Antepartum Hemorrhage Antepartum Hemorrhage Abdulah Al-Tayyem;MD;JBOGAbdulah Al-Tayyem;MD;JBOG

Consultant Ob&GynConsultant Ob&Gyn

UrogynaecologyUrogynaecology

Zarka Govern. HospitalZarka Govern. Hospital

DefinitionDefinition::

APH is bleeding from or within the genital APH is bleeding from or within the genital tract after 24 W of gestation tract after 24 W of gestation..

CausesCauses:: Placenta previa Placenta previa the most common causes the most common causes

Abruptio placentaeAbruptio placentae Rupture uterusRupture uterus Local causes: trauma,infection,tumors.Local causes: trauma,infection,tumors. Vasa previaVasa previa

Placenta previaPlacenta previa

Is the implantation of the placenta in the lower Is the implantation of the placenta in the lower uterine segment with different grades of uterine segment with different grades of encroachment on the cervix.encroachment on the cervix.

Bleeding is: -painlessBleeding is: -painless -causless -causless

classificationclassification

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APHAPHPer vaginam blood loss >15 Per vaginam blood loss >15 ml after 20 weeks’ gestationml after 20 weeks’ gestation

5% of all pregnancies5% of all pregnanciesAccounts for 20 -25% of Accounts for 20 -25% of perinatal mortalityperinatal mortality

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Severity of bleedingSeverity of bleeding

Volume Volume EstimateEstimate

Percent of Percent of circularity circularity

volumevolume

TypeType

500500 ml orml or> > 10-15%10-15%compensatedcompensated

1000-15001000-1500 mlml

15-25%15-25%mildmild

1500-20001500-2000 mlml

25-35%25-35%moderatemoderate

2000-30002000-3000 mlml

35-50%35-50%Severe Severe (shock)(shock)

Abruptio PlacentaeAbruptio Placentae

Is premature separation of a normally Is premature separation of a normally implanted placenta, may be implanted placenta, may be precipitated by a sudden increase in precipitated by a sudden increase in blood pressure or trauma blood pressure or trauma

Fetal parts are difficult to feel.Fetal parts are difficult to feel. Feta heart sound may be absentFeta heart sound may be absent Sings of hypovolemia Sings of hypovolemia Coagulopathies occur in 30% of casesCoagulopathies occur in 30% of cases

DiagnosisDiagnosis

History:History:1.1. Present obstetric historyPresent obstetric history

2.2. Symptoms of hypovolemiaSymptoms of hypovolemia

3.3. Symptoms of pre-eclampsiaSymptoms of pre-eclampsia

4.4. Lower abdominal pain or colicLower abdominal pain or colic

5.5. The presence or absence of fetal movementsThe presence or absence of fetal movements

6.6. History of ROM or labour painsHistory of ROM or labour pains

7.7. Previous uterine operationsPrevious uterine operations

8.8. History of sexual intercourse before onset of History of sexual intercourse before onset of bleedingbleeding

9.9. History of trauma or recent surgery History of trauma or recent surgery

Physical examinationPhysical examination General examination:-tachycardia,hypotenstionGeneral examination:-tachycardia,hypotenstion

-sings of shock-sings of shock

-lower limb edema.-lower limb edema. Abdominal examination: -abdominal tinderness,or rigidityAbdominal examination: -abdominal tinderness,or rigidity

-fundable level-fundable level

-FHS-FHS

-consistency of the uterus-consistency of the uterusزز Pelvic examination:Pelvic examination:

-Don not perform a digital vaginal examination at this -Don not perform a digital vaginal examination at this stage.stage.

-Inspect the external genitalia and vagina for:-Inspect the external genitalia and vagina for:

-amount of blood loss-amount of blood loss

-sings of trauma or infection.-sings of trauma or infection.

InvestigationsInvestigations

Laboratory investigations:Laboratory investigations: --ABOABO blood group and Rh typeblood group and Rh type

-Crossmatch at-Crossmatch at 2 units of blood2 units of blood

-CBC -CBC

-Fibrinogen, PTT, PT,CT-Fibrinogen, PTT, PT,CT

-Serume creatinine or BUN-Serume creatinine or BUN

-Urine analysis for protein and RBCs-Urine analysis for protein and RBCs

Perform a transvaginal ultrasound scan on all Perform a transvaginal ultrasound scan on all women in whom a low-lying placenta is women in whom a low-lying placenta is suspected from their transabdominal anomaly suspected from their transabdominal anomaly scan (at approximately 20–24 weeks) to reduce scan (at approximately 20–24 weeks) to reduce the numbers of those for whom follow-up will the numbers of those for whom follow-up will be needed. be needed.

