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HAEMORRHAGE
DEFINITION OF APH
Bleeding from the genital tract from 28
weeks gestation.
Complicates 3% of preg
Bleeding = fresh blood, clots and
soaking of a pad exclude show,
blood-stained vaginal discharge
ALWAYS = Obstetric Emergency
AETIOLOGY
Placental:
Abruptio Placentae
Placenta Praevia
Vasa Praevia
Non-Placental:
Ruptured Uterus
Decidual Bleeding
Ca Cervix
Other Local Lesions / Cervical Infection
APH of unknown origin
GENERAL MANAGEMENT
Complete history, examination and
depending on the status of the
patient, you would then resuscitate.
Never perform a digital vaginal
examination, until placenta
praevia has been excluded
ABRUPTIO PLACENTAE
DEFINITION:
RISK FACTORS
Pre-Eclampsia = most common cause!
Results in explosive haemorrhage & delivery
(precipitous labour)
Previous abruptio placenta
RISK FACTORS
Multiple pregnancy
Blunt abdominal trauma to the mother
Advanced maternal age
Social factors: cigarette smoking, cocaine abuse
CLINICAL PRESENTATION
HISTORY: risk factors, prev admission for APH/ abruptio
EXAMINATION:
Concealed / Revealed
Concealed no external bleeding, retroplacental clot
between placenta & uterine wall
Revealed Vaginal bleeding (can be fresh bleeding
if marginal placental separation) & Retroplacental
haemorrhage Dark red clots
Abdominal Pain
Pain from contractions if labour has commenced
Severe shock- pale, hypotension, tachycardia
Proteinuria if pre-eclamptic
Grades of Abruptio
BABY IS ALIVE!!!
Grade 1
Retrospective diagnosis
No Signs & Symptoms
Baby is born alive, placenta
comes out
Grade 2
Slight PV bleed + LAP
+ irritable uterus
Diagnose abruptio
placentae
before baby is born baby
alive
Grade 3B:
Same as 3A but
with Coagulopathy
INVESTIGATIONS:
Urine & Blood Investigations:
FBC
Hb or Haematocrit estimation (to determine if blood
transfusion is needed)
Imaging Studies
U/S
May show blood between placenta & uterine wall
absence does not exclude AP
May confirm foetal death
Assess Viability of the Foetus
COMPLICATIONS
Maternal:
1.
2.
3.
4.
Foetal:
1. Foetal Hypoxia & Cerebral Palsy d/t
placental separation
2. Pre-Term delivery complications of
prematurity
MANAGEMENT OF ABRUPTIO
CALL FOR HELP!
RESUS - CAB:
cannulate, catheter, breathing & bloods
Correct Hypovolaemia
Placenta Praevia
DEFINITION
Implantation of the placenta in the lower
segment of the uterus, or the placenta is in
front of the presenting part.
Lower segment definition:
On ultrasound internal os
Physiological isthmus (between histological and
physiological os)
On pv what u feel in the cervix
Classification
Grade Description
Grade 1 Placenta is in lower segment, but
the lower edge does not reach the
internal os.
Grade 2 Lower edge of placenta reaches
the internal os but does not cover
it.
Grade 3 Placenta covers internal os
partially
Grade 4 Placenta covers the internal os
Clinical Presentation
Abdominal exam:
If previous c/section - scar
fetal movements present, FH, fetal parts easily felt
soft, non-tender uterus,
Malpresentation/(4 %) abnormal lie
high presenting part/failure to engage
EIT (exam in theatre): pv para cervically and push the head into
the cervix and if u palpate sponginess then its the placenta
Diagnosis
Clinical Diagnosis
Investigations:
MUST LOCALIZE THE PLACENTA ON U/S
o Trans abdominal ultrasound: Anterior placentas
o Trans-vaginal ultrasound:
safe in the presence of placenta praevia
is more accurate than trans-abdominal
Locates posterior placentas
MRI:
especially posterior placentas
also where trans-abdominal ultrasound images have
been unsatisfactory.
Antenatal
Women with major placenta praevia who have previously
bled should be admitted and managed as inpatients from
34 weeks of gestation.
