ANTEPARTAM ANTEPARTAM HAEMORRHAGEHAEMORRHAGE

IMMEDIATE DELIVERYIMMEDIATE DELIVERY

Significant bleeding from Significant bleeding from

birth canal after 24birth canal after 24thth week week

of gestation till de.of gestation till de.

CAUSESCAUSES

PLACENTALPLACENTAL Placenta PraeviaPlacenta Praevia Placental Placental

AbruptionAbruption Vasa PraeviaVasa Praevia

NON PLACENTALNON PLACENTAL Labour (Heavy show )Labour (Heavy show ) Uterine ruptureUterine rupture Local / Non Local / Non

obstetricalobstetrical Cervicitis Cervicitis Polyp Polyp LacerationsLacerations Bleeding DisordersBleeding Disorders ConginitalConginital acquiredacquired

PLACENTA PRAEVIAPLACENTA PRAEVIA

Implantation ofImplantation of

placenta in lowerplacenta in lower

uterine segmentuterine segment

Partial Partial Complete Complete

DEGREESDEGREES

MINOR MAJORMINOR MAJOR

MMaajjoorr

ETIOLOGYETIOLOGY

Scarred or poorly vascularized Scarred or poorly vascularized endometriumendometrium

Advancing ageAdvancing age MultiparityMultiparity Previous uterine surgeriesPrevious uterine surgeries

caeserian, myomectomy, D&C, caeserian, myomectomy, D&C, ERPCERPC

BleedingBleeding

Mechanical SeperationMechanical Seperation

Rupture of Cervical dilalatation Rupture of Cervical dilalatation intravaginal intravaginal

Venous lakes effacement Venous lakes effacement manipulationmanipulation

DIAGNOSISDIAGNOSIS

Presenting complaintsPresenting complaints

Painless vaginal bleedingPainless vaginal bleeding

Mild Moderate ProfuseMild Moderate Profuse

SHOCKSHOCK

CLINICAL FINDINGSCLINICAL FINDINGS

PallorPallor

Vital SignsVital Signs HemorrhageHemorrhage StableStable UnstableUnstable

AbdomenAbdomen Soft , relaxed , non tenderSoft , relaxed , non tender LieLie transverse/oblique transverse/oblique Presenting partPresenting part high high Fetal heartsFetal hearts present present

DIAGNOSISDIAGNOSIS

HistoryHistory Clinical examinationClinical examination UltrasonographyUltrasonography Colour DopplerColour Doppler C T scanC T scan MRIMRI

MRI USGMRI USG

MANAGEMENTMANAGEMENT

Depends Depends

Amount of hemorrhage Gestational Amount of hemorrhage Gestational ageage

MANAGEMENTMANAGEMENT

AirwayAirway I/V Line I/V Line 16 / 18 Gauge cannula16 / 18 Gauge cannula

Fluids Fluids crystalloids / colloids crystalloids / colloids

Blood transfusion /FFPBlood transfusion /FFP Indwelling urinary catheterIndwelling urinary catheter Inform Senior ObstetricianInform Senior Obstetrician Avoid pelvic examinationAvoid pelvic examination

MANAGEMENTMANAGEMENT

InvestigationsInvestigations Blood grouping & cross matchBlood grouping & cross match Complete blood countsComplete blood counts Coagulation profile (Platelet count, Coagulation profile (Platelet count,

APTT,PT,FDPs)APTT,PT,FDPs) Ultrasound scanUltrasound scan ( full bladder ) ( full bladder )

EXPECTANT MANAGEMENT EXPECTANT MANAGEMENT (Preterm fetus)(Preterm fetus)

AIM AIM To prolong pregnancy till Term To prolong pregnancy till Term

Haemodynamically stableHaemodynamically stable with mild bleeding with mild bleeding and no uterine contractionsand no uterine contractions

Close observationClose observation vital signs & vaginal vital signs & vaginal bleedingbleeding

Correction of anaemiaCorrection of anaemia Steroids for fetal lung maturationSteroids for fetal lung maturation Counseled and prepared for Caeserian Counseled and prepared for Caeserian

sectionsection

IMMEDIATE DELIVERYIMMEDIATE DELIVERY

Caeserian Section / HysterotomyCaeserian Section / Hysterotomy Haemodynamically unstable.Haemodynamically unstable.

Profuse vaginal bleeding.Profuse vaginal bleeding.

After 37 completed weeks of gestation.After 37 completed weeks of gestation.

If patients has palpable uterine If patients has palpable uterine contractions.contractions.

SURGEON / ANAESTHETIST SENIORSURGEON / ANAESTHETIST SENIOR

GENERAL ANAESTHESIAGENERAL ANAESTHESIA

COMPLICATIONSCOMPLICATIONS

MaternalMaternal Anaemia Anaemia ShockShock Complications of surgery & Complications of surgery &

AnaesthesiaAnaesthesia Post Partam hemorrhagePost Partam hemorrhage Maternal mortaliy Maternal mortaliy FetalFetal Morbidity / MortalityMorbidity / Mortality

PLACENTAL ABRUPTIONPLACENTAL ABRUPTION

Bleeding following Bleeding following premature premature separation of a separation of a normally situated normally situated placenta. placenta.

