ANTEPARTUM HEMORRHAGE (APH) PRESENTER:JOY WILLIAMS 19TH/04/2010

INTRODUCTION APH is defined as vaginal bleeding occuring once d fetus has reached viability ie. >24 wks gestation to delivery of d fetus. It is one of the most ominous complications of pregnancy. It is one of the three leading causes of maternal death and a major cause of perinatal morbidity and mortality in the U.S. Differentiation must be made between obstetric and non–obstetrics causes of bleeding. Placenta praevia n abruption fa=orm over 50% of all causes of APH.

AETIOLOGY OBSTETRICS -bloody show -placenta abruption -placenta praevia -vasa praevia -DIC -uterine rupture -marginal sinus bleed NON-OBSTETRICS -cervical cancer or dysplasia -cervicitis -cervical eversion -cervical polyps -vaginal laceration -vaginitis

PLACENTA ABRUPTION Premature separation from the site of uterine implantation before delivery of the fetus. Two types (a) concealed (b) external 30% antepartum hemorrhage is due to placental separation usually the first hemorrhage is seen after the 26th week 50% occur before the onset of labour and 10-15% are not diagnosed before the second stage of labour.

ETIOLOGY Predisposing factors: previous placental separation, hypertensive states of pregnancy, advanced maternal age, multiparity, uterine distension, vascular disease, thrombophilias, uterine anomalies or tumors, cigarette smoking, alcohol consumption (>14 drinks per week), cocaine use and possibly maternal type O blood.

ETIOLOGY Precipitating factors: circumvallate placenta, trauma, sudden reduction of uterine volume, abnormally short cord, increase venous pressure

PATHOPHYSIOLOGY AND PATHOLOGY Local vascular injury that results in vascular rupture into the decidua basalis, bleeding and hematoma formation, the hematoma shears off adjacent denuded vessels, producing further bleeding and enlargement of the area of separation Due to an abrupt rise in uterine venous pressure transmitted to the intervillous space leads to engorgement of the venous bed and separation of all or part of the placenta

CLINICAL FINDINGS Larger separations are accompanied by abdominal pain, uterine irritability, hemorrhage may be visible or concealed. If the process is extensive, evidence of fetal distress, uterine tetany, DIC, hypovolemic shock may be seen. Increased uterine tonus and frequency of contractions may provide early clues of abruption, most times patients present with vaginal bleeding

LABORATORY FBC Blood group, cross-match Peripheral blood smear shows reduced platelet counts, presence of schistocytes, fibrinogen depletion with release of fibrin split products Prothrombin time, PTT, platelet count, fibrinogen and fibrin split products- help determine coagulation status

IMAGING U/S may be helpful in diagnosing placental abruption but it is inconclusive. Possible findings are hyperechoeic foci posterior to the placenta suggests fresh blood or a hypoechoeic area suggests a formed clot

TREATMENT Expectant management in placental abruption is the exception and not the rule. Appropriate when the mother is stable, fetus immature and fetal heart tracing is reassuring. Continous fetal and uterine monitoring should be done. Emergency measures, most cases are diagnosed during labour or delivery. Hemorrhage, fetal distress and uterine spasm. Blood should be collected and @ least 4 units of PRBC typed and crossed. Two large bore IV cannulas SHOULD BE PLACED AND CRYSTALLOIDS ADMINISTERED.

TREATMENT Vaginal delivery is indicated if the degree of separation appears to be limited and if continuous FHR is reassuring. When the separation is extensive but the fetus is dead, vaginal delivery is indicated. It is contraindicated when there is massive hemorrhage and operative delivery is necessary to save mother or fetus

TREATMENT Cesarean section is done when vaginal delivery is not imminent for a fetus with a reasonable chance of survival with persistent evidence of distress. It is also indicated when the fetus is in good condition but the situation is not favourable for rapid delivery in d face of progression or severe placental separation Maternal indications are uncontrollable hemorrhage, rapidly expanding uterus with concealed hemorrhage with or without live fetus

COMPLICATIONS Desseminated intravascular coagulation(DIC) Renal tubular and cortical necrosis Uterine atony

PROGNOSIS External or concealed hemorrhage, excessive blood loss, shock, nulliparity, closed cervix, absence of labor and delayed diagnosis and treatment are unfavourable Maternal mortality ranges from 0.5-5%, most die from hemorrhage(immediate or delayed), cardiac or renal failure Perinatal mortality rate is approx 5%, liveborn infants have a high morbidity rate due to predelivery hypoxia,birth trauma and hazards of prematurity

PLACENTA PREVIA The placenta is implanted in the lower uterine segment within the zone of effacement and dilatation of cervix leads to an obstruction to the descent of the presenting part. Classified into: -(a) marginal -(b) partial -(c) complete

