally Will be able to palpate vessels during cervical examination Color flow Doppler ultrasound • First sign is typically bleeding with membrane rupture • Important to remember blood loss is fetal Fetal blood circulation = 250 mL total

Ob-Gyn key TRIADS Vasa Previa ROM Vaginal bleeding Fetal bradycardia MANAGEMENT OF VASA PREVIA

• Immediate cesarean delivery if FHR concerning • Administer normal saline 10 to 20 mL/kg bolus to newborn if in shock due to blood loss after delivery UTERINE RUPTRE

• Occult dehiscence versus symptomatic rupture • Rare in an unscarred uterus <0.1% overall incidence 0.8% of women with uterine scar • Previous cesarean incision is the most common etiology

Risk Factors –

• Previous cesarean incision (most common) • Other uterine surgery involving full thickness • Inappropriate oxytocin usage • Labor induction • Uterine over‐distention • Abnormal placental attachment, difficult removal • Uterine or fetal anomaly • Gestational trophoblastic neoplasia • Adenomyosis Morbidity with Uterine Rupture

• Maternal Hemorrhage with anemia (most common) Bladder rupture Hysterectomy Maternal mortality • Fetal Respiratory distress Hypoxia Acidemia Neonatal mortality Clinical Findings – Uterine Rupture

• Sudden deterioration of FHR pattern is the most common initial sign • Vaginal bleeding • Pain, sudden onset • Stair step decrease or cessation of contractions • Loss of fetal station • Palpable fetal parts through maternal abdomen • Profound maternal tachycardia and hypotension Management – Uterine Rupture

• Symptomatic rupture – Emergent cesarean delivery – Outcome good if decision to incision delivery time occurs in under 18 minutes in one study SUMMARY

• Late pregnancy bleeding may herald diagnoses with significant potential for maternal morbidity/mortality

• Rapid clinical diagnosis is imperative In the setting of maternal hemorrhage and concerning FHR tracing, do not delay management to do diagnostic testing

• No vaginal digital examination until placental location is known

• Ultrasound can help determine the cause of bleeding

• When antenatal ultrasound identifies placenta previa, color flow Doppler study is recommended to evaluate for placenta accreta and vasa previa CASE NO 1 Diagnosis and why? A 32-year-old multigravida at 31 weeks’ gestation is admitted tothe unit after a motor-vehicle accident. She complains of sudden onset of moderate vaginal bleeding for the past hour. She has intense, constant uterine pain and frequent contractions. Fetal heart tones are regular at 145 beats/min. On inspection her perineum is grossly bloody.

CASE NO 2 What is Diagnosis and Why? A 34-year-old multigravida at 31 weeks’ gestation comes to the birthing unit stating she woke up in the middle of the night in a pool of blood. She denies pain or uterine contractions. Examination of the uterus shows the fetus to be in transverse lie. Fetal heart tones are regular at 145 beats/min. On inspection her perineum is grossly bloody.

CASE NO 3 What is Diagnosis and Why? A 21-year-old primigravida at 38 weeks’ gestation is admitted to the birthing unit at 6-cm dilation with contractions occurring every 3 min. Amniotomy (artificial rupture of membranes) is performed, resulting in sudden onset of bright red vaginal bleeding. The electronic fetal monitor tracing, which had showed a baseline fetal heart rate (FHR) of 135 beats/min with accelerations, now shows a bradycardia at 70 beats/ min. The mother’s vital signs are stable with normal blood pressure and

CASE NO 4 What is Diagnosis and Why? • 35 years old gravida 3rd para 2+0 presented at 5 am in morning having labour since 5 pm ,being looked after by dai at home since 2 am and referred to hospital for non progress of labour and bleeding p/v ,and no fetal hearts since 4 am .On examination fetal parts felt high in abdomen ,no fetal heart and fresh bleeding per . Her first born was cesarean delivery because of breech presentation. Second VBAC(vaginal birth after cesarean). SUBMISSION OF ANSWER

• Kindly briefly answer all cases and forward answers at Email address; [email protected]

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