ANTE PARTUM HAEMORRHAGE

ANTE PARTUM HAEMORRHAGE

Definition:

APH is defined as bleeding from or into the genital tract occurring from 24th week of pregnancy and prior to the birth of the baby.

Causes

1. Placenta previa

2. Abruption placenta

3.  Others

·        Marginal placental bleeding

·        Show

·        Cervical ectropian / cervical trauma

·        Cervicitis/vaginitis

·        Genital tract tumors

·        Varicosities

·        Ruptured vasa previa

 Placenta Previa

Definition:

Presence of placenta in the lower segment either completely or partially.

The placenta normally implants in the fundus of the placenta.

Incidence: 1 in 300 pregnancies

Perinatal morbidity and mortality are primarily related to the complications of placenta previa, because the hemorrhage is maternal.(fetal complications are caused indirectly to maternal bleeding)

Graded into 2 ways,

1.

Grade 1- placental edge in the lower segment but doesn’t reach the os

Grade 2-placental edge reaches the internal os but doesn’t cover it

Grade3-placenta covers the internal os partially(aymetrically)

Grade4-placenta covers internal os completely (centrally)

2.

Minor degree placenta previa- Grade 1 and 2

Mojor degree placenta previa- grade 3 and 4

Risk factors:

1.     Advancing maternal age

2.     Multiparty

3.     Multifetal gestations

4.     Prior caesarean delivery/uterine surgery

5.     Prior placenta previa

Associated conditions

·        Fetal abnormality

·        IUGR

·        Placental abruption

Clinical Diagnosis:

It is on the basis of history, physical examination and investigations.

 History: Nature of bleeding: Painless, recurrent, bright red.

Initial bleeding may not be profuse; but it is called as` warning bleeding`and requires close monitoring or refers the patient to tertiary center.

On physical examination:

– Abdominal examination: Height of uterus proportionate to gestational age, presenting part may be felt high up (not engaged).

– Malpresentations, malpositions usually present.

– Fetal heart sound may or may not be present, depending upon the amount of blood loss.usually normal if there is no significant blood loss to compromise mother .

If you suspect placenta previa, do not perform a vaginal examination !

Investigations:

 Blood investigations

      Full blood count

      blood group and Rh

cross match – 6 units

Ultrasound examination: Rules out types of placenta previa; fetal anomalies, fetal parameters, presentation and position.

Transvaginal ultrasonography is also considered more accurate than transabdominal ultrasonography.

MRI: MRI has been suggested as a safe and alternate method and may be useful in determining the presences of placenta accreta/increta/percreta.

Management patient has no bleeding or minor bleeding settled

Management depends on

Severity/degree of placenta previa

Distance to hospital

Gestatinal age

Othr factors that may make placenta previa more difficult to manage- scared uterus

Inpatient management is recommended to all major degree placenta previa who had bled after 34 weeks.

Mode of delivery

Vaginal delivery is possible if  anterior placenta 2 cm away from the os or posterior placenta 3 cm away from the os

When to deliver – if no bleeding wait until 38 weeks

A planned caesarean section must enlist the help of all those thought to be necessary

 Senior obstrecian

Senior anaesthetist

Experienced anaesthetic assistant and theater staff

Senior midwives 

Acute Treatment when major haemorrhage is identified

1. Call for help

2. Start oxygen by mask 10 – 15 L/Min

3. Insert 2 IV canula 14 gauge brown orange

4. Cross match 6 units

5. Commence following infusion

Ø Upto 2L normal saline/hartmans

Ø Colloid up to 1.5L

Ø If clinical condition is critical uncrossed match rh negative blood

Ø Cross matched blood as soon as available

      Fluids should be warmed as cold injury exacerbates DIC

6. Catheterize – keep output above 30 ml/h

7. One staff should records the following

Ø Pulse

Ø BP

Ø CVP half hourly if line is present

Ø Continues fetal heart rate

Ø Urine output

Ø Fluid input

Ø Any drug administration

Ø Measured blood loss

ABRUPTIO PLACENTA

Definition:

Abruptio placenta is the detachment of a normally located placenta from the uterus before the fetus is delivered.

 It is an obstetric emergency.

Types:

It can be classified as-

1.     Revealed (separation of placenta with blood visible outside)

2.     Concealed (blood collects behind the separated placenta. Not visible outside)

3.     Mixed, (common type).

According to Sher clinical grading for placental separation

Grade 1: (Herald bleed)

Less than 100cc of uterine bleeding

Uterus non-tender

No Fetal Distress

Grade 2

Uterus tender

Fetal Distress

Concealed Hemorrhage

Progresses to Grade 3 without delivery

Grade 3

Fetal death

Maternal shock

Extensive concealed Hemorrhage

Coagulopathy

Incidence: 1-2%

Perinatal mortality rate associated with placental abruption is high compare to placenta previa .

Risk Factors

Pregnancy Induced Hypertension

High parity

Abdominal Trauma

MVA (unrestrained, rapid deceleration)

Previous Placental Abruption (10 fold increased risk)

Twin Gestation (over distention of Uterus)

Ø Related to rapid decompression of distended Uterus

Occurs after delivery of first twin

Polyhydramnios

Maternal Substance Abuse

Ø Cocaine abuse

Ø Methamphetamine abuse

Ø Maternal Tobacco abuse (2 fold increased risk)

Increased msAFP

Maternal Thrombophilia

Complications:

Maternal complications

1.Prolonged hypovolemic shock

2.Renal Cortical necrosis

3.Coagulopathy

          Disseminated Intravascular Coagulation

          Results from thromboplastin release

4.Amniotic Fluid Embolism

5.Maternal Death

6.Uteroplacental apoplexy (Couvelaire Uterus)

       Bleeding into myometrium results in hypotonic wall

7.Risk of Postpartum Hemorrhage

Fetal complications

1.Intrauterine Growth Retardation

2.Preterm Labor

3.Intrauterine Fetal Demise

        Risk is related to degrees of separation

       Fetal death in up to 30% of cases

 Clinical Diagnosis:

Diagnosis of Placental Abruption is primarily a clinical one.

Severity of symptoms and signs depends on Severity of symptoms and signs depend on degree separation and blood loss.

Ultrasound is not a good method of diagnosing placental abruption.

Symptoms:

Vaginal Bleeding- altered blood

Painful bleeding

Signs:

Vital signs suggestive of cardiovascular compromise

1. Tachycardia

2. Orthostatic changes in blood pressure and pulse

Abdominal examination:

1. Uterus may be larger than gestational age

2. Uterine hyper tonicity/ hard tender uterus

3. Fetal demise (depending upon the severity)

Investigation

Ø Full blood count

Ø Blood grouping

Ø Cross matching

Ø Coagulogram for DIC screening

Ø Fetal heart monitoring

Ø Trans-abdominal ultrasonography done for evaluation of fetal presentation, size, fetal well-being and placental localization and separation.

Ø Kleihaur test if mother Rh negative

Treatment:

1. Bed rest for mild symptoms

2. Prompt delivery for severe symptoms with aggressive supportive measures.

Prompt delivery is usually indicated if any of the following is present(grade 2 or 3 abruption)

a) Maternal hemodynamic instability

b) Non-reassuring fetal heart rate pattern on cardiotocography

c) Near-term pregnancy

Vaginal delivery may be tried if patient is in advanced labour and baby is either not compromised or IUD

Corticosteroids should be considered (to accelerate fetal lung maturity) if gestational age is < 34 wk.