antepartum hemorrhage

AntePartumHaemorrhage
(APH)
It is genital tract bleeding after 24 weeks of pregnancy and before delivery of baby. (Bleeding in the 3rd TM )
Incidence ;3% of all pregnancies.
Causes:
A. Placental causes
Placenta praevia (1%)
Abru ptio placentae (placental abruption) 1%
Vasa praevia
B. Local cause in the vagina and cervix
? Cervicitis
? Cervical carcinoma
? Vaginal trauma
? Vaginal infection
? Cervical ectropion
C. Other causes is PTL and ruptured uterus

How to reach a dx:
History:how much bleeding, triggering factors, associated pain or contraction,fetal movement, last cervical smere.
Examination :pulse, BP,is the uterus soft or tender , fetal heart auscultation ,CTG, speculum vaginal exam after exclusion of pp.
Investigation:full blood count, coagulation screen, cross 6 units of blood,U\S.

Placenta praevia
Placenta praevia: A placenta that has implanted into the lower segment of the uterus.
( The lower segment can be defined as that part of the uterine wall used to be the isthmus before pregnancy, and within 8 cm of the internal cervical os at term )
It can be classified as either major in which the placenta covering the internal cervical os or minor when the placenta is sited within the lower segment of uterus, but does not cover the internal os, replacing the old classification.
The main risk factors are increasing age and parity ,previous uterine surgery), prior P.P (4-8% recurrence rate) ,assisted conception and structural uterine anomalies.
In women with previous C/S the placenta may implant and thus invades into the previous scar and called morbidly adherent placenta and there are 3 types:
1-placenta accreta: placenta adherent to the uterine wall.
2-placenta increta :placenta invading the uterine wall.
3- placenta percreta : placenta invading through the uterine wall.

Old classification of pp


Diagnoses:
clinical presentation:
1- Recurrent episodes of painless bright red vaginal bleeding. Mean GA at presentation is 30 wks
2- Asymptomatic (10% of cases of P.P are diagnosed incidentally by U/S)
3-A persistent malpresentation or high head in late pregnancy after 37 weeks.
4-pp may present as placental abruption.
The uterus is soft and non tender, the digital exam is contra indicated.
Diagnosis is almost exclusively done by U/S whether abdominal or vaginal U/S
An ultrasound scan will show the position of the placenta clearly within the uterus. If the placenta lies in the anterior part of the uterus and reaches into the area covered by the bladder, it is known as a low-lying placenta (before 24 weeks) and placenta praevia after 24 weeks.

Management:
1- Admit to hospital, ABC.
2- Insert a broad-bore i.v. cannula and start an infusion of normal saline if shocked patient and arrange for emergency C/S
3- Take blood for cross-matching and haemoglobin estimation.
4- Avoid all digital vaginal examinations.
5- Perform ultrasound as soon as possible to identify the cause of bleeding.
6- Cross-matched blood should be kept permanently available.
7-pationt should be admitted for observation and not allowed home until at least 24 hrs has passed without further bleeding .those pts with major pp who had recurrent bleeding should be admitted as in patients from 34 weeks. If the woman is anaemic and no longer bleeding and the baby is <37 weeks then she should be transfused aiming for a haemoglobin of >10.5g/dl. This can be repeated as necessary until the baby reaches maturity when delivery should be by Caesarean Section. Don’t forget steroid and anti –D.
8- At 36–37 weeks’ presentation, a final ultrasound should be performed and acted upon:
(a) major placenta praevia should have a Caesarean section between 37 and 38 weeks’ gestation by an experienced obstetrician
(b) Regarding the low lying placenta (placental margin within 2 cm from internal os) it is safe to wait until labour vaginal delivery is not contraindicated unless there is vaginal bleeding à( C/S).
AS ARULE, the GOAL is to obtain fetal maturation without compromising the mother health, delivery indicated If GA is reaching 37-38 weeks ,massive bleeding > 1500 ml and continuing significant bleeding .
If bleeding is severe the delivery by emergency C/S regardless of GA ( don’t forget preparation of 4-6 units of blood)
If the bleeding is not profuse ( or small repetitive attacks) the expectant management is the rule until 36-37 weeks (anemia should be corrected if present) then deliver by elective C/S after checking the fetal lung maturity.


