Lecture Notes On Aph
Lecture Notes On Aph
Lecture Notes On Aph
ANTEPARTUM AND
POSTPARTUM
HEMORRHAGES
TESHALE W.(MD)
Late pregnancy
complications
Preterm labor
Premature rupture of membranes(PROM)
Post term pregnancy
Rh-isoimmunization
Intrauterine growth restriction(IUGR)
Large/small for gestational age fetus(LGA/SGA)
Antepartum/postpartum hemorrhages
Pregnancy induced hypertension(PIH)
Poly/oligohydramnios
Gestational diabetes mellitus(GDM)
ANTEPARTUM HEMORRHAGE
Definition
Bleeding per vagina after the 28th wk of GA
Common causes:
Placental abruption
Placenta prevea
Placental abruption
Premature separation of a normally implanted
placenta
Prevalence-1% of all pregnancies
Blood loss is both maternal and fetal
Bleeding may be is concealed or revealed
Concealed hge- 20% of cases
Detachment may be complete
Complications often severe
Causes of abruption:
Maternal hypertension-commonest
Maternal abdominal trauma
Multiple gestation
Cigarette smoking
Cocaine use
Other risk factors:
PROM
Delivery of first twin
Retroplacental leiomayoma
Clinical features:
Dark and nonclotting vaginal bleeding-80%
Abdominal or back pain and uterine tenderness70%
Fetal distress
Diagnosis:
Mainly clinical
U/S- not reliable-high false negative rate
Medical challenges:
Classic presentation of abruption esp. with
posterior implantation may be absent
Failure to consider placental abruption in
preterm labor
Absence of vaginal bleeding doesnt exclude
placental abruption
DIC may occur even if clotting factors are
initially are within reference ranges
Normal U/S findings do not exclude placental
abruption
Grading of abruption:
Based on clinical and laboratory finding
Grade 0:
Asymptomatic
Retrospective diagnosis
Clot on a delivered placenta
Grade I:
50% of all cases
<500 ml blood loss or < 25% separation
Mild uterine irritability
Grade II(moderate):
30% of cases
500-1000cc of blood loss and 25-50% separation
Highly irritable and tender uterus
Deranged maternal V/S and FHB
Hardly palpable fetal parts
Grade III(severe):
25% of all cases
>1000cc of blood loss and >50% separation
Highly irritable and tender uterus
Severe lower abdominal pain
Deranged maternal V/S(shock) and FHB
Hardly palpable fetal parts
Severe anemia(<5mg/dl)
Nonreassuring BPP
Fibrinogen level <150mg/dl
Platelet count <100,000/mm
Maternal complications:
Hemorrhagic shock
Coagulopathy/DIC
Couvelaires uterus
Uterine rupture
PPH
Sheehans syndrome-infertility
Fetal complications:
Perinatal asphyxia
Anemia
IUGR
Prematurity
Fetal distress and death
Management of
abruption
All hospital admissions
Expectant management:
Preterm pregnancy with stable maternal V/S
and FHB
No life threatening complication yet developed
Strict follow up of maternal (vaginal bleeding,
V/S) and fetal conditions(FHB, BPP etc.)
Steroids for fetal lung maturity(dexamethasone,
bethamethason)
GA cut point for termination-34wks
Placenta prevea
Placental implantation in the lower uterine
Risk factors:
Endometrial scarring in the upper
segment(C/S, myomectomy, curettage ,
repaired rupture, polypectomy)
One prior C/S-0.9%
Two prior C/S-1.7%
3 or more prior C/S-3%
Multiple gestation
Multiparity(0.2% in nulliparous, 5% in
grandmultiparas)
succenturiate lobe
Need for increased placental surface area to
compensate for a reduction in uteroplacental
oxygen or nutrient delivery such as in case of:
Maternal smoking
Higher altitude residence
Multiple gestation
Causes of bleeding:
Mechanical separation such as during effacement
and dilatation
Placentitis, PV, PR, coitus
Rupture of veins in the decidual basalis
Abdominal trauma
Associated conditions:
Placenta accreta-in 5-10% of pregnancies with PP
Malpresentation
PROM
IUGR-in up to 16% of pregnancies with PP
Clinical manifestations:
Sudden, bright-red, painless vaginal bleeding is the
hallmark of PP- in 70-80% of cases of PP.
No abdominal pain or tenderness unless there is
uterine contraction which is rare(10-20% of cases)
About 10% of women term with out bleeding
Most episodes of bleeding begin after 28 th wk of GA
but spotting may also occur in the 1st and 2nd TMs
Diagnosis:
Clinical
TVU/S and TAU/S-95% diagnostic
Double set up examination
Based on U/S:
Complete PP
Placenta completely
Partial PP:
Placental edge partially covers the internal cervical
OS
Marginal PP:
Placental edge is adjacent to the internal OS
Low-lying PP:
Complications:
Premature labor
Hemorrhagic shock
Fetal distress and death
Malpresentation
Amniotic fluid embolism
Infection
Expectant management:
Preterm pregnancy with stable maternal and
fetal conditions
No life threatening complications yet developed
Strict follow up of maternal(vaginal bleeding,
V/S) and fetal(BPP, FHB) conditions
Avoiding precipitants of bleeding such as
exercise, PV, PR, coitus-strict bed rest
Steroids for fetal lung maturity
GA cut point for termination
NB:
PV is absolutely contraindicated in a pregnant
mother presenting with vaginal bleeding after
28th wk of GA until PP is ruled out by abdominal
U/S
Vasa prevea
The fetal blood vessels, unsupported by either
Postpartum
hemorrhage
Defined as:
Vaginal bleeding post delivery in excess of:
500cc in vaginal delivery
1000cc in C/S delivery
Secondary(late) PPH:
24hrs to 6wks postpartum
Retained products of placenta and membranes(RPC)
Uterine sub involution
Chronic uterine inversion
Placental polyp
Coagulation disturbances
Endometritis
Myomatous uterus
Choriocarcinoma
labor
Failure to actively manage the third stage of
labor(failure to institute ATSM)
Physiologic vs. active management of the
third stage
Signs of placental separation in ATSM
Lengthening of the umbilical cord
Gush of blood per vagina
Uterus becomes globular and firmer
Management of PPH
Anticipation of PPH-b/c 75% PPH is unpredictable
Anticipation of PPH 2to uterine atony such as in:
Prolonged labor
Multiparity
Prolonged oxytocin stimulation(induction and
augmentation)
Pregnancy induced hypertension
Previous history of PPH
Placental abruption
choriamnionitis
Polyhydramnios
Macrosomia
Myomatous uterus etc
END