Antepartum Hemorrhage

Antepartum Haemorrhage andPostpartum HaemorrhageDr Dalia JuneenathSt 302/09/2015

Bleeding In PregnancyBleeding in early PregnancyAntepartum haemorrhage (APH)Post partum Haemorrhage (PPH)Antepartum HaemorrhageAntepartum haemorrhage (APH) is bleeding from or into the genital tract occurring from 24 weeks pregnancy and prior to birth of the baby .

Epidemiology Affects 3-5% of all pregnancies 3 times more common in multiparous

3PLACENTAL

Placental AbruptionPlacenta PreviaUTERINE

RuptureScar dehiscenceLOCALVulval varicositiesVaginitisCervical erosion/Ca/ trauma/polyp

FETALVasa previa4Placental abruption Premature separation of a normally situated placenta in a viable fetus

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Revealed abruption

Concealed abruption6Risk factorsAbruption in previous pregnancyIncreased age and parityFetal growth restrictionVascular diseases: preeclampsia, maternal hypertension, renal disease,SLE and APSMechanical factors: Trauma, intercourse Sudden decompression of uterus Polyhydramnios, Multiple pregnancy 6. Smoking, cocaine use, 7. Uterine myoma8. Premature rupture of membranes/intrauterine infection9. Maternal thrombophilias7Placenta praevia

Insertion of the placenta, partially or fully, in the lower segment of the uterus

Risk factors for Placenta praeviaPrevious placenta praeviaPrevious LSCS or other uterine surgeryPrevious termination of pregnancyMultiparityAdvanced maternal ageMultiple pregnancySmokingAssisted conception9Grades of Placenta praevia

Grade I: Placenta encroaches lower segment but does not reach the cervical osGrade II: Reaches cervical os but does not cover itGrade III: Covers part of the cervical osGrade IV: Completely covers the os, even when the cervix is dilated

10SymptomsPain+/- bleeding FMPainless bleeding- often heavyMaternal signsUterine tenderness +/-contractionsShockNo Contractions

Fetal signs

Distress/deathNormal lie,+-engagedUsually normal FHAbnormal lie, unengaged,USS

Normally situated placentaLow lying placenta.AbruptionPraevia11

Vasa praevia

Fetal blood vessels from the placenta or umbilical cord cross the internal os beneath the babyHigh fetal mortality (50-75%)

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Eccentric (velamentous) cord insertion

130.04% of deliveries.

Risk factors

Prior C/S: up to 0.5%Prior uterine surgery.Hyperstimulation with oxytocin.TraumaParity > 4Forceps delivery (especially mid forceps).Breech version or extraction

Rupture of UterusRupture of UterusUterine scar dehiscence:Fetal membranes remain intact, fetus not extruded intraperitoneally, separation limited to old scar, peritoneum overlying is intactUsually no fetal distress / maternal HemorrhageUterine rupture: Separation of scar extension, rupture of fetal membranes with extrusionFetal distress / maternal hemorrhageMaternal mortalityFetal mortality = 35%

15Rupture of Uterus

16OBSTETRIC HAEMORRHAGEManagementASSESSMENTConservative DeliveryPostpartum?Prevention

Management of APH

AdmitAirway, breathing and circulationSenior staff must be involvedTwo wide bore canula Bloods for FBC , coagulation profile,Liver & renal function, Group and save/crossmatchVolume lost replaced by Crystalloid/colloid until blood is available

Severe bleeding or fetal distress: Urgent delivery of baby irrespective of gestational ageFetal monitoringRhesus negative woman- kleihauer test and prophylactic anti-D immunoglobulin

For pre-term delivery when immediate delivery is not necessary, maternal steroids

18Placental abruption Management Small abruption - Conservative management depending on gestational age - Careful monitoring of fetal condition

Moderate or severe placental abruption: - Restore blood loss - Prevent coagulopathy - Monitor urinary output - Delivery 1.Caesarean section 2.Vaginal If coagulopathy present If fetus is not compromised If fetus is dead

Placenta praevia - Management1.Near term / Term- Delivery is considered Grades I and II - May be able to deliver vaginally Grades III and IV - LSCS by senior obstetrician

Should anticipate PPH

2.Early in pregnancyContinuation of pregnancy better if possible 4 pint of crossed matched blood should be available till delivery Fetal well being and growth monitored fbc,CTG,USS

Postpartum HemorrhageDefinitionPRIMARY PPH-Blood loss of more than 500 ml within 24 hours of delivery(1000ml LSCS)SECONDAY PPH- bleeding after 24 hours and 6 weeks of deliverySeen in ~5% of deliveries.

PREVENTIONActive Management of Third stage : reduces PPH by 60%

22Risk FactorsPrenatalPre-eclampsia Previous postpartum hemorrhagePrevious C/S Multiple gestationMultiparity

Intrapartum Delivery by LSCSProlonged labourInduction of labour Operative vaginal deliveryRetained placentaEpisiotomy/Lacerations

Most patients with hemorrhage have none23Initial AssessmentIdentify possible cause of post partum hemorrhage.Simultaneous evaluation and treatment. Call for help.Remember ABCs.Use O2 4L/min.two 16g or 14g IVs.Catheterise

ALSOs 4 TsTone (Uterine tone)Tissue (Retained tissue--placenta)Trauma (Lacerations and uterine rupture)Thrombin (Bleeding disorders)25Management of Uterine AtonyMEDICAL1. Oxytocin promotes rhythmic contractions.2. ergometrine 3. Hemabate

SURGICALBalloon tamponadeHemostatic brace suturing(B-Lynch)Bilateral ligation uterine artery/ Internal Iliac arteriesSelective arterial embolisation

Hysterectomy sooner than later!

26Tissue: Retained placentaDelay of placental delivery > 30 minutes seen in ~ 6% of deliveries.Prior retained placenta increases risk.Risk increased with: prior C/S, curettage p-pregnancy, uterine infection, increased parity.

Occasionally succenturiate lobe left behind.

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Abnormal implantation28Trauma (3rd T)EpisiotomyHematomaUterine inversionUterine rupture29Vulvar hematoma

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Uterine RuptureWhen recognized, get help.ABCs.IV fluids.Surgical correction.Thrombin (4th T)Coagulopathies are rare.Suspect if oozing from puncture sites noted.Work up with platelets, PT, PTT, fibrinogen level, fibrin split products, and possibly antithrombin III.

Secondary PPHAssociated with endometritisTreat with antibioticsSurgical method if heavy/ USS indicativeThank You