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Antepartum Hemorrhage Abdulah Al-Tayyem;MD;JBOG Consultant Ob&Gyn Urogynaecology Zarka Govern. Hospital.

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Presentation on theme: "Antepartum Hemorrhage Abdulah Al-Tayyem;MD;JBOG Consultant Ob&Gyn Urogynaecology Zarka Govern. Hospital."— Presentation transcript:

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2 Antepartum Hemorrhage Abdulah Al-Tayyem;MD;JBOG Consultant Ob&Gyn Urogynaecology Zarka Govern. Hospital

3 Definition: Definition: APH is bleeding from or within the genital tract after 24 W of gestation. APH is bleeding from or within the genital tract after 24 W of gestation.Causes: Placenta previa the most common causes Placenta previa the most common causes Abruptio placentae Abruptio placentae Rupture uterus Rupture uterus Local causes: trauma,infection,tumors. Local causes: trauma,infection,tumors. Vasa previa Vasa previa

4 Placenta previa Is the implantation of the placenta in the lower uterine segment with different grades of encroachment on the cervix. Is the implantation of the placenta in the lower uterine segment with different grades of encroachment on the cervix. Bleeding is: -painless Bleeding is: -painless -causless -causless

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6 classification

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8 7 APH Per vaginam blood loss >15 ml after 20 weeks ’ gestation Per vaginam blood loss >15 ml after 20 weeks ’ gestation 5% of all pregnancies 5% of all pregnancies Accounts for % of perinatal mortality Accounts for % of perinatal mortality

9 8 Severity of bleeding Volume Estimate Percent of circularity volume Type 500 ml or > 10-15%compensated ml 15-25%mild ml 25-35%moderate ml 35-50% Severe (shock)

10 Abruptio Placentae Is premature separation of a normally implanted placenta, may be precipitated by a sudden increase in blood pressure or trauma Is premature separation of a normally implanted placenta, may be precipitated by a sudden increase in blood pressure or trauma Fetal parts are difficult to feel. Fetal parts are difficult to feel. Feta heart sound may be absent Feta heart sound may be absent Sings of hypovolemia Sings of hypovolemia Coagulopathies occur in 30% of cases Coagulopathies occur in 30% of cases

11 Diagnosis History: 1. Present obstetric history 2. Symptoms of hypovolemia 3. Symptoms of pre-eclampsia 4. Lower abdominal pain or colic 5. The presence or absence of fetal movements 6. History of ROM or labour pains 7. Previous uterine operations 8. History of sexual intercourse before onset of bleeding 9. History of trauma or recent surgery

12 Physical examination General examination:-tachycardia,hypotenstion General examination:-tachycardia,hypotenstion -sings of shock -sings of shock -lower limb edema. -lower limb edema. Abdominal examination: -abdominal tinderness,or rigidity Abdominal examination: -abdominal tinderness,or rigidity -fundable level -fundable level -FHS -FHS -consistency of the uterus ز -consistency of the uterus ز Pelvic examination: Pelvic examination: -Don not perform a digital vaginal examination at this stage. -Don not perform a digital vaginal examination at this stage. -Inspect the external genitalia and vagina for: -Inspect the external genitalia and vagina for: -amount of blood loss -amount of blood loss -sings of trauma or infection. -sings of trauma or infection.

13 Investigations Laboratory investigations: Laboratory investigations: - ABO blood group and Rh type - ABO blood group and Rh type -Crossmatch at 2 units of blood -Crossmatch at 2 units of blood -CBC -CBC -Fibrinogen, PTT, PT,CT -Fibrinogen, PTT, PT,CT -Serume creatinine or BUN -Serume creatinine or BUN -Urine analysis for protein and RBCs -Urine analysis for protein and RBCs

14 Perform a transvaginal ultrasound scan on all women in whom a low-lying placenta is suspected from their transabdominal anomaly scan (at approximately 20–24 weeks) to reduce the numbers of those for whom follow-up will be needed. Perform a transvaginal ultrasound scan on all women in whom a low-lying placenta is suspected from their transabdominal anomaly scan (at approximately 20–24 weeks) to reduce the numbers of those for whom follow-up will be needed. Transvaginal ultrasound is safe in the presence of placenta praevia and is more accurate than transabdominal ultrasound in locating the placenta. Transvaginal ultrasound is safe in the presence of placenta praevia and is more accurate than transabdominal ultrasound in locating the placenta.