Women who are at risk should visit a nearby hospital
immediately if she experiences any bleeding, contractions
or pain (including vague supra-pubic pain)
Prior to delivery, all women with placenta praevia
should have had antenatal discussions regarding:
1. delivery,
2. risk of haemorrhage,
3. possible blood transfusion and major surgical
interventions such as a hysterectomy
4. any objections or queries dealt with effectively
If the placenta
does
not cover
the cervix, or
immediately
should
bleeding
recur
Delivery
cannot by
be c/section
felt, can rupture
membranes
and
if bleeding
recurs and
induce
labour
fetus
viable.
Elective
preferred method
Before
34 c/section
weeks
however
cause massive
haemorrhage
IV beta-2can
stimulants
can be used,
provided
Manageme
nt
1 -PP
Typical
presentation
-small bleed
-stops spontaneously
Depends on
1. clinical
2.
severity of bleeding
presentation
3. degree of praevia
4. gestational
age associated
-Admit pt
-Bed rest, ( of
left
lateral packed cells
-correction
anaemia
position
) discussions regarding
--antenatal
delivery, the risk of haemorrhage,
possible blood transfusion and major
surgical interventions such as a
hysterectomy and any objections or
Manageme
nt PP
Resuscitate ( IF
NECESSARY)
- ABC - oxygen via face
mask
- 2 wide bore (16 G) IV line
- Transfuse 2-4 units of
blood
- Fluid Ringers Lactate
-Coagulopathy 4 Fresh Dried
Management
Con..
- Bloo
FBC - haemoglobin or haematocrit
ds
estimation, platelet count
-U+E - urea and creatinine levels for renal
function
-INR - clotting profile (as markers of severe
coagulopathy)
-Crossmatch
oMonitor Patient
-Insert a Folly Catheter
- + CVP ( measure hourly)
-observe general condition
-monitor BP, HR, Pad checks
Assess
-Look for causes of Preterm
Labour
-vaginal swabs
-Fetal kick count
-Decide on timing of
delivery Elective C/S once
fetus is viable(37
completed wks ideally)
Between 28(viability) - 34
weeks
steroids should be givenBetamethasone 12mg IM / 12
hourly (FLM)
If contraction occur before 34
weeks they may be suppressed
Tocolyse B2 Stimulant
C\S should be performed
when the pregnancy
>37 weeks
-If on ultrasound scan the placenta covers
the cervix or the placenta perform
c/section.
-If the placenta does not cover the cervix,
or cannot be felt, u can rupture
membranes and induce labour
-c/section can however cause massive
haemorrhage and should be performed
by an experienced doctor or consultant
obstetrician.
-Transfer to a level 2 or 3 hospital
for elective c/section.
Management Con
Post Delivery Management
-Administer a drip with oxytocin
20units in 1 liter of Ringers lactate to
prevent postpartum haemorrhage (PPH)
-Monitor Urine output, BP, H.R, CVP
-Postnatal blood tests for Hb and
haematocrit
,platelet count, serum urea and
creatinine on the day after delivery
-if dead fetus -Mum should be provided
with grief counseling
Place
nta
incre
ta
Place
nta
percr
eta
Complications
Maternal
Fetal
APH
Mal-presentation
Abnormal
placentation
PPH
IUGR( 15%
incidence)
Premature
delivery
Death
d risk of
puerperal
sepsis
NON-PLACENTAL CAUSES
RUPTURED UTERUS
Uncommon cause of APH
Risk factors:
-Previous myomectomy or classical C/S
-Excessive oxytocin
-Multi-parity
Presentation: Painful vaginal bleeding with
loss of station, absent fetal heart sounds
and movements
Management: resuscitation, emergency
LOCAL LESIONS-Benign
Warts, polyps, ulcers, trauma during coitus
or iatrogenic lacerations
Cervicitis: cervical swab and antibiotics
LOCAL LESIONS-Malignant
Ca Cervix: rare cause of APH. After you
have excluded the placental causes do a
SSE and examine the cervix and vagina
thoroughly (primary vaginal carcinoma or
choriocarcinoma)
Abruptio vs Placenta
Praevia
Abruptio
(Pt
Hypertension,
Placenta
Placenta Praevia
(SYMP) Pain(generalized),
FMF/ abs
EXA
M
Shock
EXA
M
(GEN) shock
prev abruptio,
blunt abd
trauma, ROM
(GEN
Hard tender irritable
)
uterus, HOF increased
(ABD for GA, difficult to
)
asses fetus, absent
(PV)- FHR (sometimes)
(U/S) Dark imminent bleeding
with clots Normal placental
site,