ANTEPARTUM FAJANA

FEBISOLA PHILIP
HEAMORRHAGE 1001677
OUTLINE
INTRODUCTION
CAUSES
PLACENTA PREVIA
PLACENTAL ABRUPTION
VASA PREVIA
 ANTEPARTUM
HEAMORRHAGE
This is defined as any bleeding from the
genital tract occurring after the (age of
viability) 24weeks/28wks of gestation.
The causes can either be
Placental
or
Local.
Placental causes Local causes
Placental abruption Cervicitis
Placenta praevia Cervical eversion

Vasa praevia Cervical polyps

Cervical carcinoma
Vaginal trauma
Vaginal infection
(4cs and 2vs)
EPIDEMIOLOGY
The incidence of antepartum haemorrhage is
3 per cent. It is estimated that 1 per cent is
attributable
to placenta praevia, 1 per cent is attributable to
placental abruption and the remaining 1 per cent
is from other causes.
PLACENTA PREVIA
Placenta praevia occurs when the placenta is implanted
in the lower segment of the uterus, such that it is adjacent, touches
or overlies.
Leading cause of third trimester bleeding
Incidence is higher in early pregnancy
Most resolve as the pregnancy progress
Three types.
Marginal Placenta Previa
Placenta proximate to the margin of the internal Os. doesnt cover
the Os

Partial Placenta Previa

The placenta partially occludes the Os but doesnt completely cover
it

Complete Placenta Previa

The internal os is fully covered by the placenta.
Associated with greatest risk of morbidity and mortality
RISK FACTORS
Increasing maternal age
Multiparity*
Previous hx of uterine sugery*
Multiple gestation
Smoking
Previous hx of curettage in spontaneous or induced
abortion.
Patients with placenta previa are at higher risk of
developing placenta accreta, increta and percreta
COMPLICATIONS
Post partum hemorrhage
Morbid adherence and PPH
Usually associated with abnormal lie and breech presentation
May lead to cesarean section
Intractable PPH may lead to hysterectomy
Clinical features
History: Typically, Painless bleeds, which may increase in frequency and
intensity over several weeks. Such bleeding may be severe.

Examination
Vaginal examination can provoke massive bleeding and is never
performed in a woman who is bleeding vaginally unless placenta praevia
has been excluded

Investigation To make the diagnosis, ultrasound is used.

To assess fetal and maternal well-being: cardiotocography (CTG), a full
blood count (FBC), clotting studies and cross-match are
needed.
MANAGEMENT
Assess and resuscitate
Subsequent management depend on
Gestational age, maternal stability, and fetal distress.
If the bleeding is minor, observe for at least 24 hours and may
discharge if no further bleeding
Patient bleeding recurrently should be admitted by week 34 and
monitor closely.
CS should be done in major bleeding
If pregnancy is not up to term and bleeding is mild. Patient is
managed via Mcafee Regimen.
Admit
Complete bed rest and close monitoring
Check hematocrit and augment as necessary.
Blood grouping cross matching and standby availability of 4 unit of
blood
Give steroids
Tocolysis.
INDICATION FOR DELIVERY
Gestational age 37-38 weeks
Massive blood loss more than 1.5L
Fetal distress
Onset of labour
IUFD
PLACENTAL ABRUPTION
Is the premature separation of a normally sited placenta from the
uterine wall.
It occurs in 1% of pregnancies
Placenta separation is usually associated with acute fetal distress

Fetal death about 30% of cases

RISK FACTORS/AETIOLOGY
Abdominal trauma
preeclampsia
Maternal hypertension
Polyhydraminos
IUGR
Twin gestation
Smoking
Previous abruption
COMPLICATIONS
DIC
ACUTE KIDNEY INJURY
SHOCK
FETOMATERNAL HEAMORRHAGE
FETAL DEATH
MATENAL DEATH
CLINICAL FEATURES
ABDOMINAL PAIN
VAGINAL BLEEDING
UTERINE COTRACTION
BLEEDING MAY BE CONCEALED (20%)
OR REVEALED
TENDER, HARD UTERUS ON PALPATION.
PALLOR AND TACHYCARDIA IN SEVERE CASES
FETAL DISTRESS.
HYPOTESION
INVESTIGATION
The diagnosis is usually made on clinical grounds.
Investigations help to establish the severity of the abruption,
to plan appropriate resuscitation, and whether and
how to deliver the fetus. To establish fetal well-being, CTG is
performed. Ultrasound can be used to estimate fetal weight at
preterm gestations and will exclude placenta praevia, But a placental
abruption may not be visible.To establish maternal well-being, FBC,
coagulation screen and cross-match are performed. Catheterization
with hourly urine output, regular FBC, coagulation, and
urea and creatinine (U&E) estimations and even BP monitoring.
MANAGEMENT
Assess and resuscitate.
less severe case, depending on maternal stability may be manage
Conservatively.
Give analgesics
Urine Catheterization
Definitive management is delivery.
However the timing and mode of delivery depends on the severity,
fetal status and maternal stability.
 depends on the fetal state and gestation.
The mother must be stabilized first.
If there is fetal distress, urgent delivery by Caesarean section is required
If there is no fetal distress, but the gestation is 37 weeks or more,
induction of labour with amniotomy is performed. The fetal heart is
monitored continuously, maternal condition is closely observed and
Caesarean section is performed if fetal distress ensues.
If the fetus is dead, coagulopathy is also likely. Blood products are given
and labour is induced.
VASA PREVIA
Vasa previa is present when fetal vessels traverse the fetal
membrane over the internal cervical os.
Usually associated velamentous insertion of the umbilical cord
Succeteriate placenta.
The bleeding is usually seen when the membrane rupture either
spontaneously or artificially
It is associated with high perinatal mortality.
Emergency caesarean section is the immediate course of action.
Incidence is about 1in 5000 pregnancy.
REFERENCE
Obstetrics by Ten Teachers, 19Edition
Current diagnosis and treatment Obstetric & Gynecology
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