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Definition Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 22 weeks (>500g) of pregnancy and prior to the birth of the baby. complicates 3–5% of pregnancies leading cause of perinatal and maternal mortality worldwide. Up to one-fifth of very preterm babies are born in association with APH Most of the time unpredictable. RCOG
SeverityNO consistent definitions of the severity of APH.It is recognised that the amount of blood lost is often underestimated .The amount of blood coming from the introitus may not represent the total blood lost (for example in a concealed placental abruption).It is important to assess for signs of clinical shock. The presence of fetal compromise or fetal demise is an important indicator of volume depletion. RCOG Guidelines
Different terminologies used: Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection Minor haemorrhage – blood loss less than 50 ml that has settled Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock Massive haemorrhage – blood loss greater than 1000 ml and/or signs of clinical shock. Recurrent APH - > one episode RCOG Guidelines
Etiology Placenta praevia Abruptio placenta Vasa praevia Excessive show Local causes ( bleeding from cervix, vagina and vulva ) Inderterminate APH
Placenta Praevia (PP) Implantation of placenta over or near the internal os of cervix. Confirm diagnosis of PP can be done at 28 weeks when LUS forming.Leading cause of vaginal bleeding in the 2nd and 3rd trimester.
Risk Factors of Placenta Praevia Previous placenta praevia (4-8%) Previous caesarean sections ( risk with numbers of c-section) Previous termination of pregnancy Multiparity Advanced maternal age (>40 years) Multiple pregnancy Smoking Deficient endometrium due to presence or history of: - uterine scar -endometritis -manual removal of placenta - curettage -submucous fibroid Assisted conception RCOG
Clinical classification Minor : Deliver vaginally Type 1 Posterior > likelihood of Type 1 (anterior/posterior) fetal distress Type 2 anterior Major: Caesarean section Type 2 posterior (dangerous type) Type 2 posterior > Type 3 chance of fetal distress Type 3 & 4 anterior –cut Type 4 through placenta to deliver. Hence need to be fast and efficient.
Abruptio Placenta (AP) Separation of normally located placenta after 22 weeks of gestation ( > 500g) and prior to delivery of fetus.
Risk factors:- Previous history of AP- Maternal hypertension- Advanced maternal age- Trauma ( domestic violence, accident, fall)- Smoking/alcohol/cocaine- Short umbilical cord- Sudden decompression of uterus ( PROM/delivery of 1st twins)- Retroplacental fibroids- Idiopathic
Obstetrics Emergency!!Diagnosed CLINICALLY : Painful vaginal bleeding -80% Tense and tender abdomen/back pain (70%) Fetal distress( 60%) Abnormal uterine contractions (hypertonic and high frequency) Preterm labour ( 25%) Fetal death ( 15%)Ultrasound is NOT USEFUL to diagnose AP. Retroplacental clots (hyperechoic) easily missed. Obstetrics today
Vasa Praevia (VP) Rupture of fetal vessels that run in membrane below fetal presenting part which is unsupported by placenta/ umbilical cord. Predisposing Factors:-Velamentous insertion of the umbilical cord-Accesory placental lobes-Multiple gestations Obstetrics today
The term velamentousinsertion is used todescribe the condition inwhich the umbilical cordinserts on thechorioamnioticmembranes rather than onthe placental mass.
Diagnosis of VP Antenatal diagnosis –reduced perinatal mortality and morbidity. Painless vaginal bleeding at the time of spontaneous rupture of membrane or post amniotomy Fetal bradycardia Fetal shock or death can occur rapidly at the time of diagnosis due to blood loss constitutes a major bulk of blood volume is fetus ( 3kg fetus-300ml) Hence, ALWAYS check the fetal heart after rupture of membrane or amniotomy. Definitive diagnosis by inspecting the placenta and fetal membrane after delivery. Obstetrics today
Complications of APHMaternal complications Fetal complicationsAnaemia Fetal hypoxiaInfection Small for gestational age and fetal growth restrictionMaternal shock Prematurity (iatrogenic and spontaneous)Renal tubular necrosis Fetal deathConsumptive coagulopathyPostpartum haemorrhageProlonged hospital stayPsychological sequelaeComplications of blood transfusion RCOG Guidelines
Clinical assessment in APH First and foremost Mother and fetal well being (mother is the priority) establish whether urgent intervention is required to manage maternal or fetal compromise. Assess the extent of vaginal bleeding, cardiovascular condition of the mother Assess fetal wellbeing.
