Antepartum haemorrhage
Antepartum Haemorrhage
Definition:
Vaginal
bleeding from •
24
weeks of gestation
to
delivery of the baby
The
incidence is 3% •
Causes
Placental
causes:
Most
worrying as potentially the mother
and
/fetus’ life in danger
These
include :
Placental
abruption
Placenta
praevia
Vasa
pravia
LOCAL
CAUSES :
Cervicitis
Cervical
carinoma
Vaginal
trauma or infection
Antipartum
haemorrhage should be taken •
seriously
and any women presenting with
ahistory
of fresh vaginal bleeding must be
investigated
promptly and properly. The
key
question is whether the bleeding is
placental
and compromising the mother
and
/or fetus ,or whether it has aless
significant
cause .
Normally,it
will be obvious from looking at •
a
women whether the situation is in
extremis
or not
A
pale,tachycardiac women looking anoxious with
a
painful,firm abdomen ,clothes soaked in fresh
blood
and reduced fetal movement needs
emergency
assessment and management
.Awomen
has little bleeding with no systemic
signs
or symptoms represent a different end of
spectrum
HISTORY :
How
much the bleeding
? Triggering
factors?
Associated
pain or
contraction?
Is
the baby moving?
Last
cervical smear
(date/normal
or abnormal)?
EXAMINATION:
Pulse
, blood pressure
Is
the uterus soft or tender and
firm?
Fetal
heart auscultation/CTG
Speculum
vaginal examination ,
with
a particular importance
placed
on visualizing the
cervix
(Having
established the placenta
is
not apraevia ,preferably
using
a portable US machine
INVESTIGATION:
Depending
on the degree of
bleeding
, full blood count
,clotting
and if suspected praevia
or
abruption ,cross-match 6 pints
of
blood
US
(fetal size, presentation,
aminotic
fluid, placental position
and
abruption)
Abruptio placenta
It
is premature separation of the
normally
implanted placenta
complicates
0.5 to 1.5percent of all
pregnancies
Predisposing factor:
1.Hypertention
2.Trauma
3.Polyhydromnios
with rapid decompression
on
membrane rupture
4.Tobacco
use
5.Cocaine
use
6.PROM
7.Short
umbilical cord
8.maternal
age >35 y
9.Placenta
previa
10.Poor
nutrition and anemia
Pathophysiology:
Placental
sepeparation is initiated by:
Hemorrhage
into decidua basalis
-----?formation of decidual hematoma------?
the
resulting separation of the decidua from
the
basal plate---?
further
separation and bleeding with
compression
and destruction of placental
tissue
Blood Pathways:?
*concealed
hemorrhage
*revealed
hemorrhage
*Couvelair
uterus
Diagnosis:
Is
clinical diagnosis
Symptoms:
Investigations:draw
blood for
Hb,cross
matching.complete blood
picture
.pcv
Fibrinogen
level
Partial
thromboplastin time
Prothrombin
time
Pelvic
exam
Fetal
monitoring
Benefit
of ultrasonography??
3:
-confirm
-exclude
-finding
co exsiting pathology
Abruptio
placentae Normal fetal ultrasound
Maternal and fetal risks
-fetus
at significant risk of hypoxia
and
death
-mortality
rate 35%,A.p. account for
15%
of stillbirth
-50%have
neurological impairment
_DIC
20%
-hypovolemic
shock
-acute
renal failure and acute
tubular
necrosis
-·
if the site of placental attachment starts to
hemorrhage
after the delivery and loss of
blood
cannot be controlled by other means,
a
hysterectomy (removal of the uterus) may
become
necessary.
Treatment in steps
GENERAL
MEASURES
·
Abruptio placentae is an emergency,
but
there is usually time to obtain advice
by
telephone and arrange safe
transportation
to the hospital. Panic is
not
helpful. If the placenta separation is
slight,
you may be able to return home for
bed
rest and close observation after
examination.
·
Hospitalization required (except for mild
cases).
The mother will be carefully
monitored
for symptoms of shock and
signs
of fetal distress, which include
abnormal
heart rates.
With
careful monitoring of maternal
hemodynamic
status,fetal monitoring
serial
evaluation of hematocrit and
coagulation
profile
Blood
products for replacement should
always
be available
Large
bore i.v line should be secured
Foley’s
catheter for the monitoring of
urine
output
Fluid
resuscitation with ringer
lactate,blood(whole
or packed cells)
Indications
for cesarean
section
in abruptio
placentae
Prognosis
:
Factors
associated with poor prognosis
following
increase the risk for death in
both
the mother and baby:
1.Closed
cervix
2.Delayed
diagnosis and treatment of
placental
abruption
3.Excessive
blood loss, leading
to
shock
4.Hidden
(concealed) uterine bleeding
in
pregnancy
5.No
labor