15 Ultrasound Confirm the fetal viability Confirm the fetal viability Localize the site of placenta,and its relation to the cervix Localize the site of placenta,and its relation to the cervix Estimating the gestational age Estimating the gestational age Detecting the presence of retroplacental hematoma Detecting the presence of retroplacental hematoma In case of sever bleeding, do not wait for an US examination.Begin first aid management and the quickly start active management. In case of sever bleeding, do not wait for an US examination.Begin first aid management and the quickly start active management. Even if the amount of bleeding is mild NEVER perform PV examination until placenta previa has been excluded by US Even if the amount of bleeding is mild NEVER perform PV examination until placenta previa has been excluded by US

16 Diagnosis of Antepatrm Hemorrhage Painless vaginal bleeding after 24w.? Painless vaginal bleeding after 24w.? Symptoms and sings: Symptoms and sings: -shock -bleeding may be precipitated by intercourse -shock -bleeding may be precipitated by intercourse -relaxed uterus -normal fetal condition -relaxed uterus -normal fetal condition -fetal presentation not in the pelvis/ lower uterine pole feels empty. -fetal presentation not in the pelvis/ lower uterine pole feels empty. Dg: Placenta previa Dg: Placenta previa

17 Vaginal bleeding after 24 w,intermitent,or constant abdominal pain? Vaginal bleeding after 24 w,intermitent,or constant abdominal pain? Symptoms and sings: Symptoms and sings: -Shock -tense/tender uterus -Shock -tense/tender uterus -decreased /absent fetal movements. -decreased /absent fetal movements. -fetal distress/absent fetal heart sound. -fetal distress/absent fetal heart sound. Dg: Abruptio placentae. Dg: Abruptio placentae. ( R/O co-exciting PIH) ( R/O co-exciting PIH)

18 Bleeding(intra-abdominal and/or vaginal)? Bleeding(intra-abdominal and/or vaginal)? Sever abdominal pain(may decreas after rupture)? Sever abdominal pain(may decreas after rupture)? Previous uterine scar? Previous uterine scar? - shock -abdominal distention/free fluid. - shock -abdominal distention/free fluid. -abnormal uterine contour -tender abdomin -abnormal uterine contour -tender abdomin -easily palpable fetal parts -rapid maternal puls -easily palpable fetal parts -rapid maternal puls -absent fetal movements and FHS -absent fetal movements and FHS Dg: Ruptured uterus Dg: Ruptured uterus

19 Mild vaginal bleeding after 24 w(mild)? Mild vaginal bleeding after 24 w(mild)? Symptoms and sings: Symptoms and sings: -clinically stable -clinically stable -fetal assessment showed fetal distress -fetal assessment showed fetal distress that can not be explained by the mild bleeding. that can not be explained by the mild bleeding. Dg : Vasa previa Dg : Vasa previa

20 Complications of placenta previa -shock -shock -postpartum hemorrhage -postpartum hemorrhage - Women with placenta previa are at high risk for PPH and placenta accreta/increta; a common finding is at the site of a previous cesarean section a common finding is at the site of a previous cesarean section

21 Complications of abruptio placentae Maternal shock Maternal shock Fetal death Fetal death Uterine atony Uterine atony Amniotic fluid embolism Amniotic fluid embolism Caogulopathy( 30%) Caogulopathy( 30%) Renal failure Renal failure The principal cause of maternal death is renal failure due to prolonged hypotension. The principal cause of maternal death is renal failure due to prolonged hypotension. Don not underestimate the amount of the hemorrhage Don not underestimate the amount of the hemorrhage

