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Antepartum hemorrhage

This document discusses antepartum hemorrhage (APH), specifically placenta previa and placental abruption. It defines APH as bleeding from or into the genital tract after 28 weeks of pregnancy but before birth. Placenta previa is when the placenta implants over the lower uterine segment or cervical os, while placental abruption is the premature separation of a normally implanted placenta. Both can cause painless vaginal bleeding and are medical emergencies. The document outlines risk factors, clinical features, diagnosis, potential complications, and management approaches for each condition.

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Antepartum Hemorrhage Presenter: Oriba Dan Langoya, MBchB V Makerere university College of Health Sciences Supervisor Dr. Nakabembe, Dept. of Obstetrics& Gynecology
Introduction APH • It is defined as bleeding from or into the genital tract after the 28th week of pregnancy but before the birth of the baby • (the first and second stage of labor are thus included)
Introduction • Slight vaginal bleeding is common during active labor. • This “bloody show” is the consequence of effacement and dilatation of the cervix, with tearing of small vessels. • Uterine bleeding, however, coming from above the cervix, is concerning. • “Any pregnancy with antepartum bleeding remains at increased risk for an adverse outcome even though bleeding has stopped and placenta previa has been excludedsonographically.”
Placenta Previa • When the placenta is implanted partially or completely over the lower uterine segment (over and adjacent to the internal os) Classification
Classification • Workshop sponsored by the National Institutes of Health (Dashe, 2013) • Placenta previa. • The internal os is covered partially or completely by placenta. • Low-lying placenta— • Implantation in the lower uterine segment is such that the placental edge does not reach the internal os and remains outside a 2-cm wide perimeter around the os.
Incidence and Associated Factors • Reported incidences for placenta previa average 0.3 percent or 1 case per 300 to 400 deliveries. • Multiparity • Increased maternal age (> 35 years) • History of previous cesarean section or any other scar in the uterus (myomectomy or hysterotomy) • Placental size and abnormality (succenturiate lobes) • Smoking — causes placental hypertrophy to compensate carbon monoxide induced hypoxemia. • Prior curettage. • Elevated Prenatal Screening MSAFP Levels
Clinical Features • Painless bleeding is the most characteristic event with placenta previa. • Sudden onset, painless, apparently causeless and recurrent. • Bleeding usually does not appear until near the end of the second trimester or later, but it can begin even before mid pregnancy.
Diagnosis • Sonographic evaluation • Double set-up technique • Magnetic Resonance Imaging.
Abdominal examination: • The size of the uterus is proportionate to the period of gestation. • The uterus feels relaxed, soft and elastic without any localized area of tenderness. • Persistence of malpresentation like breech or transverse or unstable lie is more frequent. • The head is floating • Fetal heart sound is usually present, unless there is major separation of the placenta • Vulval inspection: Only inspection is to be done to note whether the bleeding is still occurring or has ceased, • In placenta praevia, the blood is bright red as the bleeding occurs from the separated utero-placental sinuses
MANAGEMENT • Women with a previa are managed depending on their individual clinical circumstances. • The three factors that usually are considered include  fetal age and thus maturity;  labor; and  bleeding and its severity  If the fetus is preterm and there is no persistent active bleeding, management favours close observation in an obstetrical unit.
MANAGEMENT • After bleeding has ceased for about 2 days and the fetus is judged to be healthy, the woman can usually be discharged home. • In other cases, prolonged hospitalization may be ideal. • For women who are near term and who are not bleeding, plans are made for scheduled cesarean delivery. • Timing is important to maximize fetal growth but to minimize the possibility of antepartum hemorrhage • A National Institutes of Health workshop concluded that women with a previa are best served by elective delivery at 36 to 37 completed weeks
Delivery • Practically all women with placenta previa undergo cesarean delivery. • Following placental removal, there may be uncontrollable hemorrhage because of poorly contracted smooth muscle of the lower uterine segment.
ADMISSION TO HOSPITAL • All cases of APH, even if the bleeding is slight or absent by the time the patient reaches the hospital, should be admitted. • TREATMENT ON ADMISSION
TREATMENT ON ADMISSION • IMMEDIATE ATTENTION: • Overall assessment of the case is quickly made as regards : 1. Amount of the blood loss — by noting the general condition, pallor, pulse rate and blood pressure 2. Blood samples are taken for group, cross matching and estimation of haemoglobin 3. A large-bore IV cannula is sited and an infusion of normal saline is started and compatible cross matched blood transfusion should be arranged 4. Gentle abdominal palpation to ascertain any uterine tenderness and auscultation to note the fetal heart rate 5. Inspection of the vulva to note the presence of any active bleeding.
