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Antepartum Haemorhhage(Aph)

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Antepartum Haemorhhage(Aph) ANTEPARTUM HAEMORHHAGE(APH) MAJ SAMIA NASREEN CLASSIFIED GYNAECOLOGIST CMH OBJECTIVES OF PRESENTATION • Identify serious causes of vaginal bleeding in the second half of pregnancy • 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 fetus. • It complicates (3-4%) of all pregnancies. • It is an obstetric emergency because it endanger the life of both the mother and fetus. • Hemorrhage remain the most frequent cause of maternal deaths. • 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 • Placenta previa • Placental abruption • Uterine scar disruption Life Threatening • Ruptured vasa previa • Cervical polyp • Bloody show/cervical change • Cervicitis or cervical ectropion • Vaginal trauma • Cervical cancer 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 gestational age (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 blood 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 pain 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 uterus 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 • Abdominal trauma • Tobacco, cocaine, stimulants • Thrombophilias • Chorioamnionitis • Oligohydramnios 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 bleNeodrminagl 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 cervix 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 placentas • Velamentous insertion of the umbilical cord 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 – Uterine Rupture • Previous cesarean incision (most common) • Other uterine surgery involving full thickness myometrium • Inappropriate oxytocin usage • Labor induction • Uterine over‐distention
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