AETIOLOGYAETIOLOGY

Advance ageAdvance age Multiparity Multiparity Poor nutritional status Poor nutritional status Past History ( Past History ( recurrence 15 –20% )recurrence 15 –20% ) HypertentionHypertention Abdominal Trauma Abdominal Trauma Smoking Smoking Uterine Decompression Uterine Decompression ( polyhydramniose , Twins )( polyhydramniose , Twins ) Chorio amnionitis Chorio amnionitis Fibroid, Folic Acid deficiencyFibroid, Folic Acid deficiency

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Local Vascular injuryLocal Vascular injury ((Pre eclampsiaPre eclampsia))

Haematoma Formation in Haematoma Formation in Decidua BasalisDecidua Basalis

Separation of PlacentaSeparation of Placenta

Venous Venous EngorgementEngorgement

Abrupt uterine venous Abrupt uterine venous pressurepressure

Revealed Concealed Revealed Concealed

SIGNS & SYMPTOMSSIGNS & SYMPTOMS

Small separation of Small separation of the placentathe placenta::

Vaginal bleeding Vaginal bleeding ±± Mild pain or discomfort.Mild pain or discomfort. Abdominal pain. Abdominal pain.

Back pain Back pain

Vital signs StableVital signs Stable Abdomen Abdomen

Soft/ Tenderness ±Soft/ Tenderness ±

FoetusFoetus uncompromiseduncompromised

Large separation of the placenta:Large separation of the placenta:

Heavy vaginal bleeding.Heavy vaginal bleeding.

Severe pain in the lower abdomen or back.Severe pain in the lower abdomen or back.

Hard, tender abdomen.Hard, tender abdomen.

Shock (tachycardia, fall in BP rapid breathing, and Shock (tachycardia, fall in BP rapid breathing, and dizziness).dizziness).

Fetal distress; fetal heart sounds inaudible.Fetal distress; fetal heart sounds inaudible.

Coagulopathy Coagulopathy [DIC]) – Thromboplastine from placenta is [DIC]) – Thromboplastine from placenta is

released into the mother's circulation causing blood clotting released into the mother's circulation causing blood clotting defects. defects.

Renal cortical necrosis ---- AnureaRenal cortical necrosis ---- Anurea

EXAMINATIOBNEXAMINATIOBN

GPEGPE depends upon Hemorrhagedepends upon Hemorrhage.. PallorPallorPulse Pulse B.PB.P

ABDOMINAL EXAMINATIONABDOMINAL EXAMINATIONFundal height larger than datesFundal height larger than datesHard and tender Hard and tender Fetal Part and FHSFetal Part and FHS

PELVIC EXAMINATIONPELVIC EXAMINATIONExclude placenta praevia by USG Exclude placenta praevia by USG P/S examinationP/S examinationP/V examinationP/V examination

INVESTIGATIONSINVESTIGATIONS

Blood grouping. Blood grouping. Blood Complete picture.Blood Complete picture. Coagulation Profile,Coagulation Profile,

Platelet counts, PT, APTT, FDPs Platelet counts, PT, APTT, FDPs

Serum FibrinogenSerum Fibrinogen Renal ProfileRenal Profile Viral SerologyViral Serology

INVESTIGATIONINVESTIGATION

: : Ultrasonography (Useful but not reliable )Ultrasonography (Useful but not reliable )

MANAGEMENTMANAGEMENT

I/V access I/V access Two large bore cannulas.Two large bore cannulas. Save blood for cross match/ Save blood for cross match/

investigation(20 ml)investigation(20 ml) I/V fluids Crystelloids /colloidsI/V fluids Crystelloids /colloids Indwelling urinary catheterIndwelling urinary catheter AnalgesiaAnalgesia Blood transfusions / Fresh frozen plasmaBlood transfusions / Fresh frozen plasma

( Screened & Cross matched )( Screened & Cross matched ) Vital Signs monitoringVital Signs monitoring

MANAGEMENTMANAGEMENT Expectant Expectant : : Mild marginal Abruption with stable mother & Mild marginal Abruption with stable mother &

fetusfetus . . Strict maternal & fetal monitoring.Strict maternal & fetal monitoring.

Vaginal Delivery:Vaginal Delivery: If degree of separation is limited ,If degree of separation is limited , revealed hemorrhage revealed hemorrhage After amniotomy & oxytocin infusion short labour After amniotomy & oxytocin infusion short labour

is expected.is expected. Dead fetusDead fetus No complicationsNo complications

MANAGEMENTMANAGEMENT

Caeserian Section:Caeserian Section:

Maternal IndicationsMaternal Indications

Uncontrollable revealed hemorrhageUncontrollable revealed hemorrhage

Rapidly expanding concealed hemorrhageRapidly expanding concealed hemorrhage

Vaginal delivery is not imminentVaginal delivery is not imminent

Fetal IndicationsFetal Indications Alive fetus with reasonable chances of Alive fetus with reasonable chances of

survivalsurvival

COMPLICATIONSCOMPLICATIONS

MATERNAL MATERNAL Shock (Shock (Hypovolemic, / Neurogenic )Hypovolemic, / Neurogenic )

DICDICRenal failure Renal failure PPH PPH ( Couvelier uterus ,uterine atony , DIC )( Couvelier uterus ,uterine atony , DIC )Maternal mortality ( 0.5% --- 5 % )Maternal mortality ( 0.5% --- 5 % )

FETALFETALPerinatal mortality ( 50 % --- 80 % )Perinatal mortality ( 50 % --- 80 % )

FOLLOW UPFOLLOW UP

Follow up visitsFollow up visits ContraceptionContraception Counsel for chances of recurrence in Counsel for chances of recurrence in

next pregnancy , next pregnancy , early antenatal bookingearly antenatal booking