ETIOLOGY Multiparity, advancing age, previous C/S, scarred or poorly vascularized endometrium in the corpus, large placenta, succenturiate lobe, multiple gestation. Bleeding in placenta praevia is due to (a)mechanical separation from its implantation site during formation of the lower uterine segment or during effacement and cervical dilatation (b)placentitis (c) rupture of poorly supported venous lakes in d decidua basalis that have been engorged with venous blood

DIAGNOSIS Every patient suspected to have placenta previa should be hospitalized and cross match blood @ hand. Vaginal and rectal examination should not be performed to avoid hemorrhage 95% are diagnosed via U/S

SYMPTOMS AND SIGNS Painless, sudden and profuse bleeding , bright red clotted blood. Bleeding rarely produces shock. Uterus is soft, relaxed and non-tender High presenting cannot be pressed into the pelvic inlet Infant will pressent in a transverse or oblique in approx 15%

DIFFERENTIAL DIAGNOSIS Placenta abruption Circumvallate placenta

TREATMENT Depends on the amount of uterine bleeding, duration of pregnancy and viability of fetus, degree of placenta previa, presentation, position and station of fetus, gravidity and parity of the patient, status of the cervix and whether or not labour has begun Patient should be admitted and blood should be readily available for transfusion

TREATMENT Expectant therapy because hemorrhage may occur early in pregnancy before pulmonary maturity, transfusions to replace blood loss, use of tocolytic agents to prevent premature labour and prolong pregnancy to about 32-34 weeks C/S is the delivery of choice. Vaginal delivery is usually indicated for marginal placenta previa and when the presentation is cephalic plus there should be constant FHR monitoring any signs of distress do C/S

COMPLICATIONS Maternal: hemorrhage, shock, death, operative trauma, infection and embolism, placenta previa accreta Fetal: prematurity, fetal hemorrhage due to tearing of the placenta occurs with vaginal manipulation and upon entry into the uterine cavity as C/S is done

PROGNOSIS Maternal: due to rapid recourse to C/S, use of banked blood and expertly administered anaesthesia the mortality has fallen to less than 1 in 1000 fetal: perinatal mortality has reduced to approx 1%. Premature labour, placenta abruption, cord accidents and uncontrollable hemorrhage cannot be avoided, can be reduced with ideal obsteric and newborn care

COMPARISON OF HAEMORRAGE FROM P PRAEVIA & ABRUPTION PLACENTA PRAEVIA(PP) PLACENTA ABRUPTION(PA) Painless(80%) Patient is less distressed Soft abdomen Abnormal lie & presentation CTG usually normal No particular association with pre-eclampsia No coagulation defect initially Painful Patient is distressed Tender, tense abdomen Normal lie & presentation Abnormal CTG likely May be associated with pre-eclampsia Coagulation defect may occur early

UTERINE RUPTURE Tearing of d uterus occurs most commonly in association with a previous scar on d uterus. Major cause of maternal death Two types: -(a) complete: traumatic and spontaneous -(b) incomplete

RISK FACTORS Hysterotomy Trauma Uterine over-distension Uterine anomalies Placenta percreta Invasive mole Choriocarcinoma Neglected obstructed labour Improper use of oxytocin

CLINICAL FINDINGS Fetal heart rate abnormalities Increased suprapubic pain and tenderness with labour Sudden cessation of uterine contractions with a tearing sensation Vaginal bleeding or bloody urine Recession of the fetal presenting part

TREATMENT Prepare the patient for URGENT C/S Control of maternal haemorrage

COMPLICATIONS Haemorrage Shock Postoperative infection Bladder or ureteral damage Thrombophlebitis Amniotic fluid embolus DIC Pituitary failure Death

PREVENTION Identify patients @ risk of uterine rupture Early diagnosis of abnormal presentation Correct administering of oxytocin during labour Good obstetric assessment and technique Correct use of partograph

PROGNOSIS Maternal mortality rate is 4.2% Perinatal mortality rate is 46%

VASA PRAEVIA Is d term used where umbilical cord vessels abnormally transverse d membranes n overlie d internal cervical os. Occurs in 1 in 3000 pregnancies. Is associated with either a velamentous insertion of d cord into d placenta(from d side) or with a succenturiate(satellite or accessory) lobe of d placenta. D vessels are at risk of tearing wen dey are stretched during cervical dilatation in labor or amniotomy.

Fetal mortality from vasa praevia is 35-95%, there is no significant risk to d mother. Diagnosis must, therefore, be suspected clinically by a combination of relatively small volume bld loss(<500ml), no maternal pain n an abnormal CTG, oft following ARM. May also be diagnosed antenatally on ultrasound with demonstration of doppler flow in d vessels beneath d fetus.

TREATMENT Immediate CS performed Transfusion of d neonate.

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