- Bleeding after the 24th week of pregnancy Antepartum haemorrhage (APH)

bleeding from the genital tract after the 24th week of pregnancy, and before the onset of labour. , it is caused by: Bleeding from local lesions of the genital tract (incidental causes). Placental separation due to placenta praevia or placental abruption.

Causes of bleeding in late pregnancy Cause Placenta praevia Placental abruption ‘Unclassified bleeding’of w hich: Marginal Show Cervicitis Trauma -Vulvovaginal varicosities Genital tumours Genital infections Haematuria Vasa praevia Other

Effect on the mother severely anemic woman will affect her anxiety. -medical shock and blood clotting disorders. Maternal death Effect on the fetus -Fetal mortality and morbidity -Stillbirth - neonatal death - neurological damage in the baby due to abruption placenta & hypoxia .

Initial appraisal of a woman with APH -Antepartum haemorrhage is unpredictable - A rapid decision Assessment of maternal condition a history. Assess v\s and documentation. pallor or restlessness. Assess the blood loss (consider retaining soiled sheets and clothes Perform a gentle abdominal examination, while assessing for signs of labour.

Avoid any vaginal or rectal examination be undertaken, nor should an enema or suppositories be administered to a woman experiencing an APH as these could result in torrential haemorrhage. -Sometimes bleeding from haemorrhoids

Assessment of fetal condition asked baby movement as much as normal listen to the fetal heart. An ultrasound. Speed of action is vital. -Supportive treatment for moderate or severe blood loss and/or maternal collapse would consist of: emotional support for the woman and her partner/relatives rapid fluid replacement (warmed) with a plasma expander, with whole blood if necessary administering appropriate analgesia

Comparison of clinical issues in placental abruption and placenta praevia قراءة من الكتاب

Placenta praevia( p.p ) - the placenta is partially or wholly implanted in the lower uterine segment. - The lower uterine segment grows and stretches progressively after the 12th week of pregnancy. - In later weeks this may cause the placenta to separate and severe bleeding can occur. - The amount of bleeding is not usually associated with any particular type of activity and commonly occurs when the woman is resting. - The low placental location allows all of the lost blood to escape unimpeded and a retroplacental clot is not formed.

pain is not a feature of placenta praevia. a history of a small repeated blood loss at intervals throughout pregnancy others may have a sudden single episode of vaginal bleeding after the 20th week. severe haemorrhage occurs most frequently aher the 34th week of pregnancy. The degree of placenta praevia does not necessarily correspond to the amount of bleeding. A type 4 placenta praevia may never bleed before the onset of spontaneous labour or elective caesarean section in late pregnancy or, conversely, some women with placenta praevia type 1 may experience relatively heavy bleeding from early in their pregnancy.

Degrees of placenta praevia Type 1 placenta praevia -The majority of the placenta is in the upper uterine segment - mild Blood - mother and fetus in good condition. -Vaginal birth is possible

Type 2 placenta praevia -The placenta is partially located in the lower segment - near the internal cervical os (marginal placenta praevia) - moderate Blood loss - the conditions of the mother and fetus can vary. - Fetal hypoxia is more than maternal shock. -Vaginal birth is possible, particularly if the placenta is anterior.

Type 3 placenta praevia - placenta over the internal cervical os but not centrally - severe Bleeding, particularly when the lower segment stretches and the cervix begins to efface and dilate in late pregnancy. - Vaginal birth is inappropriate because the placenta precedes the fetus.

Type 4 placenta praevia - placenta is located centrally over the internal cervical os - torrential haemorrhage -Caesarean section is essential to save the lives of the woman and fetus.

Incidence - women with increasing age and parity, - women who smoke - those who have had a previous caesarean section. - increased risk of recurrence of a placenta praevia in a previous pregnancy

Management - using ultrasonic scanning is a definitive diagnosis, and establish its degree. - scan at 20 weeks of pregnancy is not very useful when vaginal bleeding starts in later pregnancy, as the placenta tends to migrate up the uterine wall as the uterus grows in a developing pregnancy.

management decisions will depend on: the amount of bleeding the condition of the woman and fetus the location of the placenta the stage of the pregnancy

Conservative management - if bleeding is slight and the woman and fetus are well. - hospitalization & bed rest until bleeding has stopped. - A speculum examination will have ruled out incidental causes. - A visit to the special care baby unit/ contact with the neonatal team to prepare the woman and her family for the possibility of pre-term birth.

