Engidaw Ambelu

1. Antepartal hemorrhage (APH)
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For yr 2 anesthesia student
by Dr Abebe Chanie

2. Objectives
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 At the end of this session students will able to;
 define APH
 List differential diagnosis of APH
 Define AP &PP
 List risk factors for AP&PP
 Describe principle of mgt of APH

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Obstetric hrrge along with HTN and infection as
one of the infamous triads maternal death .
o Leading cause of ICU admission
o 12% maternal death
o Most important cause of maternal death world
wide and responsible for half of all postpartal
death

4. APH
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• Definition; Vaginal bleeding after 28 wks of
pregnancy but before delivery of the fetus
• The 1st and 2nd stage of labor included
Incidence is 3-4%

5. Causes of APH
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o Abruptio placenta 40% of APH (1:80 pregnancies)
o placenta pravia 20% (1:200 pregnancies)
o Indeterminate APH or APH of UK origin (uncertain, unclassified)
35-50% of APH
o Local causes
• Cervicitis
• Cervical polyp or Ca
• Vulvar or vaginal varices
• Hematuria & rectal bleeding
• Heavy show
• Vasa praevia
• Marginal sinus rupture
• Circumvallate placenta
• Abnormal clotting mechanism

6. ■ Placental Abruption
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 Separation of the placenta—either partially or
totally—from its implantation site before
delivery is described by the Latin term
abruptio placentae
 premature separation of the normally
implanted placenta is most descriptive
because it excludes separation of a placenta
previa implanted over the internal cervical os.

7. Etiopathogenesis
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1. Rupture of decidual spiral arterioles
2. initiated by hemorrhage into the decidua
basalis
3. The decidua then splits
4. Decidual hematoma expands and cause
compression of adjacent placenta and further
split

8. Can be
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1. Revealed or
external ;
bleeding
typically
insinuates itself
between the
membranes and
uterus,
ultimately
escaping through
the cervix to
vagina
2.Concealed ; the
blood is retained
between the
detached
placenta and the
uterus

9. Risk factors
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 Prior abruption
 Increased age and parity
 Preeclampsia
 Chronic hypertension
 Chorioamnionitis
 Preterm ruptured membranes
 Multi fetal gestation
 Low birth weight
 Hydramnios
 Cigarette smoking
 Thrombophilias
 Cocaine use
 Uterine leiomyoma

10. Clinical Findings and Diagnosis
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• Most women present ;with sudden-onset abdominal
pain, vaginal bleeding, and uterine tenderness
• Vaginal bleeding (>80 percent of patients)
• Abdominal pain (>50 percent)
• Uterine contractions
• Uterine tenderness
• Non reassuring FHR tracing
 Fetal death
 DIC (concealed)
• The amount of vaginal bleeding does not correlate well with the extent
of maternal hemorrhage and cannot be used to gauge the severity of
abruption

11. Grading of placental abruption
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 Grade 1: A mild abruption
characterized by;
 slight vaginal bleeding and minimal uterine
irritability
 Maternal blood pressure and fibrinogen levels
are unaffected,and
 the fetal heart rate pattern is normal
 40 percent of placental abruptions are grade
1.

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Grade 2: A partial abruption
mild to moderate vaginal bleeding
signifi cant uterine irritability or contractions
Maternal blood pressure is maintained, but
the pulse is often elevated and postural blood
volume deficits may be present
The fibrinogen level may be decreased
the fetal heart rate often shows signs of fetal
compromise
account for 45 percent of all placental abruptions.

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Grade 3: A large or complete abruption
moderate to severe vaginal bleeding or
occult uterine bleeding with painful,
uterine contractions
 Maternal hypotension and coagulopathy
are frequently present along with fetal death
Accounts 15 percent of placental abruptions
Grade 0 ;a retrospective diagnosis of abruptio
placentae

14. Complications
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 Hypovolemic Shock Placental abruption is one
of several notable obstetrical entities that may
be complicated by massive and sometimes
torrential hemorrhage
 Consumptive Coagulopathy placental
abruption and amnionic-fluid embolism—led to
the defibrination syndrome, which is
referred to as consumptive coagulopathy or
disseminated intravascular coagulation

15. complication
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• FM hemorrhage
• uteroplacental apoplexy (couvelaire Ux)
extravasation of blood into the ux myometrium
red to purple discoloration of the serosal
surface
• Fibrin deposits to small vessels, hypoxic
damage to organs - - corpulmonale
• sheehan’s syndrome
• acute renal & tubular necrosis
• Fetal hypoxia &IUFD, IUGR, prematurity,
• PPH-ux atony

16. Investigations
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Sonography sensitive for about 25% -used to
rule out placental abruption
 Laboratory is not useful in making the
diagnosis but supports a diagnosis of severe
abruption
 Hypofibrinogenemia and evidence of DIC are
supportive of the diagnosis; however, clinical
correlation is necessary.

