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DEFINITION:
Bleeding from the genital tract after the
ANTEPARTUM HAEMORRHAGE
EPIDEMIOLOGY:
CAUSES OF APH
PLACENTAL BLEEDING EXTRA-PLACENTAL BLEEDING
CERVICAL POLYPS
CARCINOMA OF CERVIX
LOCAL TRAUMA
Placenta Praevia
2) 3)
PLACENTA PRAEVIA
DEFINITION: The implantation of placenta over or near the internal os of the cervix.
T2 + T3 4 main types
CLASSIFICATI ON
TYPE 4
4
TYPE 3
3A 3B 2B
TYPE 2
2A 1A
TYPE 1
1B
MAJOR
MINOR
AETIOLOG Y
UNKNOWN! However some theories are postulated regarding this:
1. 2. 3.
4.
Multiparity
PRESENTATIO N
SYMPTOMS: Painless and causeless recurrent vaginal bleeding. May be precipated by coitus Bright red Warning Haemorrhages May/May not have contractions simultaneously with the bleeding SIGNS: Vital signs degree of haemorrhage General condition of anaemia proportional to visible blood loss
GENERAL FEATURES
Features of shock and degree of anaemia proportional to amt. of blood loss. Pulse and BP - hypotensive and tachycardic if in shock
SPECIFIC FEATURES
ABDOMINAL:
Non-tender Symphysiofundal height usually corresponds with period of gestation Lie of fetus = Unstable or Normal Presenting part high above pelvic brim Fetal Heart Sound usually present
VULVA:
Bleeding stil occurring or has ceased Character of blood NB:VAGINAL EXAMINATION IS DANGEROUS SINCE IT MAY PRECIPITATE HEAVY BLEEDING.
DIAGNOSI S
CLINICAL: Internal Examination - double set up examination. Direct visualization during Caesarian Section. Examination of Placenta following Vaginal Delivery.
LOCALIZATION OF THE PLACENTA:(CONFIRMATION) Transabdominal Ultrasound Transvaginal Ultrasound Translabial Ultrasound Transperineal Ultrasound MRI
PREVENTIO N
Adequate Antenatal Care Antenatal diagnosis of Low Lying Placenta at 20 weeks with routine USS.Repeat at 34 weeks for confirmation.
ADMISSION TO HOSPITAL
ALL APH CASES MUST BE ADMITTED AND MANAGED AT A TERTIARY HEALTH CARE UNIT WITH FACILITIES FOR:
Ultrasound Scan Blood transfusions Emergency Caesarian Sections Neonatal intensive care unit
EMERGENCY MANAGEMENT
IV line with a wide bore cannula Isotonic fluids until blood available Blood tests: Group & Cross Match, CBC (Hb) KLEIHAUER-BETKE test (Anti D given if Rh -)
FORMULATION OF TREATMENT
DEPENDS UPON :
EXPECTANT TREATMENT
Prerequisites: 1. Availability of Cross Matched Blood for transfusion 2. Facilities for Caesarian Section 3. Maternal Anemia Corrected Selection: Hb>10g/dl Gestational period less than 38 weeks Active Vaginal bleed absent Fetal well being shown by ultrasound
CONDUC T
Bedrest
Routine blood investigations Blood loss monitored by sanitary pad count Fetal surveillance by ultrasound 2-3 week intervals Supplementary haematinics Use of tocolysis (MgSo4)
INDICATIONS: 1. Bleeding at or after 38 weeks 2. Patient is in labour 3. Patient is in an exsanguinated state at time of admission 4. Bleeding continues with moderate degree 5. Baby is dead or congenitally deformed CONDUCT: Caesarian Section-USS evidence of placenta preavia where placental edge is 2cm from internal os. Vaginal Delivery-considered where placental edge is 2-3cm from internal cervical os
DEFINITIVE TREATMENT
COMPLICATIO NS
MATERNAL: DURING PREGNANCYShock Malpresentation Premature Labour DURING LABOUREarly rupture or membrane Cord prolapse Slow dilatation Intraparum haemorrhage Postpartum haemorrhage Retained placenta FETAL: Low birth weight Asphyxia IUGR Congenital malformation Fetal anemia Rh isoimmunization PUERPERIUM: Sepsis is increased due to Increased operative interference Placental site near to vagina Anemia and devitalized state of patient
Placenta Praevia
2) 3)
2) Abruptio Placentae
