ANTEPARTUM HAEMORHAGE

Ooi Say Ting MBBS 2007/2012

Antepartum Hemorrhage (APH)

Bleeding from genital tract between period of fetal viability to the onset of labour Fetal viable (22 weeks onward) An important contributor to perinatal & maternal deaths

Causes of APH
Placental causes -placenta praevia -abruptio placentae -vasa praevia Preterm labour Local causes -polyps, cervicitis, cervical carcinoma, vaginal trauma or vaginal infection Indeterminate hemorrhage Others: uterine rupture

What you must do?

Initial evaluation: Bleeding profusely? Life threatening- Mama 1st
Assess ABCDE and resuscitation 2 large bore IV line
+ cross match, Hb estimation, coagulation profile (platelet, fibrinogen [serum] , PT, APTT) + immediate fluid resuscitation

Prepare 4 unit of blood CVL or Swan-Ganz catheter for fluid replacement, right atrial pressure, pulmonary artery pressure, pulmonary capillary and sampling of mixed venous blood for oxygen sampling

As the patient stable, check for causes of bleeding Monitor vital sign Also CTG for uterine contraction and fetal heart rate for fetal well being and exclude labour

Exclude placenta praevia by ultrasound 1st

Pelvic examination with sterile speculum to look for local causes (don t forget medical causes of bleeding disorder and also preterm labour)

Placenta Praevia

Placenta Previae (PP)

20% of APH During pregnancy, the placenta moves as the uterus stretches and grows. In early pregnancy, a low-lying placenta is very common. But as the pregnancy progresses, the growing uterus should "pull" the placenta resolved toward the top of the uterus. By the third trimester, 90% of these placenta should be near the top of the uterus, leaving the opening of the cervix clear for the delivery. However, complete placenta praevia less likely to resolve. placenta remains in the lower portion of the uterus, partly or completely covering this opening. This is called a previa. complication of pregnancy in which the placenta grows in the lower part of the uterus and covers all or part of the cervical os.

Types of PP
Type 1 : just encroaches onto lower segment Type 2 : extended to margin of internal os, in this case, it can be futhur devided into anterior(a) and posterior(b) Type 3 : partially covers cervical os Type 4 : totally covers cervical os even at full dilatation of cervix
Minor PP

Major PP

Risk factors of PP
Multiple gestation Uterine scar due to caeserean section, myomectomy, previous dilatation & curettage Smoking Previous PP Old age(3 times greater in women over 30 years of age than in women under 20 years of age) assisted reproductive technology, such as in-vitro fertilization.

Symptoms of PP
Painless per vaginal bleeding (70% PP) Severe bleeding Asymptomatic : (10% PP)- ultrasonographic diagnosis

Signs of PP
Abdomen: soft, non tender, fetal parts easily felt Malpresentation:tranverse lie, oblique lie Signs of hypovolaemic shock: increased pulse rate, hypotension, signs of peripheral vasoconstriction.

 Ultrasonography: when placenta praevia diagnosed at 2nd trimester, a repeat scan at 30 weeks for follow-up evaluation. Transabdominal ultrasound (95%) miss in posterior or low fetal vertex Transvaginal ultrasound

Complications of PP
Maternal
Rebleeding Massive APH DIC Caesarean section Postpartum haemorrhage (lower segment contract less well) Placenta accreta (10% PP) Massive transfusion and its complication Maternal death

Complications of PP (cont.)
Fetal
Prematurity Asphyxia Malformations IUGR Malpresentation

Management of PP
Aim: 1st Mama health 2nd obtain fetal maturity BLEEDING

Severe

Not severe

Resuscitation

Fetus mature (37th week with lung maturity)

Fetus not mature

Emergency Caesarean section (for maternal in 1st place)

Caesarean section

Mc Cafee regime Admit to ward Close observation 2 units of grouped & cross-matched blood Elective Caesarean section when fetus mature