17. PLACENTAL PREVIA
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 The Latin previa means going before
 the placenta goes before the fetus into the
birth canal.

18. PP
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 Definition; In obstetrics, placenta previa
describes a placenta that is implanted
somewhere in the lower uterine segment, either
over or very near the internal cervical os
Classification
 Placenta previa—the internal os is covered
partially or completely by placenta In the past,
these were either total or partial previa
 Low-lying placenta—implantation in the lower
segment of uterus is such that the placental
edge does not reach the internal os and remains
outside a 2-cm wide perimeter around the os

19. Risk factors
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 Increasing parity
 Increasing maternal age
 Cigarette smoking (2x >non smoker)
 Residence in higher altitude
 Multiple gestations
 Previous placenta previa
 Prior curettage Prior
 cesarean delivery

20. Clinical presentation
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 Painless third-trimester bleeding was a
common presentation for placenta previa in
the past, whereas most cases of placenta
previa are now detected antenatally with
ultrasound before the onset of significant
bleeding
• Sudden, painless, causeless, recurrent
V.bleeding & bright red

21. causes of bleeding
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formation of LUS and cervical dilatation
separation of placenta by trauma
-VE ,coitus ,ECVV/S proportional to blood
loss
• High presenting part or abnormal lie
• Non tender abdomen & normal uterine tone

22. Diagnosis
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 Previa should not be excluded until sonographic
evaluation has clearly proved its absence
 Diagnosis by clinical examination is done using
the double set-up technique but
 digital examination should not be performed
unless delivery is planned
 A cervical digital examination is done with the
woman in an operating room and with
preparations for immediate cesarean delivery.
 Even the gentlest examination cancause
torrential hemorrhage

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 Sonography
Transabdominal sonography is confirmatory an
average accuracy of 96 percent has been
reported
Transvaginal sonography is safe, and the results
are superior
 Magnetic Resonance Imaging not for routine
use but for placenta accreta syndrome

24. Laboratory
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• CBC, Blood group & Rh
• Coagulation profile –PT, PTT, fibrinogen
• Peripheral blood smear

25. Complications
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• Adherent placenta
• IUGR
• Rh sensitization
• Prematurity
• Maternal mortality
• Perinatal mortality
• Infection
• PPH

26. Complications
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 Abnormally Implanted Placenta A frequent and
serious associated with placenta previa arises
from its abnormally firm placental attachment
 because of poorly developed decidua that lines
the lower uterine segment
 Placenta accrete syndromes arise from
abnormal placental implantation and adherence
and are classified according to the depth of
placental ingrowth into the uterine wall. These
include placenta accreta, increta, and percreta

27. Management
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Depends on
• Fetal condition
• Maternal condition
• GA
• Extent of bleeding
• labour
Management Options
• Expectant (conservative)
• Termination (definitive )

28. Basic principles
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• Secure iv line resuscitate with crystalloids
• Admit to the labor and delivery area for
maternal and fetal monitoring
• Monitor maternal v/s, urine output, amount of
bleeding
• Identify underlying cause & Rx causes
• Monitor fetal condition
• Don’t do pelvic examination
• Prepare at least 2 unit of x- mathed blood

29. Termination
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• At or after 37 weeks
• Patient in labor
• Pt in exsanguinated state on admission
• Bleeding is continuing and of moderate degree
• Baby is dead or congenitally deformed

30. Modes of delivery
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placenta praevia
Vaginal –type1 & anterior type2 (marginal)
- If no sever bleeding or fetal distress
CS – type II posterior, III & IV even if no sever
bleeding

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Abruptio placenta
• Vaginal
* Induction by amniotomy
• CS – Unsatisfactory progress of labor
– Worsening complication
– Fetal distress
– Life threatening hemorrhage
– when delay in delivery is likely to seriously
endanger the mother or fetus because of
severe hypertonus, life-threatening
hemorrhage, or disseminated intravascular
coagulation.

32. Expectant management
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• Mother in good health status
• GA <37 weeks
• no active vaginal bleeding
• Good fetal well being
component of expectant management
Bed rest with bathroom privilege
Periodic inspection of vulvar pads
Fetal surveillance
Speculum examination 2-3 day after bleeding stops to
exclude local causes
follow with APH follow up sheet

33. Vasa previa
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• Def- the velamentous insertion of fetal vessels over the
cervical os.
• Fetal vessels lack protection from Wharton's jelly and
are prone to rupture.
• When the vessels rupture, the fetus is at high risk for
exsanguination.
• The overall perinatal mortality is 58 to 73 percent

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• usually presents after rupture of membranes
with the acute onset of vaginal bleeding from a
lacerated fetal vessel.
• If immediate intervention is not provided, fetal
bradycardia and subsequent death occur.
Diagnosis
• By palpation of the fetal vessels within the
membranes during labor
• Acute onset of vaginal bleeding and fetal
bradycardia or death after membrane rupture.
• Sonography and Doppler imaging, antenatally.

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THANK U