Defintion: Separation before delivery of a normally sited placenta i.e. one in the upper uterine segment
BIRTHS = 30,987
DEATHS = 860 Perinatal mortality rate = 27.7/1000 births
NUMBER OF PERINATAL DEATHS
391
LEADING CAUSES OF EARLY NEONATAL DEATHS: 1) Respiratory Distress Syndrome 2) Birth asphyxia 3) Sepsis
469
LEADING CAUSES OF FETAL DEATHS: 1) Hypertensive disorders of pregnancy 2) Abruptio Placentae 3) Diabetes Mellitus 4) Intrapartum fetal distress 5) Congenital anomalies
RISK FACTORS
MATERNAL: Age Parity Hypertensive STRUCTURAL: Sudden uterine decompression Uterine abnormalities
disorders of pregnancy
Cigarette smoking Cocaine use Serum AFP Thrombophilias
PPROM
Retroplacental leiomyoma Short umbilical cord EXTERNAL: Physical trauma Cephalic Version
PATHOPHYSIOLOGY
Vasospasm of the uterine vessels
Uterus contracts and appears bruised, purplish and mottled (Couvelaire uterus)
VARIETIES
Concealed / Internal Revealed / External
Mixed
SYMPTOMS
Abdominal Pain:
Onset = sudden Nature = constant (not contractile) Intensity = progressively becomes worse Spreads
GENERAL FEATURES
Tachycardia Low-volume pulse BP = normal or slightly elevated (If mild) Shock (If severe separation occurred)
SPECIFIC FEATURES
UTERUS:
-Tender
STRUCTURAL CLASSIFICATION
ABRUPTIO PLACENTAE
EXTENT OF SEPARATION
LOCATION OF SEPARATION
PARTIAL
COMPLETE
MARGINAL
CENTRAL
S T R U C T U R A L
C L A S S I F I C A T I O N
CLINICAL CLASSIFICATION
CLASS 0 Diagnosis made retrospec tively by finding an organized blood clot or a depressed area on a delivered placenta
CLASS 1 (mild) No vaginal bleeding to mild vaginal bleeding Normal maternal BP and heart rate
CLASS 2 (moderate)
CLASS 3 (severe)
No vaginal bleeding to No vaginal bleeding moderate vaginal to heavy vaginal bleeding bleeding Maternal tachycardia with orthostatic changes in BP and heart rate Moderate to severe uterine tenderness with possible tetanic contractions Hypofibrinogenemia (ie, 50-250 mg/dL) Maternal shock
No coagulopathy
Coagulopathy
No fetal distress
Fetal distress
DIAGNOSIS
DIAGNOSIS OF EXCLUSION
SPECULUM: No local causes
ULTRASONOGRAPHY: Requires great deal of operator skill Presence of retroplacental clots Failure to show placenta praevia
DIFFERENTIALS
Blunt Abdominal Trauma Acute Appendicitis DIC Ovarian Cysts Ovarian Torsion Placenta Previa Delivery Ectopic Pregnancy Preeclampsia Shock: Haemorrhagic/ Hypovolemic Vaginitis
COMPLICATIONS
MATERNAL: DIC FETAL: Anoxia
Renal failure
Postpartum Haemorrhage Hypertension
Death
MANAGEMENT
MILD < 38/40: -No deterioration of clinical condition + Resolution of symptoms Conservative Mx 38/40: - Expedite delivery Route = Vaginal Induction of Labour = Amniotomy + Syntocinon Infusion CTG MODERATE OR SEVERE Maintain blood volume Expedite delivery Prevent DIC: Adequate transfusion of whole blood Treating DIC: Adequate transfusion of whole blood + cryoprecipitate + fresh frozen plasma OR packed red cells + platelets + fresh frozen plasma
MANAGEMENT
BLOOD INVESTIGATIONS: CBC PT, PTT Group & Cross-match (Reserve 4 units of fresh whole blood)
Fibrinogen, U&Es
Kleihauer-Betke test
MANAGEMENT
VE + AMNIOTOMY:
1) Induce/ accelerate labour 2) Decrease intra-uterine pressure reduce uterine tension 3) Internal fetal heart rate monitoring
MANAGEMENT
MOST CRITICAL TIME for patient = during 3rd stage of labour
IV Syntocinon with birth of anterior shoulder Continue with a HIGH-DOSE SYNTOCINON INFUSION: Couvelaire uterus contracts + retracts poorly during postpartum period postpartum haemorrhage
Placenta Praevia
2) 3)
AETIOLOGY
Vasa Previa Bloody show Trauma Uterine rupture Marginal sinus rupture
LOWER GENITAL TRACT: Vulval varicose veins Vaginal lacerations Vulvovaginal infections Cervical polyp Cervicitis Cervical carcinoma.
