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Dr.Meelad..

lec 1 obstetric 26-11-2013

Antepartum hemorrhage
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Is bleeding which usually takes place after 24 wks.of gestation ( it is 3rd trimester
bleeding )
Three major causes :
2- Abruptio placenta

3- Incidental causes
Normally placenta is located in fundus of uterus but when localized more down (
placenta preavia ) & when fetus grow downward , it will push placenta & it will
bleed easily .

Placenta preavia
Abnormally situated placenta in lower uterine segment or covering the os .

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Grading :
1. Low lying placenta ( Grade I )
Placenta here is situated in the lower uterine segment near the os but not reaching the
os .

2. Marginal placenta preavia ( grade II )


placenta is reaching the os .

3. Partial placenta preavia ( grade III )


partially placenta cover the os .

4. Complete placenta preavia ( grade IV)


totally cover the os .

Causes of placenta preavia( high risk group ):


1- Previous Hx of excessive curetting ( curettage)
2- Previous Hx of caesarean section .
3- Anemia
4- Grand multiparous lady
5- With progress age
6- Previous Hx of placenta preavia
7- Disturbance of contour of uterus like presence of a fundally situated fibroid .

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Presentation :
1- Bleeding after 24 wks of gestat\ion usually the 1st episode ( attack ) of vaginal
bleeding is small in amount , does not affect the life of pt. , painless , causeless .

usually occurs when the pt rises up morning from his bed with a bleeding seen on
thighs & the bed.
2- recurrence usually after 2nd attack which is more aggressive in nature & may affect
the life of the pt.

Predisposing factors are :


1. Intercourse
2. Heavy exercise 3. Lifting heavy things .

Examination :
General condition of pt is corresponded to the amount of vaginal bleeding i.e
vital signs in 1st attack are not affected & with increase amount of bleeding they
will be deteriorated .

Abdominal exam.
a. Uterus is soft & not tender .
b. Fetal part can be detected easily
c. Fetal heart can be detected easily & most of the time fetal condition is not
affected.
d. Uterus size is slightly larger than date & the head is not engaged or the date of
uterus is correspond to date of amenorrhea.

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Diagnosis :
US examinationis very helpful in detecting placental site with an accuracy of 96 % but
sometime there is a difficulty when the placenta is situated posteriorly , the better
technique is vaginal US scanning but sometime it is risky because it may create bleeding
.

Digital examination ( bimanual exam. ) can be very helpful in determining the age of
placenta .

Pelvic examination is contraindicated in lady with placenta preavia***

Pelvic exam. Is only indicated if we are sure that bleeding is not due to placenta
preavia.
It have been performed that digital examination can lead to sever uncontrollable
bleeding in 1:16 pt.

Management :
Depend upon the

a- General condition of pt.


b- Amount of vaginal bleeding
c- Age of gestation

1- If the amount of bleeding is minimal and the general condition of pt is stable ,


conservative Mx is mandatory if gestational age is not near to term ( immature
baby ) . this is called expectant Mx in which we can performed Ixs for:
the hematocrit & total blood count, US assessment for grading . Correction of
anemia if it is present ,Hospitalization & Preparation of blood.

2- If the bleeding is moderate & mildly affecting general condition of pt with


immature baby, blood transfusion is mandatory , close observation of bleeding ,
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aiming here is to prolong pregnancy until reaching fetal maturity & the termination
of pregnancy accordingly
3- If the pt has sever vaginal bleeding affecting life of pt ; irrespective of maturity of
baby , termination of pregnancy is mandatory ( to save life of mother ) . In this
condition preparation of 4 pines of blood & termination of pregnancy by caesarian
section & transfer the baby to baby care unit.

Measures of Expectant Management:


1- It have been seen that inhibition of uterine contraction isimportant in order not to
allowing placenta preavia to be turned & this can be done by giving nefidipin 10 mg
\4times daily for inhibition of uterine contraction .
Beta agonists are not so much recommended because they exacerbate tachycardia &
may affect the bleeding .

