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

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

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

classification

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APH Per vaginam blood loss >15 ml after 20 weeks’ gestation 5% of all pregnancies Accounts for 20 -25% of perinatal mortality 7

Severity of bleeding Volume Estimate Percent of circularity volume Type 500 ml or > 10-15% compensated 1000-1500 ml 15-25% mild 1500-2000 ml 25-35% moderate 2000-3000 ml 35-50% Severe (shock) 8

Abruptio Placentae 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. Feta heart sound may be absent Sings of hypovolemia Coagulopathies occur in 30% of cases

Diagnosis History: Present obstetric history Symptoms of hypovolemia Symptoms of pre-eclampsia Lower abdominal pain or colic The presence or absence of fetal movements History of ROM or labour pains Previous uterine operations History of sexual intercourse before onset of bleeding History of trauma or recent surgery

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

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

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.

Ultrasound Confirm the fetal viability Localize the site of placenta,and its relation to the cervix Estimating the gestational age 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 . Even if the amount of bleeding is mild NEVER perform PV examination until placenta previa has been excluded by US

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

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

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

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

Complications of placenta previa -shock -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

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

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

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

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

When to use conservative management Bleeding is light or has stopped AND The fetus is alive AND 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)

In abruptio placentae: When the clinical diagnosis is clear 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

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

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

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

Comparison of presentation of abruption v. praevia v. rupture Abdominal pain Yes No variable Vaginal bleeding Old dark Fresh DIC Common Rare Fetal distress 29

Associated with velamentous insertion of the 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 is FETAL (not maternal as with placenta praevia) Fetal death may occur with trivial symptoms

Examination of the placenta showed a velamentous insertion of the umbilical cord and a lacerated fetal vessel as a result of spontaneous rupture of the membranes. In this case, the unprotected fetal vessels passed over the cervical os, a vasa previa. 31 31

Comparison of presentation of abruption v. praevia v. rupture Abdominal pain Yes No variable Vaginal bleeding Old dark Fresh DIC Common Rare Fetal distress