Antepartum Hemorrhage

Definition Incidence Etiology Placenta previa Placenta is partially or totally implanted over the lower uterine segment. 1/200 of pregnancies beyond 24 w. A. Maternal i. Uterine scarring : Prior CS : 4 x more common Prior D&C Prior surgical evacuation for abortion ii. Increased age & parity. iii. Anemia iv. Previously hx of PP v. Smoking B. Fetal i. Multiple pregnancy ii. Placenta membranacea iii. Large placenta : DM & Rh isoimmunisation iv. Delayed development of the chorion Placental Abruption Separation of the normally implanted placenta before onset of labor. 1% of deliveries A. Hypertension Previously toxemic accidental hemorrhage Responsible for 50% of cases Associated with PET or chronic HTN Associated w severe form of placental abuption Hemorrhage occurs 2ry to degenerative changes in the decidual arterioles. B. In non HTN pt : Trauma to abdomen PPROM Sudden release of IUP ; in sudden rupture of membranes in polyhramnios. Cigarette smoking, alcohol & cocaine Uterine fibroid : implanted over it Traction on the placenta by a short umbilical cord Folic acid defiency Abnormal placenta as circumvallate placenta Thrombophilias : protein C&S defiency, APL synd Revealed Bleeding dissects its way between membranes & uterus & escapes thru the cx casuing external hemorrhage. There is separation of the edge of the placenta & usually bleeding is not extensive. Concealed o Less often, blood does not escape externally but is retained between the uterus & detached placenta. Bleeding is concealed due to : Atony of the uterine ms Adherent margins of placenta to the uterine wall Adherent membranes to the uterine wall Mixed Most common type which usually starts as concealed then is expelled by strong uterine contractions thru the cx.

Types

Low lying placenta (type I) PP marginalis (type II) PP incomplete centralis (Type III) PP compete centralis (type IV) Type I & II : PP minor degree Type III & IV : PP major degree

Placental edge encroaches upon the lower uterine segment , but not be reaching the marginof internal os Lower edge of placenta is reaching the margins of IO. It maybe implanted anteriorly (type II ant ) or posteriorly (type II posterior) Placenta partially covers the IO. So, it covers the partially dilated cx Placenta complete covers the IO. So, it covers the fully dilated cx

Antepartum Hemorrhage
CP Symptoms : rd The cardinal symp of PP is painless, causeless, recurrent vx bleeding during 3 trimester of pregnancy Signs : General exam o Proportionate to the amount of blood loss o Pallor due to blood loss Abdominal exam o Lax, fundal level equals the period of amenorrhea Vaginal exam Double set up (no role) 1. US Main tool in dx Safe, rapid , accurate in dx TVS is more accurate 2. MRI Safe but expensive. Depends on : Severity of bleeding Patient is in labor or not Gestational age Type of PP Assessment of severity of bleeding Mild blood loss The loss is <15% of intravascular volume - no changes of the vital signs - no postural tachycardia or hypotension Moderate blood 15-30% of IV vol : loss - postural tachycardia & hypotension 1. 2. Concealed Sudden severe abd pain Symp of pre exlampsia Revealed Main complaint is vx bleeding 2. Hx of external trauma Vital signs are proportionate to the amount of bleeding. Abd exam : lax, uterus is neither hard nor tender. Local : vx bleeding which is dark / fresh, usually not severe. 1.

Shock & collapse not proportionate to the amount of vx bleeding. Abd exam : rigid, uterus is larger than period of amenorrhea. Local : no vx bleeding

Dx

Management

Delivery is indicated in: - pt in labor -mature fetus Route : 1) Vaginal delivery -PP lateralis & marginalis ant. -managed by artificial rupture of membranes & pitocin drip 2) CS: - in marginalis post, incomplete, & complete centralis Conservative ttt -bleeding stopped -<36 w with immature lungs -no maternal ds Give corticosteroids to enhance fetal lung maturity Resuscitation then CS

1. History o Antepartum hemorrhage with abdominal pain o Of the cause is pre exlampsia 2. CP 3. Investigations : US : confirm dx & evaluate fetal condition Lab : CBC, RFT & DIC First aid : - morphine & antishock measures if bleeding is severe bleeding 2) ttt at hospital : - blood sample for ; CBC,Rh typing, cross matching with 4 units of fresh blood - US for placental localization When abruption placenta is dx clinically or by US : Start 2 IV lines in mod or severe cases Insert foleys catheter Deliver o2 via nasal mask Dx whether pt is in labor or not Evaluate fetal condition : Gestational age Alive or dead

Severe blood

>30 % of IV vol

Dead fetus Correction of maternal hypovol - fluid infusion & blood transfusion - fresh blood if DIC Termination IAROM & oxytocin drip if pt in labor Advantages o Reduced high IUP o It stimulates uterine contractions o Relieves pain & improves

Living fetus Uterus is rigid with fetal distress : do urgent CS Uterus is soft & fetus is mature : do induction of labor Fetus is premature : expectant management with fetal monitoring till reaching fetal maturity.

Antepartum Hemorrhage
loss - shock, tachycardia, hypotension, oliguria -persistent loss of fresh blood from vagina 1.resuscitation 2. delivery : -urgent lower segment CSec regardless gestational age IIo 1. 2. shock CS When the cond of pt deteriorates Shock Renal failure ARF : due to hypovolemia that is exaggerated by reflex renal vasospam in reaction to uterine distension 75% : caused by ATN (reversible ) and 25% in CAN (irreversible) DIC Clinically : excess bleeding at modest trauma Fetal complications: Asphyxia : due to placental separation & titanic uterine contractions. Prematurity : mostly induced

Complications

Maternal a) During pregnancy Hemorrhage resulting in anemia, hypovolemic shock, RF &Sheehans synd Preterm labor Malpresentation & non engagement of the head b) During labor Uterine inertia PROM, cord prolapsed Increase incidence of CS Increase incidence of placenta accrete Air embolism c) Puerperium 1) Post partum hemorrhage : Lower uterine segment cant retract to stop bleeding 2) Retained placental remnants 3) Puerperal sepsis : due to retained placental remnants 4) Anemia Fetal 1) Prematurity 2) Malpresentation & malposition leading to prolonged labor & traumatic delivery 3) Vasa previa

3. o 4.