COMPLICATIONS AND PROGNOSIS:
MATERNAL
1-The major cause of death in women with placenta praevia now is postpartum haemorrhage (PPH). PPH is common because the lower segment does not contract and retract as in the upper segment. This may lead to an emergency hysterectomy if the bleeding cannot be stopped
2-Antepartum and intrapartum bleeding is constant threat to the woman
3-DIC
4-Another risk is the placenta accreta, increta or percreta ( adherent placenta) which require cesarean hysterectomy.
FETAL
Bleeding from placenta praevia is maternal in origin.
The risks to the fetus are prematurity, malpresentation and abnormal lie

Placental abruption
It is a premature separation of the placenta leading to bleeding from the placental bed of a normally sited placenta. It can be revealed or concealed.
Aetiology and risk factors:
The causes of abruption are not known but the following factors are associated:
1-Proteinuric maternal hypertension ,fetal growth restriction, due to defective trophoblast invasion.
2-Multiparity
3-Trauma. ECV and seat belt injuries (rarely).
4-Overstretched uterus (polyhydramnios, multiple pregnancy) at the time that the membranes rupture (sudden decompression).
5-Previous placental abruption.
6-PROM
7-Smoking, cocaine use, alcohol and folate deficiency
8-anticoagulant therapy.



Diagnoses
clinical presentation
1- MAJOR ABRUPTION
Women present with abdominal pain and vaginal bleeding. The blood loss that is visible (revealed haemorrhage) is often less than the degree of shock. (present with varying degree of shock).
On examination:
1 The uterus is woody hard; due to tonic contraction.
2 tender uterus
3 The fetal parts cannot be felt.
4 fetal movement may be decreased or the fetus may be dead.
5 CTG may demonstrate a non reassuring or abnormal FHR pattern.
2- MINOR ABRUPTION
Minor abruptions are often not diagnosed until after delivery. They may present with:
• Mild abdominal pain associated with uterine tightening (contractions).
• APH.
• There may be uterine tenderness.
Occasionally U\S demonstrate the presence of retroplacental clots but it is un reliable diagnostic tool.

Management
Major placental abruption is a life-threatening condition for both the mother and the baby.
If the fetus is still alive:
• ABC: Insert two large-bore i.v. cannulae and infusion of normal saline/colloid.
• Send blood for cross-match of 4 units, haemoglobin and coagulation studies.
• Immediate Caesarean section if necessary to save the baby’s life
• there is high risk of postpartum haemorrhage (BE CAREFUL).
• Adequate fluid replacement following the Caesarean section.
• Monitor urine output
If the fetus is dead, then the woman should be allowed to deliver vaginallyvitally stable .
This usually happens rapidly (within 4–6 hours) as the abruption stimulates labour.
If not in labour induce it if not contraindicated.
C/S if there is obstetrical indication
• Epidural analgesia is contraindicated because of the risk of coagulopathy If a coagulopathy has developed or the woman starts to bleed, she should be managed in conjunction with a consultant haematologist.
(a) Give fresh frozen plasma.
(b) Ask the blood bank to get 6 units of platelets ready.
The consumptive coagulopathy begins to improve immediately after uterine evacuation and resolve within 4–6 hours of delivery of the placenta.

Complications and effects of placental abruption
1-Hypovolemic shock :There is a tendency to under estimate the blood loss either due to concealed hge or in cases of hypertension. Central venous pressure monitoring is helpful in blood loss assessment and accurate fluid replacement.
2-DIC
3-Acute renal failure:secondary to poor renal perfusion,hypovolemia ,hypotension and DIC.the prognoses is excellent.
4-fetomaternal hge: which is imp in Rh negative pts.so we should do a kelihauer test.
5-perinatal mortality:influenced by size of abruption , interval to delivery,GA and other associations like FGR or PE.
6-FGR: in cases of recurrent chronic abruption.

Vasa praevia
It is acondition when fetal vessels traverse the fetal membranes over the internal cervical os.
? It is usually suspected when either spontaneous or artificial rupture of membrane accompanied by painless fresh vaginal bleeding from rupture of the fetal vessels ,so the lost blood is fetal in origin and the fetus can rapidly exsanguinate ; so should be managed immediately once suspected by emergency C\S if the baby still alive.