-A decision will be made with the woman about how and when the birth will be managed. -a danger of postpartum haemorrhage because the placenta has been situated in the lower segment where there are fewer oblique muscle fibres and the action of the living ligatures is less effective

Immediate management of life-threatening bleeding - immediate birth of the baby by caesarean section regardless of the location of the placenta. - place of birth at hospital - the woman will be extremely anxious and the midwife must comfort and encourage her, sharing information with her as much as possible. - partner support. -If the placenta is situated anteriorly in the uterus, this may complicate the surgical approach as it underlies the site of the normal incision.

- placenta praevia (types 3 and 4) caesarean section is required even if the fetus has died in utero. - Such management aims to prevent torrential haemorrhage and possible maternal death.

Complications Maternal shock, resulting from blood loss and hypovolaemia. Anaesthetic and surgical complications Placenta accreta. Air embolism, when the sinuses in the placental bed have been broken. Postpartum haemorrhage: despite the administration of uterotonic drugs at the birth, a ligation of the internal iliac artery. A caesarean hysterectomy may be required to save the woman's life. Maternal death. Fetal hypoxia. Fetal death, depending on gestation and amount of blood loss.

Placental abruption (accidental hemorrhage ) -Premature separation of a normally situated placenta - occurring after the 24th week of pregnancy. - The etiology is not always clear, associated risk is hypertension a sudden reduction in uterine size, when the membranes rupture after the birth of a first twin trauma (ECV)external cephalic version of a fetus presenting by the breech a road traffic accident domestic violence high parity previous caesarean section cigarette smoking

Incidence -30% as concealed and 70% being revealed - a combination of both (mixed haemorrhage). - blood loss may be mild, moderate or severe, ranging from a few spots to continually soaking clothes and bed linen.

-I n revealed hemorrhage: -blood escapes from the placental site - separates the membranes from the uterine wall - drains through the vagina.

- concealed haemorrhage - blood is retained behind the placenta - forced back into the myometrium - infiltrating the space between the muscle fibres of the uterus (extravasation ) -a completely concealed abruption with no vaginal bleeding. the woman will have s&s of hypovolaemic shock -blood loss is moderate or severe she will experience extreme pain.

- what is extravasation -seepage of blood outside the normal vascular channels - cause marked damage -at operation, the uterus will appear bruised, edematous and enlarged. ( Couvelaire uterus or uterine apoplexy

Mild separation of the placenta -a woman self-admits to the maternity unit with slight vaginal bleeding. - woman and fetus are in a stable condition - no indication of shock. - fetus is alive -normal heart sounds. - uterus is normal - no tenderness on palpation

-The management ultrasound to determine the site & degree of concealed bleeding continuous monitoring of the fetal heart rate cardiotocograph (CTG) should be undertaken once or twice daily before 37 weeks. She may return home if there is no further bleeding and the placenta has been found to be in the upper uterine segment.

The woman should be encouraged to return to hospital if there is any further bleeding. after 37th week of pregnancy IOL heavy bleeding or evidence of fetal compromise indicate C.S -rest & comfort -emotional support. - remember Physical domestic abuse -consider if the woman is severely anaemic.

Moderate separation of the placenta -1\4 of the placenta will have separated -concealed haemorrhage must also be considered. - shocked and pain, with uterine tenderness and abdominal guarding. -hypoxic, IUFD Management : Fluid replacement ,a central venous pressure (CVP) line. CTG if the fetus is alive, immediate caesarean section If the fetus is in good condition or has died, vaginal birth may be considered as this enables the uterus to contract and control the bleeding. amniotomy is usually sufficient to induce labour. Oxytocics. The use of drugs to stop labour is usually inappropriate

Severe separation of the placenta - an acute obstetric emergency -2\3 of the placenta has detached - 2000 ml of blood or more are lost. - blood may be concealed behind the placenta. - shock is sever -BP low , with pre-eclampsia the reading within the normal range -The fetus mostly dead. - severe abdominal pain -tenderness and the uterus would have a board-like consistency

Complications of sever abruptio: coagulation defects renal failure pituitary failure postpartum haemorrhage

Treatment : - the same as for moderate haemorrhage: Whole blood transfused rapidly with the woman's CVP. Labour may begin spontaneously ,amniotomy alert for signs of uterine contraction causing periodic intensifying of the abdominal pain. If bleeding continues or a compromised fetal heart rate is present, caesarean section will be required

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