ANTEPARTUM HEMORRHAGE-PLACENTA PREVIA AND ABPRUPTION

ANTEPARTUM HEMORRHAGE-PLACENTA PREVIA AND ABPRUPTION

➡️Antepartum Hemorrhage

Dfn;

Bleeding from the vagina of the pregnant mother after the fetus is viable (~28 wks and above) and before the fetus is born (before the 3rd stage of labour).

?Causes and differential diagnosis

1.Placenta praevia

2.Abruptio placentae

3.Vasa praevia

4. Trauma

5.Coagulopathy

6.Rupture of uterus

7.Cervical/vaginal lesions (cancer, trauma etc)

? Signs and symptoms

Patients usually present with the following Symptoms:

– Vaginal bleeding – 80%

– Abdominal or back pain and uterine tenderness – 70%

– Fetal distress – 60%

– Abnormal uterine contractions (eg, hypertonic, high frequency) – 35%

– Idiopathic premature labor – 25%

– Fetal death – 15%

?Management of antepartum Haemorrhage

-Examine Bleeding Uterus: FH, contractions, tenderness

-Presentation of the fetus

-Emergency (mother/fetus/both

-Mother-blood loss:

-Viability of the Fetus

-Maturity of the Fetus

Risk factors for placental abruption/placenta previa

-delivery if necessary c/s

-vaginal delivery( in case of dead fetus from placental abruption without severe blood loss).

?Placenta praevia

Introduction:

Placenta praevia (also known as low lying placenta)

is a complication of pregnancy, when the placenta is in the lower segment of the uterus and covers part or all of the cervix.

Between three and six of every 1000 pregnant women have this problem.

Bleeding may be a symptom of the condition.

As the lower part of the uterus stretches in the second half of pregnancy, the placenta may become detached, causing severe bleeding.

The baby cannot be born vaginally if the placenta is totally obstructing the opening from the womb.

Uncontrolled bleeding (haemorrhage) is life-threatening for both mother and baby, although this is rare.

If the bleeding doesn’t stop, or if the mother goes into premature labour, the baby will need to be delivered by caesarean section even if the date on which he was due isn’t for quite a few weeks.

Types of Placenta Praevia

Placenta praevia can be divided into four types, of which the first two are the most common:

I) the placenta is positioned low in the womb, but the baby can still be born vaginally.

II) the lower edge of the placenta touches the opening of your cervix, but does not cover it, so the baby can be born vaginally.

III) the placenta partially covers the opening of your cervix. The baby will need to be born by caesarean section.

IV) the placenta completely covers the opening of your cervix. The baby will need to be born by caesarean section.

Warning signs of placenta praevia?

Painless vaginal bleeding during the last three months of pregnancy is often a warning sign.

However, there may be no warning signs at all and the fact that you have placenta praevia may only be discovered during a routine ultrasound scan.

*Are some women more at risk than others?

Women who are having their second or subsequent baby are more at risk than women having their first.

Also slightly more at risk are women who have given birth to a baby by caesarean section, or who have previously had a pregnancy with placenta praevia, or who smoke.

However, most women with placenta praevia have no obvious risk factors.

How is placenta praevia treated?

Treatment depends on whether pt is bleeding and how far on in pregnancy she is.

If the condition is diagnosed after the 20th week, but no bleeding, may probably be advised to refrain from any vigorous exercise and to take life easy.

If she is bleeding heavily, has to be admitted to hospital so that the bleeding can be controlled, but even when it stops, pt might well be asked to stay in hospital until her baby is ready to be born.

Complications

(a) Maternal complications;

-Hemorrhagic shock

-Consumptive coagulopathy

-Placenta accreta or increta more common in low lying placenta and placenta previa

-Hysterectomy in case of plac. increta with severe postnatal bleeding

(b) Fetal complications;

-Prematurity

?Abruptio placentae / placental abruption

Dfn;

Separation of the placenta from its site of implantation before delivery

Separation is either total or partial

Its frequency 1:100

Risk factors for Placental abruption

-Chronic hypertension

-Pregnancy induced hypertension and/or preeclampsia

-Preterm rupture of membranes (esp. in cases of polyhydramnion)

-External trauma

-Uterine fibroids at the site of placental implantation

-History of placental abruption

?Signs and symptoms

~Vaginal bleeding

~Abd. Pain/Uterine tenderness

~High frequency contractions

~Fetal distress or fetal death

Management;

Cases with severe maternal blood loss:

Immediate delivery irrespective of the status of the fetus (maturity, fetal distress) usually by cesaerean section.

Replacement of blood and fluid, and close observation of maternal condition.

Cases with dead fetus but only moderate blood loss:

If vaginal delivery seems likely in the near future (hours): try vaginal delivery

Cases with fetal distress but only moderate blood loss:

Deliver by immediate c/s if fetus is likely to survive (maturity)

Complications

(a) Maternal complications;

~Hemorrhagic shock

~Consumptive coagulopathy Fetal complications

~Death

(b) Fertal complication;

~Prematurity

?Ectopic pregnancy

Leading cause of maternal death in 1st trimester

Usually: 5-8 weeks after LMP

Possible signs & symptoms (only present in 15%)

– Amenorrhea, followed by

– Abdominal pain

– Abnormal vaginal bleeding 2% of all pregnancies

Risk factors (present in < 50%)

– History of PID, previous ectopic, tubal surgery or sterilization procedure

– Endometriosis,

– Use of superovulating agents/reproduction techniques

– IUD

Treatment

– Large bore IV and fluid resuscitation

– Lab investigations

– Definitive therapy

Methotrexate

Laparoscopic salpingectomy

Laparotomy

?Amniotic fluid embolus

Definition

– Release of amniotic fluid into the maternal circulation during intense contractions

Most common during labor

Leading cause of death in induced abortions and miscarriages

Rare: 1/8000 – 1/80,000 births

Mortality 60%

Amniotic fluid embolus Possible signs

– Respiratory distress

– Cardiovascular collapse

– Cyanosis

– Hemorrhage

– Coma

Treatment

– Cardiovascular resuscitation

– Intubation and oxygenation

– Treatment for DIC