Petro Mulder

24/ 10/ 2012

Bleeding from genital tract from 24 weeks till term GA of 24 weeks = 500 grams average

•3 – 5 % of pregnancies

•3 x more in Multiparous > Nulliparous

•Maternal deaths due to APH: 67 % avoidable deaths

BENIGN:

*HEAVY “SHOW” – most common

PATHOLOGICAL:

*ABRUPTIO PLACENTAE: 1/ 100

*PLACENTAE PRAEVIA: 1/ 200

*VASA PRAEVIA: 1/ 2000-3000

*UTERINE RUPTURE: ≤ 1 % in scarred uteri

NON-OBSTETRIC CAUSES: *BLEEDING FROM LOWER GENITAL TRACT *CERVICAL: -ectropion -polyps -cervicitis/ infection - Cervical CA *VAGINAL: -infection -neoplasm -trauma -varices *BLEEDING DISORDERS -rare, 1/ 10 000 *UNKNOWN ORIGIN -in 40 % of APH cases no definite cause identified -diagnosis of exclusion

*GIT – BLEEDING: -hemorrhoids -inflammatory bowel disease -neoplasm *URINARY TRACT - BLEEDING: -infection -stones -neoplasm

DEFINITION:

IMPLANTATION OF PLACENTA (PARTIALLY / COMPLETELY) IN LOWER SEGMENT OF UTERUS

ETIOLOGY:

-NO DEFINITE CAUSE

-ENDOMETRIAL FACTORS:

Uterine scarring

Excessive / repeated curettage

Congenital uterine abnormalities

-PLACENTAL FACTORS

Placentomegaly

Abnormal formation of placenta

-CONCEPTUS RELATED FACTORS

Delay in development/ maturation of fertilized ovum

•MULTIPARITY > NULLIPARITY

•AMA

•PRIOR UTERINE SURGERY: C-section, Myomectomy

•PREVIOUS PLACENTA PRAEVIA

•UTERINE MALFORMATION

•ART (ASSISTED REPRODUCTIVE TECHNIQUES)

*GRADE I:

PLACENTA ENCROACHES ON LOWER SEGMENT, BUT DOES NOT REACH THE INTERNAL CERVICAL OS

*GRADE II:

PLACENTA REACHES INTERNAL OS, BUT DOES NOT COVER IT

*GRADE III:

PLACENTA PARTIALLY COVERS INTERNAL OS

*GRADE IV:

PLACENTA COMPLETELY COVERS INTERNAL CERVICAL OS, EVEN WHEN CERVIX DILATED

CLASSICAL: CONTEMPO-RARY:

ULTRA-SOUND:

TYPE I MARGINAL

TYPE II LATERAL MINOR

TYPE III

TYPE IV CENTRAL MAJOR

•PAINLESS PV BLEEDING •ABDOMINAL EXAM: -uterus soft, not tender/ irritable -contractions present/ absent -presenting part not engaged/ high -abnormal/ unstable lie •MATERNAL CVS COMPROMISE •FETAL COMPROMISE •NO PV EXAM ALLOWED!

MATERNAL COMPLICATIONS:

•MAJOR APH, SHOCK, DEATH

•PPH

•ANEMIA DUE TO CHRONIC HEMORRHAGE

•RH-SENSITIZATION

•COAGULOPATHY/ DIC

•MORBIDLY ADHERENT PLACENTA:

PLACENTA ACCRETA OCCURS IN 10 % OF PLACENTA PRAEVIA

FOETAL COMPLICATIONS:

*PREMATURITY

*ABRUPTIO PLACENTAE

*FETAL INSULT:

-HIE

-CP

*IUD

DEFINITION:

PREMATURE SEPERATION OF PLACENTA FROM UTERINE WALL, WITH OR WITHOUT PV BLEEDING, IN A VIABLE GESTATION

TYPES OF ABRUPTIO PLACENTAE:

•CONSEALED

•REVEALED

•MIXTURE

PATHOLOGY:

*HEMORRHAGE INTO DECIDUA BASALIS

*SPLITTING OF DECIDUA

*HEMATOMA OF DECIDUA

*SEPERATION, COMPRESSION & DESTRUCTION OF ADJACENT PLACENTA

RISK FACTORS: *AMA *↑ PARITY *VASCULAR DISEASE: -HYPERTENSIVE DISEASE IN PREGN, PET, SLE, APLS *MECHANICAL FACTORS: -TRAUMA, SUDDEN DECOMPRESSION (MULTIPLES, POLYHYDRAMNIOS) *SMOKING *DRUGS: -COCAINE *FIBROIDS/ MYOMAS *PROM *AORTA-CAVAL COMPRESSION SYNDROME