2- Administration of betamethazone( steroid therapy ) is sometime helpful in


enhancing fetal maturity .
3- Supplementation of iron therapy improves anemia.
4- Stool softness by high residual diet.
5- The role of cervical currelage operation is still under the trial.

Indications of caesarean section according to type of placenta preavia:


In grade I , grade II placenta anterior , sometime we allow a vaginal delivery to
take place

but in placenta preavia grade II posterior , grade III & grade IIII, the should be
terminated by caesarean section.

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Abruptio placenta
Is the early separation ( premature separation ) of a normally situated placenta.

This condition usually occurs before delivery in which the bed of placenta will be turned
or damaged leading to formation of retro- placental clot.

Causes;
1- Folic acid deficiency
2- Trauma
3- Previous Hx of abruptio placenta
4- Grand multiparity
5- Hypertensive disorders
6- Increase with maternal age.

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Presentation:
1. Revealed type , bleeding can be seen through vagina but in
2. concealed type blood is trapped in uterus & then it will invade myometrium in
leading to condition called ( conulaire uterus ). In this condition uterus will be
purple in color , the full myometrium if full involved with blood & it will be
larger for date.

Pathophysiology;Because there is a big retro-placental clot & bleeding inside the


uterus this will initiate the tissue thromboplastin factors leading to activation of specially
intrinsic pathway of coagulation leading to consumption of blood clotting factors &
platelet & final result will be intravascular thrombosis & small thromboemboli&
hemolysis known as DIC.

Presentation :
Usually pt general condition does not correspond to the amount of bleeding .
In moderate sever cases of abruptio placenta, vital signs are usually deteriorated ,
there will be tachycardia , hypotensive attack , cold, thready pulse , dry mouth &
tongue. pt has sever abdominal pain.

On examination:
Uterus is much larger than date, tense , tender , fetal part can not be detected , & fetal
heart is usually absent , we can not detect the fetal lie , there is muscle gardening &
abdominal rigidity .

-Sometimes US is not so much helpful in detecting the retro-placental clot but can roll
out placenta preavia, so pelvic examination can be performed here to assess the cervical
condition & weather the pt is in labor or not .
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Usually pt with abruption placenta , they run in labor:
Assessment of ( blood profile ) are mandatory to see any coagulation defect. Prepare
at least 4-6 pines of blood for pt& start immediate transfusion & resuscitation by
ringer lactate fluid & insert catheter to assess amount of urine output & assess
vaginal examination to plane for termination of pregnancy ( delivery ).

Usually pt at time of presentation may have 50 % of prenatal mortality ( dead fetus )


( aim here to have vaginal delivery to escape in unstable , hematological condition
of pt rupture of membrane & oxytocin derivatives & bd. Transfusion & most of pt
will have vaginal delivery ( aim is vaginal delivery & give blood transfusion in case
of dead fetus.

Caesarian section is indicated in :


1- If there is obstetrical problem like abnormal lie or cephalopelvicdisproportion .
2- Uncontrollable bleeding
3- If the fetus is alive & there is a chance of saving him \her.

Vasa Preavia
Bleeding here is from fetal site in which there is a damage to the cord from fetal site
rather than maternal site .

This condition usually occurs when cord is inserted eccentric toward the placenta
Usually there is an antepartum bleeding affecting fetal & fetus have tachycardia &
there will be loss of fetal varrbility& the bradycardia& there is birth asphyxia.

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Rx is either termination of pregnancyorintra-uterine transmission

Incidental causes :
These are cause local situated in vagina or cervix like cervixitis , cervical erosion &
cervical cancer.

For clinical aspect:


1/3 placenta preavia

1/3 abruptio placenta

1/3 incidental & whole % is 1-1,5 per l00 pregnancy

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Khalil.A.A

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