22 Management General rules: General rules: -call for help -keep women NPO -call for help -keep women NPO -remember that mother and the neonate -remember that mother and the neonate require evaluation and intervention if needed require evaluation and intervention if needed

23 First aid management Insert 2 wide bore cannulae Insert 2 wide bore cannulae Blood for CBC,crossmatch Blood for CBC,crossmatch Immediately star iv crystalloid solutions Immediately star iv crystalloid solutions Provide 100% oxygen via mask Provide 100% oxygen via mask Warm the women Warm the women Insert Foley catheter Insert Foley catheter Monitor blood pressure and pulse/ 5 min Monitor blood pressure and pulse/ 5 min Monitor urine output /hour Monitor urine output /hour

24 Indications of when to terminate pregnancy Women in labour Women in labour Bleeding is heavy(evidente or hidden) manifested by shock Bleeding is heavy(evidente or hidden) manifested by shock Gestational age equals or more 37 w Gestational age equals or more 37 w There is fetal distress There is fetal distress There is IUFD and /or fatal congenital anomalies by US There is IUFD and /or fatal congenital anomalies by US

25 When to use conservative management Bleeding is light or has stopped AND Bleeding is light or has stopped AND The fetus is alive AND The fetus is alive AND The fetus is premature. The fetus is premature. Cases of abruptio placentae which are diagnosed only on US examination, with no clinical finding( no bleeding, no shock, no tender or tonically contracted uterus) Cases of abruptio placentae which are diagnosed only on US examination, with no clinical finding( no bleeding, no shock, no tender or tonically contracted uterus)

26 In abruptio placentae: When the clinical diagnosis is clear When the clinical diagnosis is clear Or in the presence of acute fetal distress: …. Do not waste your time for US examination. Or in the presence of acute fetal distress: …. Do not waste your time for US examination. US is neither sensitive nor specific diagnosis modality in abruptio placentae US is neither sensitive nor specific diagnosis modality in abruptio placentae

27 Monitoring during hospital say Check pulse every 3o min/2h, then hourly/6h, then every 4 h. Check pulse every 3o min/2h, then hourly/6h, then every 4 h. Perform gentle uterine massage/30 min Perform gentle uterine massage/30 min APH predispose for PPH APH predispose for PPH Check for vaginal bleeding Check for vaginal bleeding Check urine output/ 2h Check urine output/ 2h

28 Conditions that should be met before discharge No active bleeding No active bleeding No fever No fever Open bowel Open bowel Stable general condition Stable general condition Satisfactory urine output Satisfactory urine output No wound complications No wound complications

29 28 Placental migration Bleeding C/Section Expectant management Management of Placenta praevia in a Pregnancy of viable gestational age Fetal distress Bleeding Fetal lung maturity Sono assessment q 3-4 weeks Complete resolution Trial of labor (low-lying only) Double set-up Trial of labor

30 29 Comparison of presentation of abruption v. praevia v. rupture Abruptio n PraeviaRupture Abdomin al pain YesNovariable Vaginal bleeding Old dark FreshFresh DICCommonRareRare Fetal distress CommonRareCommon

31 Associated with velamentous insertion of the umbilical cord (1% of deliveries) Associated with velamentous insertion of the umbilical cord (1% of deliveries) Bleeding occurs with rupture of the amniotic membranes (the umbilical vessels are only supported by amnion Bleeding occurs with rupture of the amniotic membranes (the umbilical vessels are only supported by amnion Bleeding is FETAL (not maternal as with placenta praevia) Bleeding is FETAL (not maternal as with placenta praevia) Fetal death may occur with trivial symptoms Fetal death may occur with trivial symptoms

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33 Comparison of presentation of abruption v. praevia v. rupture Abruptio n PraeviaRupture Abdomin al pain YesNovariable Vaginal bleeding Old dark FreshFresh DICCommonRareRare Fetal distress CommonRareCommon


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