ANTEPARTUM HAEMORRHAGE

ANTEPARTUM HAEMORRHAGE It is defined as bleeding from or into the genital tract after the 28th week of pregnancy but before the birth of the baby (the first and second stage of labor are thus included). It should be considered a medical emergency(regardless of whether there is pain) and medical attention should be sought immediately, as if it is left untreated it can lead to death of the mother and/or fetus.

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RAJNI SHARMA M.Sc , PhD, FACEN, FCCS FACULTY: ATCN, BLS, ACLS, MCS, CELS ANTEPARTUM HAEMORRHAGE It is defined as bleeding from or into the genital tract after the 28th week of pregnancy but before the birth of the baby (the first and second stage of labor are thus included). It should be considered a medical emergency(regardless of whether there is pain) and medical attention should be sought immediately, as if it is left untreated it can lead to death of the mother and/or fetus. CAUSES ABRUPTIO PLACENTA (SYN: ACCIDENTAL HEMORRHAGE. PREMATURE SEPARATION PLACENTA)  OF It is one form of Antepartum hemorrhage where the bleeding occurs due to premature separation of normally situated placenta. VARIETIES (1) Revealed : (2) Concealed : (3) Mixed : Bleeding is almost always maternal. But placental tear may cause fetal bleeding. PATHOPHYSIOLOGY  Bleeding into the decidua basalis leads to separation of the placenta. Hematoma formation further separates the placenta from the uterine wall, causing compression of these structures and compromise of blood supply to the fetus. The myometrium in this area becomes weakened and may rupture with increased intrauterine pressure during contractions. A myometrium rupture immediately leads to a life-threatening obstetrical emergency RISK FACTORS (a) high birth order pregnancies with gravida 5 and above — three times more common than in first birth  (b) advancing age of the mother  (c) poor socio-economic condition  (d) malnutrition  (e) smoking (vasospasm).  (d) Hypertension in pregnancy  (e) Trauma  (f) Sudden uterine decompression  (g) Short cord  RISK FACTORS Supine hypotension syndrome  Placental anomaly: Circumvallate placenta  Sick placenta:  Folic acid deficiency even without evidence of overt megaloblastic erythropoiesis  Uterine factor: Placenta implanted over a septum  Torsion of the uterus leads to increased venous pressure and rupture of the veins  Cocaine abuse is associated with increased risk of transient hypertension, vasospasm and placental abruption.  Thrombophilias  Prior abruption  CHANGES IN OTHER ORGANS: Kidneys may show acute cortical necrosis or acute tubular necrosis.  Shock proteinuria  BLOOD COAGULOPATHY: Blood coagulopathy is due to excess consumption of plasma fibrinogen due to disseminated intravascular coagulation and retroplacental bleeding  CLINICAL CLASSIFICATION: Grade—0:  Grade—1 (40%):(i) vaginal bleeding is slight (ii) uterus: irritable, tenderness may be minimal or absent (iii) maternal BP and fibrinogen levels unaffected (iv) FHS is good  Grade—2 (45%):(i) vaginal bleedingmild to moderate (ii) uterine tenderness is always present (iii) maternal pulse ↑, BP is maintained (iv) fibrinogen level may be decreased (v) shock is absent (vi) fetal distress or even fetal death occurs  Prevention of known factors likely to cause placental separation are  Early detection and effective therapy of preeclampsia and other hypertensive disorders of pregnancy.  Needle puncture during amniocentesis should be under ultrasound guidance.  Avoidance of trauma—specially forceful external cephalic version under anesthesia.  To avoid sudden decompression of the uterus— in acute or chronic hydramnios, amniocentesis is preferable to artificial rupture of the membranes. To avoid supine hypotension the patient is advised to lie in the left lateral position in the later months of pregnancy.  Routine administration of folic acid from the early pregnancy — of doubtful value  COMPLICATIONS OF ABRUPTIO PLACENTAE MATERNAL: 1.revealed type In concealed variety 1. Hemorrhage 2. Shock 3. Blood coagulation disorders 4. Oliguria and anuria (a) hypovolemia (b) serotonin liberated from the damaged uterine muscle producing renal ischemia and (c) acute tubular necrosis (5) Postpartum hemorrhage due to — (a) atony of the uterus and (b) increase in serum FDP (6) Puerperal sepsis.  PLACENTA PREVIA When the placenta is implanted partially or completely over the lower uterine segment (over and adjacent to the internal os) it is called placenta previa. ETIOLOGY  Dropping down theory  Persistence of chorionic activity  Defective decidua  Big surface area of the placenta THE MECHANISMS OF SPONTANEOUS CONTROL OF BLEEDING ARE:    (1) Thrombosis of the open sinuses. (2) Mechanical pressure by the presenting part. (3) Placental infarction. RISK FACTORS (a) Multiparity  (b) Increased maternal age (> 35 years)  (c) History of previous cesarean section or any other scar in the uterus (myomectomy or hysterecotomy)  (d) Placental size (mentioned before) and abnormality  (e) Smoking — causes placental hypertrophy to compensate carbon monoxide induced hypoxemia (f) Prior curettage.   Dangerous placenta previa is the name given to the typeII posterior placenta previa SYMPTOMS   SIGNS: General condition and anemia are proportionate to the visible blood loss. 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% THE MECHANISMS OF SPONTANEOUS CONTROL OF BLEEDING ARE: (1) Thrombosis of the open sinuses. (2) Mechanical pressure by the presenting part. (3)Placental infarction. PLACENTAL MIGRATION:  (i) With the progressive increase in the length of lower uterine segment, the lower placental edge relocates away from the cervical os  (ii) Due to trophotropism (growth of trophoblastic tissue towards the fundus), there is resolution of placenta previa. ABDOMINAL EXAMINATION: The size of the uterus is proportionate to the period of gestation.  The uterus feels relaxed, soft and elastic without any localized area of tenderness.  Persistence of malpresentation  The head is floating  Fetal heart sound usually present -Stallworthy’s sign  Vulval inspection: only inspection is to be done to note whether the bleeding is still occurring or has ceased, character of the blood  Vaginal examination must not be done outside the operation theater in the hospital, as it can provoke further separation of placenta with torrential hemorrhage and may be fatal. CONFIRMATION OF DIAGNOSIS I. localization of Placenta (Placentography)  Sonography  Magnetic resonance imaging (MRI)  II. Clinical  By internal examination (double set up examination) Direct visualization during cesarean section Examination of the placenta following vaginal delivery  WORKUP/INVESTIGATIONS       Laboratory Studies Hemoglobin Hematocrit Platelets Prothrombin time/activated partial thromboplastin time Blood type VASA PREVIA Definition: bleeding from umbilical vessels.  Diagnosis: Apt test (hemoglobin alkaline denaturation test.  Complications: bleeding is fetal in origin  (mortality is >75%).  Treatment: Emergent CS if fetus is viable. MANEGEMENT: The management of this condition is largely dependent on the severity of the haemorrhage and the condition of the mother and the fetus.  DO NOT PERFORM A DIGITAL EXAMINATION.  Thank you View publication stats

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ANTEPARTUM HAEMORRHAGE

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