Transvaginal ultrasound is safe in the presence Transvaginal ultrasound is safe in the presence of placenta praevia and is more accurate than of placenta praevia and is more accurate than transabdominal ultrasound in locating the transabdominal ultrasound in locating the placenta. placenta.

UltrasoundUltrasound Confirm the fetal viabilityConfirm the fetal viability Localize the site of placenta,and its relation to the Localize the site of placenta,and its relation to the

cervixcervix Estimating the gestational ageEstimating the gestational age Detecting the presence of retroplacental Detecting the presence of retroplacental

hematoma hematoma In case of sever bleeding, do not wait for an US In case of sever bleeding, do not wait for an US

examination .Begin first aid management and the examination .Begin first aid management and the quickly start active management .quickly start active management .

Even if the amount of bleeding is mild NEVER Even if the amount of bleeding is mild NEVER perform PV examination until placenta previa has perform PV examination until placenta previa has been excluded by US been excluded by US

Diagnosis of Antepatrm HemorrhageDiagnosis of Antepatrm Hemorrhage

Painless vaginal bleedingPainless vaginal bleeding after 24w.?after 24w.? Symptoms and sings: Symptoms and sings:

-shock -bleeding may be precipitated -shock -bleeding may be precipitated by intercourse by intercourse

-relaxed uterus -normal fetal condition-relaxed uterus -normal fetal condition

-fetal presentation not in the pelvis/ lower -fetal presentation not in the pelvis/ lower uterine pole feels empty.uterine pole feels empty.

Dg:Dg: Placenta previaPlacenta previa

VaginalVaginal bleeding after 24 bleeding after 24 w,intermitent,or constant abdominal w,intermitent,or constant abdominal painpain??

Symptoms and sings:Symptoms and sings:

-Shock -tense/tender uterus-Shock -tense/tender uterus

-decreased /absent fetal movements.-decreased /absent fetal movements.

-fetal distress/absent fetal heart sound.-fetal distress/absent fetal heart sound.

Dg: Abruptio placentaeDg: Abruptio placentae..

( R/O co-exciting PIH)( R/O co-exciting PIH)

Bleeding(intra-abdominal and/or Bleeding(intra-abdominal and/or vaginal)?vaginal)?

Sever abdominal pain(may decreas Sever abdominal pain(may decreas after rupture)?after rupture)?

Previous uterine scar?Previous uterine scar?

- shock -abdominal distention/free fluid.- shock -abdominal distention/free fluid.

-abnormal uterine contour -tender -abnormal uterine contour -tender abdominabdomin

-easily palpable fetal parts -rapid maternal -easily palpable fetal parts -rapid maternal pulspuls

-absent fetal movements and FHS-absent fetal movements and FHS

Dg: Ruptured uterusDg: Ruptured uterus

Mild vaginal bleeding after 24 Mild vaginal bleeding after 24 w(mild)?w(mild)?

Symptoms and sings:Symptoms and sings:

-clinically stable-clinically stable

-fetal assessment showed fetal distress-fetal assessment showed fetal distress

that can not be explained by the mild that can not be explained by the mild bleeding.bleeding.

Dg : Vasa previaDg : Vasa previa

Complications of placenta previaComplications of placenta previa

-shock -shock

-postpartum hemorrhage-postpartum hemorrhage - Women with placenta previa are at Women with placenta previa are at

high risk for PPH and placenta high risk for PPH and placenta accreta/increta;accreta/increta;

a common finding is at the site of a a common finding is at the site of a previous cesarean sectionprevious cesarean section

Complications of abruptio placentaeComplications of abruptio placentae

Maternal shockMaternal shock Fetal deathFetal death Uterine atonyUterine atony Amniotic fluid embolismAmniotic fluid embolism Caogulopathy( 30%)Caogulopathy( 30%) Renal failureRenal failure The principal cause of maternal death is The principal cause of maternal death is

renal failure due to prolonged hypotension renal failure due to prolonged hypotension ..