Full HistoryShould be taken after the mother is stable. associated pain with the haemorrhage?Continuous pain : Placental abruption.Intermittent pain : Labour. Risk factors for abruption and placenta praevia should be identified. reduced fetal movements? If the APH is associated with spontaneous or iatrogenic rupture of the fetal membranes : ruptured vasa praevia Previous cervical smear history possibility of Ca cervix. Symptomatic pregnant women usually present with APH (mostly postcoital) or vaginal discharge.
Examination General: PULSE & BP ( a MUST!) Abdomen:- The tense, tender or ‘woody’ feel to the uterus indicates a significant abruption.- Painless bleeding, high fetal presenting part – Placenta praevia- soft, non-tender uterus may suggest a lower genital tract cause or bleeding from placenta or vasa praevia.
Examination Speculum :-identify cervical dilatation or visualise a lower genital tract cause. Digital vaginal examination- Should NOT be done until Placenta Praevia has been excluded by USG. RCOG Guidelines
Investigations FBC Coagulation profile Blood Grouping and CXM, GSH. Ultrasound- TRO PP/ IUD D-dimer : AP colour doppler TVS – VP In all women who are RhD-negative, a Kleihauer test should be performed to quantify FMH to gauge the dose of anti-D Ig required.Fetal monitoring: CTG monitoring RCOG Guidelines
Management WHEN to admit? Based on individual assessment-Discharge after reassurance and counsellingWomen presenting with spotting who are no longer bleeding and where placenta praevia has been Excluded.However, a woman with spotting + previous IUD due to placenta abruption, an admission would be appropriate.- All women with APH heavier than spotting and women with ongoing bleeding should remain in hospital at least until the bleeding has stopped.
Management If preterm delivery is anticipated, a single course of antenatal corticosteroids ( dexamethasone 12mg 12 hourly ,2 doses) to women between 24 and 34 weeks 6 days of gestation. Tocolytics should NOT be given unless for VERY preterm women who need time to transfer to hospital with NICU. For very preterm ( 24-26 weeks) ,-conservative management if mother is stable .-Delivery of fetus – life threatening At these gestations, experienced neonatologists should be involved in the counselling of the woman and her partner RCOG
ManagementFor Placenta Praevia Conservative – MaCafee’s regime( premature < 37 weeks;mother haemodynamically stable,no active bleeding, fetus stable)-advise bed rest, keep pad chart, vital signs monitoring , Ultrasound, steroids, GSH, Daily CTG and biophysical profile, fetal movement count. Plan for delivery ( >37 weeks)Crossmatch 4 units of blood.
Definitive treatment Type I,II(ant) Type II( post), III,IV ARM +/- oxytocin Caesarean sectionSatisfactory progresswithout bleeding Bleeding continues Caesarean sectionVaginal delivery
For Abruptio placenta,(obsemergency) ICU admission : Close monitoring and resuscitation!- ABC ( high flow O2, aggressive fluid resuscitation)- Continuous Vital signs monitoring and urine output- Monitor vaginal bleeding – strict pad chart- Continuous CTG for fetal heart rate- Crossmatch 4 units of blood- FFP – coagulopathy- Dexamethasone – preterm
Abruptio PlacentaDecide Mode of delivery Vaginal delivery – when fetal death Caesarean section –if maternal/ fetal health compromised- Indicated when early DIC sets in- Consent should be taken for hysterectomy in case bleeding could not be controlled. Obstetrics today
Management For Rh negative mothers,Anti-D Ig should be given to all after any presentation with APH, independent of whether routine antenatal prophylactic anti-D has been administered.In the non-sensitised RhD-negative woman for all events after 20 weeks of gestation, at least 500 iuanti-D Ig should be given followed by a test to identify FMH, if greater than 4 ml red blood cells; additionalanti-D Ig should be given as required. RCOG Guidelines