MANAGEMENT < 34/40 • Admit, bed rest • Steroids • Hb, hct, type & screen • No D/C, unless transport avail. • Deliver- @ 37/40 - Severe bleed 34-38/40 • Admit • Bed rest • Hb, hct, type & screen • Deliver if severe bleed • NVD-low lying placenta - > 60% success • C/S-Grade 2-4
COMPLICATIONS OF PLACENTA PREVIA Maternal • During pregnancy— Antepartum hemorrhage with varying degrees of shock. Malpresentation Premature labor Death due to massive hemorrhage during the ante-partum, intrapartum or postpartum period. • During labor • Early rupture of the membranes • Cord prolapse due to abnormal attachment of the cord • Slow dilatation • Intrapartum hemorrhage • Increased incidence of operative interference • Postpartum hemorrhage
FETAL COMPLICATIONS IN PLACENTA PREVIA • Low birth weight • Asphyxia • Intrauterine death • Birth injuries • Congenital malformation
PREVENTION: Placenta previa is one of the inherent obstetric hazards and in majority the cause is unknown. Thus to minimize the risks, the following guidelines are useful. • — Adequate antenatal care to improve the health status of women and correction of anemia. • — Antenatal diagnosis of low lying placenta at 20 weeks with routine ultrasound needs repeat ultrasound • — Examination at 34 weeks to confirm the diagnosis. • — Significance of “warning hemorrhage” should not be ignored.
Placental abruption • from the latin abruptio placentae - “rending asunder of the placenta,” • Is a form of antepartum haemorrhage occuring due to premature separation of the normally implanted placenta • significant cause of perinatal mortality (15–20%) and maternal mortality (2–5%).
Varieties a. Concealed: the blood is retained between the membranes and the decidua(rare) b. Revealed: the blood insinuates downwards between the membranes and the decidua ( commonest) c. Mixed: some part of the blood collects inside (concealed) and a part is expelled out (revealed)
Aetiology • Unknown in the majority of cases • there is an association with defective trophoblastic invasion, as with pre-eclampsia and FGR. • Other associations include direct abdominal trauma, high parity, uterine over-distension, sudden decompression of the uterus.
Risk factors • Hypertension • Smoking • Trauma to abdomen • Cocaine use • Anticoagulant therapy • Polyhydramnios • FGR • Chorioamnionitis • Short cord • Preterm ruptured membranes • Uterine leiomyomas
Pathogenesis • initiated by hemorrhage into the decidua basalis • expands to cause separation and compression of the adjacent placenta. • depending upon the extent of pathology, there may be degeneration and necrosis of the decidua basalis as well as the placenta adjacent to it.
• Most blood in the retroplacental hematoma in a nontraumatic placental abruption is maternal. • This is because hemorrhage is caused by separation within the maternal decidua, and placental villi are usually initially intact.
Clinical features and diagnosis • Most women with a placental abruption have sudden-onset abdominal pain, vaginal bleeding, and uterine tenderness( usually tense=‘woody hard’) • Bleeding may be concealed so its absence does not preclude the diagnosis. • Large abruptions may present with maternal shock and/or collapse. • Depending on the size and location of the abruption, the fetus may be dead, in distress or unaffected.
• Diagnosis is usually made on clinical grounds. • Sonography has limited use because the placenta and fresh clots may have similar imaging characteristics. • negative findings with sonographic examination do not exclude placental abruption.
Complications • Hypovolemic shock • Consumptive coagulopathy • AKI • Fetal death • Couvelaire uterus
Management Differs depending on gestational, maternal and fetal status Resuscitation • Call for help • Talk to the patient • Assess ABCs – manage accordingly • Insert two large bore cannulae • Blood grouping + xmatching • DIC screen- CBC, bleeding and clotting time,d- dimers
• Asssess fetal well being • Placental localization • Plasma expanders • Blood transfusion/FFP/platelets
Placental abruption - mgt 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
Placental abruption - mgt Any gestation age, fetus dead, continuing severe bleeding: • Resuscitate pt, correct volume deficit Correct anaemia, preferably with fresh blood products • check for and correct coagulopathy, • 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)