Don not underestimate the amount of the Don not underestimate the amount of the hemorrhagehemorrhage

ManagementManagement

General rulesGeneral rules::

-call for help -keep women NPO-call for help -keep women NPO

-remember that mother and the neonate-remember that mother and the neonate

require evaluation and intervention if require evaluation and intervention if neededneeded

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

Indications of when to terminate Indications of when to terminate pregnancypregnancy

Women in labourWomen in labour Bleeding is heavy(evidente or Bleeding is heavy(evidente or

hidden) manifested by shockhidden) manifested by shock Gestational ageGestational age equals equals or more 37 wor more 37 w There is fetal distressThere is fetal distress There is IUFD and /or fatal congenital There is IUFD and /or fatal congenital

anomalies by US anomalies by US

When to use conservative managementWhen to use conservative management

Bleeding is light or has stopped ANDBleeding is light or has stopped AND The fetus is alive ANDThe fetus is alive AND The fetus is premature.The fetus is premature. Cases of abruptio placentae which Cases of abruptio placentae which

are diagnosed only on US are diagnosed only on US examination, with no clinical examination, with no clinical finding( no bleeding, no shock, no finding( no bleeding, no shock, no tender or tonically contracted uterus)tender or tonically contracted uterus)

In abruptio placentae:In abruptio placentae:

When the clinical diagnosis is clearWhen the clinical diagnosis is clear Or in the presence of acute fetal Or in the presence of acute fetal

distress:…. Do not waste your time distress:…. Do not waste your time for US examination.for US examination.

US is neither sensitive nor specific US is neither sensitive nor specific diagnosis modality in abruptio diagnosis modality in abruptio placentaeplacentae

Monitoring during hospital sayMonitoring during hospital say

Check pulseCheck pulse every 3o min/2h, then every 3o min/2h, then hourly/6h, then every 4 h.hourly/6h, then every 4 h.

Perform gentle uterine massage/30 minPerform gentle uterine massage/30 min

APH predispose for PPHAPH predispose for PPH Check for vaginal bleedingCheck for vaginal bleeding Check urine output/ 2hCheck urine output/ 2h

Conditions that should be met before Conditions that should be met before dischargedischarge

No active bleedingNo active bleeding No feverNo fever Open bowelOpen bowel Stable general conditionStable general condition Satisfactory urine outputSatisfactory urine output No wound complicationsNo wound complications

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Placentalmigration

Bleeding

C/Section

Expectantmanagement

Management of Placenta praevia in a Pregnancy of viable gestational age

Fetal distress

Bleeding

Fetal lung maturity

Sono assessmentq 3-4 weeks

CompleteresolutionTrial of labor

)low-lying only(Double set-up

Trial of labor

+ -

-+

+

-+

- -

++

-

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Comparison of presentation of Comparison of presentation of abruption v. praevia v. ruptureabruption v. praevia v. rupture

AbruptioAbruptionn

PraeviaPraeviaRuptureRupture

AbdominAbdominal painal pain

YesYesNoNovariablevariable

Vaginal Vaginal bleedingbleeding

Old darkOld darkFreshFreshFreshFresh

DICDICCommonCommonRareRareRareRare

Fetal Fetal distressdistress

CommonCommonRareRareCommonCommon

Associated with Associated with velamentousvelamentous insertion of the insertion of the umbilical cord (1% umbilical cord (1% of deliveries)of deliveries)

Bleeding occurs with rupture of the Bleeding occurs with rupture of the amniotic amniotic membranes (the membranes (the umbilical vessels are only umbilical vessels are only supported supported by amnionby amnion

Bleeding is FETAL (not maternal as Bleeding is FETAL (not maternal as with with placenta praevia)placenta praevia)

Fetal death may occur with trivial Fetal death may occur with trivial symptomssymptoms

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Comparison of presentation of Comparison of presentation of abruption v. praevia v. ruptureabruption v. praevia v. rupture

RuptureRupturePraeviaPraeviaAbruptioAbruptionn

variablevariableNoNoYesYesAbdominAbdominal painal pain

FreshFreshFreshFreshOld darkOld darkVaginal Vaginal bleedingbleeding

RareRareRareRareCommonCommonDICDIC

CommonCommonRareRareCommonCommonFetal Fetal distressdistress