1) VASA PREVIA
Definition: An obstetric complication whereby fetal vessels cross or run in close proximity to the internal cervical os or lower uterine segment and are at increased risk for rupture due to lack of supporting membranes, rupture of membranes, labour and advance of fetal head.
If rupture occurs, bleeding from feto-maternal circulation and fetal exsanguination occurs
ASSOCIATED CONDITIONS
vilamentous cord insertion low lying placenta bi-lobed or multi-lobed placenta succenturiate lobed placenta multiple pregnancies pregnancies resulting from IVF
DIAGNOSIS
Triad = membrane rupture, painless vaginal bleeding, fetal bradycardia/ heart rate abnormalities
US with colour flow Doppler vessel crossing the membranes over the internal cervical os The kleihauer betke or apt test fetal Hb
Fetal blood loss condition deadly (95%)
MANAGEMENT
The international vasa previa foundation recommends PELVIC REST Hospitalization in the T3 (30-32 weeks) risk of rupture Delivery by C-section at 35 weeks highest survival rate with VP
Immediate blood transfusion and aggressive resuscitation of the infant in the event of a rupture
Steroids promote lung maturity
2) BLOODY SHOW
Definition: Passage of a small amount of blood or blood tinged mucus through the vagina. It occurs just before the onset of labour or in early labour as cervical changes free mucus and blood occupied in the cervical glands or os.
3) UTERINE RUPTURE
Definition: Breach in the integrity of the myometrial wall
UTERINE RUPTURE
INCOMPLETE
Peritoneum is still intact
RISK FACTORS
previous uterine incisions high parity abnormal fetal presentation uterine overdistension-fetal enlargement eg hydrocephalus, macrosomnia
PRESENTATION
Initially subtle Old caesarean scar dehiscence Sudden fetal heart decelerations abdominal pain PV bleed diaphragmatic irritation loss of fetal station hypovolemic shock cessation of uterine contractions
MANAGEMENT
antibiotics
INFECTIONS
Cervicitis STIs (Chlamydia, gonorrhea, syphilis) IUDs allergic reactions to spermicides or condoms bleeding. To stop the bleeding treat underlying cause ie. Role of antibiotics in infections.
CERVICAL POLYPS
Definition: Benign tumour of cervical canal commonly associated with inflammation of the cervix but uncommon in pregnancy.
Can be seen during pelvic examination. Biopsy determines nature of the cells. Management: controlling symptoms of anaemia from bleeding.
CERVICAL CANCER
rare cause of APH Staging must be determined and decision must be made on whether to continue with the pregnancy. If pregnancy continues, C-section is done when the fetus is able to survive outside the womb and then treatment is started right away.
PRESENTATION
Symptoms: - anxiety - pain - heaviness - discomfort during walking - dyspareunia - pruritus - thrombosis - bleeding
Normally resolves after pregnancy.
REFERENCES
Textbook of Obstetrics, 1988. Published by Lexicon Trinidad Ltd., 3rd Edition, Trinidad. 2008.
Obstetrics by Ten Teachers, 2006. Published by Hodder Arnold, 19th Edition, London. 2011.
An Audit of Perinatal Mortality, West Indian Med J 2001 Sep;50(3):243-4, Bassaw B, Roopnarinesingh, Sirjusingh A.