*PV BLEEDING & PAIN

*CONTINIOUS PAIN, NOT ALLEVIATED BETWEEN CONTRACTIONS

1. MILD TYPE:

*ABRUPTIO ≤ 1/3

•PV BLEEDING PRESENT/ ABSENT

2. SEVERE TYPE:

*ABRUPTION > 1/3

*LARGE RETROPLACENTAL HEMATOMA

*PV BLEEDING & PERSISTENT ABDOMINAL PAIN

*”WOODY”HARD UTERUS WITH PAIN & TENDERNESS

*FHR-CHANGES (CTG-pattern)

*MATERNAL HYPOVOLEMIC/ HEMORRHAGIC SHOCK

MATERNAL COMPLICATIONS:

*HYPOVOLEMIC/ HEMORRHAGIC SHOCK

*PPH

*COAGULOPATHY/ DIC

*AMNIOTIC FLUID EMBOLISM

*RH-SENSITIZATION

*ORGAN SYSTEM DYSFUNCTION/ FAILURE

-ATN

-SHEEHAN SYNDROME

*DEATH

FETAL COMPLICATIONS:

*PREMATURITY

*IUGR IN CHRONIC ABRUPTIO

*HIE & CP

*FETAL DEATH

*CLINICAL DIAGNOSIS

*ULTRASOUND:

-EXCLUDE PLACENTA PRAEVIA

-FETAL VIABILITY

-RETROPLACENTAL HEMATOMA

*CTG:

-BRADYCARDIA/ TACHYCARDIA

-SINUSOIDAL PATTERN

*LABORATORY TESTS:

-CONSUMPTIVE COAGULOPATHY: PLATELETS, CLOTTING PROFILE

-LFT, RFT

DEFINITION:

FETAL BLOODVESSELS FROM CORD/ PLACENTA RUN IN THE MEMBRANES

*ROM → RUPTURE OF FETAL BLOODVESSELS IN MEMBRANES → EXSANGUINATION → FETAL DEATH

*HIGH FETAL MORTALITY (50 – 75 %)

RISK FACTORS FOR VASA PRAEVIA:

1. ECCENTRIC/ VELAMENTOUS CORD INSERTION

2. SUCCENTURIATE LOBE/ BI-LOBAR PLACENTA

3. MULTIPLES

4. PLACENTA PRAEVIA

5. ART (ASSISTED REPRODUCTIVE TECHNIQUES)

6. PREVIOUS UTERINE SURGERY / CURETTAGE

*MODERATE PV BLEEDING & FETAL DISTRESS (TACHY/ BRADY)

*VESSELS MAY BE VISIBLE/ PALPABLE THROUGH DILATED CERVIX

*VESSELS VISIBLE ON ULTRASOUND TVS (COLOUR DOPPLER)

*DEFINITIVE DIAGNOSIS BASED ON DETECTING FETAL BLOOD:

-FETAL HEMOGLOBIN (KLEIHAUER-BETKE TEST)

-FETAL RBC’s (NUCLEATED)

SCAR DEHISCENCE:

*MEMBRANES INTACT OVER SCAR, FETUS NOT IN PERITONEAL CAVITY

*SEPERATION LIMITED TO OLD/ PREVIOUS SCAR (FENESTRATION = WINDOW), INTACT OVERLYING PERITONEUM

*USUALLY NOT FETAL DISTRESS/ SEVERE MATERNAL BLEEDING

RUPTURE:

*SEPERATION OF SCAR

*EXTENSION OF SCAR

*ROM WITH EXTRUSION OF FETUS INTO ABDOMINAL CAVITY

*SEVERE MATERNAL HEMORRHAGE & FETAL DISTRESS

*FETAL MORTALITY 35 – 50 %

1. PREVIOUS UTERINE SURGERY

2. GRANDE MULTIPARA

3. NON-JUDISCIOUS USE OF OXYTOTICS & PROSTAGLANDINS

4. SHOULDER DYSTOCIA

5. FORCEPS

6. TRAUMA

7. UTERINE ABNORMALITIES

MATERNAL:

-HIGH INDEX OF SUSPICION

-PV BLEEDING ANTE-OR INTRA-PARTUM

-MATERNAL HYPOVOLEMIC/ HEMORRHAGIC SHOCK

FETAL:

-FETAL DISTRESS (CTG-CHANGES)

-STATION OF HEAD & APPLICATION “REGRESSES”, CERVICAL DILATATION “REVERSES”

-DISPLACEMENT OF CERVIX

-FETAL PARTS PALPABLE THROUGH ABDOMINAL WALL

MATERNAL:

-HEMORRHAGE

-BLADDER RUPTURE

-PPH

-COAGULOPATHY

-DEATH

FETAL:

-RESPIRATORY DISTRESS

-HIE/ CP

-ASPHYXIA

-DEATH

ABRUPTIO PRAEVIA RUPTURE

ABD. PAIN PRESENT ABSENT PRO-GRESSIVE

PV BLEEDING OLD/ FRESH

FRESH FRESH

DIC COMMON RARE RARE

ACUTE FETAL DISTRESS

COMMON RARE COMMON