ANTEPARTUM HAEMORRHAGE

Posted: July 15, 2010 by gerardloh in O & G

ANTEPARTUM  HAEMORRHAGE

Definition

n      Bleeding from the genital tract in pregnancy before the onset of labour at gestations of 22 weeks or beyond

Etiology

n      Placenta causes: Placenta Praevia, Placenta Abruption, Vasa Praevia

n      Local causes: cervical polyps, cervicitis, vaginitis, cervical cancer

Placenta Praevia

n      Definition :- Placenta that is implanted partly or entirely in the lower uterine segment.

Grades

n      Type I : Low placental implantation but the lower edge does not reach the internal cervical os.

n      Type II : The lower placental edge reaches the internal cervical os but does not cover it.

n      Type III : The placenta completely covers the internal os     when the cervix is closed, but only partially covers when the cervix is dilated.

n      Type IV : The placenta covers the internal os when the cervix is either closed or dilated.

Grades:Minor I –II a-anterior

Major IIb-posterior, III, IV

Risk Factors

Previous placenta praevia,caesarean section or abortion.

Previous pregnancies, esp. a large number of closely spaced pregnancies, are at higher risk.

Women younger than 20 & women older than 30 are at increasing risk as they get older.

Women with a large placentae from twins or erythroblastosis

Smoking or cocaine usage

Placenta accreta (adhere), increta (invade), percreta( penetrate through myometrium)

Assisted conception

Uterine structure abnormality

Placenta Abruption

Definition :- Premature separation of normally situated placenta from its uterine attachment prior to 3rd stage of labor.

Risk Factors

q     Pre-eclampsia

q     Abdominal trauma

q     Abruptio in previous pregnancy (10 fold increased risk)

q     Multiparity

q     multiple gestation (over distention of uterus)

q     Cord traction

q     Smoking

q     Sudden decompression of the uterus

q     Maternal Substance Abuse (Cocaine, alcohol)

q     Maternal Tobacco abuse (2 fold increased risk)

q     Polyhydramnios

Differences between placenta praevia and placenta abruptio

placenta praevia placenta abruptio
Pain painless painful
Uterus Soft, non tender Tense, tender, irritable,

hard ly palpate fetal parts

Fetal position Not engagement, malpresentation Normal, head maybe engaged
Fetal heart Usually normal Absent or abnormal
A/w pre-eclampsia N0 Yes
Haemodynamic signs Proportional Signs of hypovolaemic shock with increase pulse rate, hypotension, and peripheral vasoconstriction.

To access the patientHistory and General Examination

1.History

n      Severity of the bleeding

n      Time of onset

n      Any provoking factors

n      Associated with pain/uterine activity

n      H(x) of ruptured membranes

n      Previous episodes

n      Fetal movement

n      Cervical smear h(x)

n      Review of previous ultrasound report

2.Resuscitation Measures

n      2 IV access

n      Crystalloid / Colloid

n      CBD

n      IO chart

n      GXM

Parameter Explanation & reason
1 Quick but thorough history
2 Vital signs Estimate blood loss (BP,Pulse)
3 Palpate abdomen uterine size, activity, tenderness, presenting, part, lie
4 Ultrasonograpy -fetus viability

-fetus abnormality

-location of placenta

-adequacy of the liquor

-growth parameters

5 CTG and fetal heart monitoring Determines fetal well-being.
6 No Vaginal examination ONLY After exclude placenta Praevia first by US !!!

Investigations

  • FBC Check haemoglobin level to rule out anaemia and maintain haemoglobin level above 10g/dL
  • Coagulation Profile :APTT,Serum fibrinogen,PT

Check for any bleeding tendency in this patient due impaired coagulation.

  • UFEME
  • BUSE

Conservative Management

Admit ( according to RCOG is 28weeks)

Monitor BP & Pulse rate

Pad chart

Minimise abdominal examination

Appropriate investigations are done – FBC & GXM/GSH ( 2units)

Monitor fetal well being

– Fetal kick chart(daily)

– CTG (weekly)

– U/S ( forthnightly)

Steroid injection(> 24w, <36w)- IM dexamethasone12mg stat and repeat the second dose after 12 hours.

Any symptoms or signs of labour

  • * Placenta Praevia – must deliver by 38 weeks. If baby is dead, do not perform Caesarean section, instead induce & augment labour
  • Placenta abruptio- must deliver  as soon as possible (within 2 hour)

In severe AP or when got DIVC, transfuse DIVC regime

DIVC regime:       4 units FFP

6 units cryoprecipitate

2 units platelet concentrate

Management (PA)

1.Resuscitation Measures

Complications on the Mother

q     hypovolaemic shock

q     disseminated intravascular coagulation(DIC)

q     Acute renal failure

q     Postpartum hemorrhage

– Couvelaire uterus

-Bleeding into myometrium results in hypotonic wall

-Risk of Postpartum Hemorrhage

q     Feto-maternal hemorrhage

q     Maternal mortality

q     Recurrence risk higher

q     Amniotic fluid embolism

Complications on the Fetus

q     Perinatal mortality-influenced by size of abruption, interval to delivery, gestational age at which the abruption and delivery have occurred, others factors (growth retardation related to poor placentation)

q     Intrauterine growth restriction

q     Preterm birth

q     Low birth weight

Vasa praevia

-In a normal gestational sac, the umbilical cord is inserted into the middle of the placenta and entirely enclosed in the amniotic sac.

-Velamentous insertion means that the cord is inserted on the amniotic membrane rather than on the placenta with blood vessels stretching along the membrane between the insertion point and the placenta.

  • occur when the fetal vessels run in the membranes below the presenting fetal part, unsupported by placental tissue or umbilical cord at the cervical opening
  • Spontaneous or artificial rupture of membranes often leads rupture of these vessels with likely resultant fetal exsanguination (reported fetal mortality 33-100%).
  • -Must be suspected when APH occurs in a woman especially if,bleed is a bright red trickle .
    -fetal heart shows sudden tachycardia or sudden deceleration (even persistent bradycardia!) and the fetal distress appears disproportionate to the relatively ‘little’ bleed
    -occurs just after ARM
  • Antenatal diagnosis can be made using transvaginal sonography in combination with color Doppler.

Indeterminate APHdiagnosis by exclusion of PP, PA, lesion and trauma of genital tract.

Comments
  1. a_ghaus says:

    thanks. i was looking out what is DIVC regime and here i found one. HO Msia Boleh!

  2. Mat Merboki says:

    i thinks the definition of APH started after 24weeks of POA and beyond it….not 22 weeks…

    • Jien says:

      it depends on which country you are looking at. different places has different definition for it. for some places is 20 weeks and beyond.

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