Management of PP
Vaginal delivery is possible if Minor PP and no further episodes of PV bleeding Anteriorly placed minor PP
In posteriorly placed, fetal head can t descent into pelvis -> compress placenta -> asphyxia

Anticipate for PPH

Abruptio Placentae (AP)

Uterine bleeding in to decidua basilis causing haematoma. Follow by premature separation of a normally sited placenta. Causing more bleed Compress and destroy placenta 3 types: Revealed : blood tracks down the uterus between membranes and uterine wall Concealed : blood remains in uterine cavity Couvelair uterus: blood force into uterine muscle into peritoneal cavity (bluish colour)

Revealed AP

Concealed AP

Grading of AP
Grade 0 : asymptomatic diagnosed after deliver placenta (depress area at placenta or organised clot) Grade 1 : vaginal bleeding(mild), uterine tetany, tenderness Grade 2 : vaginal bleeding(moderate),moderate to severe uterine tenderness with tetanic contraction, fetal distress Grade 3 : persistent abdominal pain, maternal shock, fetal demise, marked uterine tetany with board-like rigidity, hypofibrinoegn, coagulation defects, and may have heavy vaginal bleeding

Risk factors of AP
Hypertension
Multiparity Direct trauma to uterus(road accident, ECV) Sudden decompression(after delivery of 1st twin, release of liquor in polyhydramnios) Uterine over-distension(polyhydramnios and multiple gestation) Short umbilical cord Folate dificiency Smoking Cocaine abuse Previous AP

Symptoms of AP
Important to differentiate with PP (AP is clinical diagnosis) Pain, hyperactive uterine contraction, increase tone( tetanic more than 5 contractions per 10 minutes) Bleeding per vagina (in revealed AP) Difficult to appreciate fetal movement

Signs of AP
Clinical evidences of shock e.g. restlessness, pallor, cold and clammy extremities BP elevated initially, then hypotension Abdominal examination: woody hardness (tense and tender), uterus larger than POG, difficult to feel fetal parts, difficult to hear fetal heart beats

Complications of AP
DIVC : due to consumption of fibrin, clotting factors and platlets, resulting in continued bleeding and furthur depletion of these factors Hypovolaemic shock Acute ranal failure Intrauterine death (IUD) IUGR Preterm labour

Investigations of AP
Ultrasound
retro-placental clot Detect only 2%

Full blood count and DIVC screening Urine microscopy examination check UTI Diagnosis of AP is clinical -inspection of placenta after the 3rd stage of labour is complete. Amniotomy : blood stained amniotic fluid CTG abnormalities

Management of AP
(maternal safety is compromise!!!)

Immediate delivery & emptying of uterus irrespective of the maturity

of the uterus:

Steps:
Resuscitation and assessment of the coagulation status, DIVC screening. Monitor urinary output Ultrasound examination to check viability of fetus, (if alive) plus CTG tracing to look out for fetal distress Intensive continuous monitoring mother and foetus VE -> favourable the cervix -> immediate delivery

If fetus is:
Alive, not in labour: emergency caesarean section Distressed: Immediate caesarean section/ ventouse/ forceps delivery Dead: Artificial rupture of the membranes + syntocinon to augment the labour BUT DO NOT PROLONG LABOUR if cervix is unfavourable and labour may be prolonged => Immediate caesarean section (to prevent DIVC & PPH) Do not use tocolytic. Uterine tone must be maintain after deliver.

Indeterminate Hemorrhage (IH)

ORIGIN Bleeding due to marginal separation of a normally sited placenta leading to a reduced functional reserved. COMING INTO DIAGNOSIS Painless per vaginal bleeding where placenta is in the upper segment Amount of bleeding is not profuse Clinical assessment : fetal parts easily palpable and fetal heart sound easily heard. Speculum examination No abruption or local lesion Ultrasound to access the site of placenta FBC, CTG examination PROGNOSIS Good prognosis for fetus and mother