Antepartum haemorrhage

General Consideration Definition is bleeding from the genital tract in pregnancy at ≥ 24 wks gestation before onset of labor

CAUSES OF APH Unexplained (79%) Placenta previa ( 1%) Placental abruption (1%) Others (1%) including Maternal : incidental ( cervical erosion, ectropion) , local infection of cervix/ vagina , show , genital tract tumors , trauma , varicosities.

2- fetal : vasa previa this occurs when fetal vessels run in membranes below the presenting part May present with vaginal bleeding after rupture of fetal membranes followe by rapid fetal distress

Antepartum haemorrhage : assessment by rapid assessment of maternal & fetal condition History ( gestational age , amount of bleeding, associated factors coitus / trauma , abdominal pain , fetal movement , previous episode of bleeding in this pregnancy, previous uterine scar , leakage of fluid , smoker, position of placenta , previous obstetric hx)

Maternal assessment ; vital sign include BP, PULSE , oxygen saturation , urine output , other sign of haemo dynamic compression Uterine palpation: size , tenderness , fetal lie, presenting part ( engaged or not ) Never do vaginal examination in the presence of vaginal bleeding without excluding placenta previa Once exclude PP , speculum examination should do to assess degree of bleeding & possible local causes of bleeding

Fetal assessment Establish weather a fetal heart can be heard Send mother for CBP, KLEIHAUER test , Blood group & cross match & coagulation screen & prepare 6 units of bloods

Placenta preaevia The placenta is implanted ( wholly or in part) in the lower segment of the uterus Major ( grade 3 & 4) Minor ( grade 1& 2) The bleeding is from maternal not fetal circulation & is more likely to comprise the mother than the fetus .

RISK FACTORS OF PP. Multiple gestation Previous uterine scar Uterine structural anomaly Assisted conception

Diagnosis. U/S : transvaginal ultrasound is safe & more accurate than trans abdominal u/s in locating the placenta

treatment Rapid assessment of maternal & fetal condition Resuscitation Woman with major PP who bled previously should admitted from 34 wks gestation If pat. With severe bleeding → C/S If moderate bleeding & G A ≥ 36 wks→ C/S BUT if GA ≤ 36 wks & immature lung then give pat. Decadron & tocolytic if stable condition → expectant mx

If unstable after resuscitation → C/S IF MILD bleeding ≥36 wks & mature lung ( L/S ratio) →C/S & less than 36 wks expectant MX If minor pp ≤ 2cm from internal os then C/S

Placental abruption Types : Placenta separates partly or completely from uterus before delivery of fetus Types : Concealed: blood accumulates behind placenta in uterine cavity. No external bleeding evident (≤20%) Revealed : vaginal bleeding

Risk factors Hypertension Smoking Trauma to abdomen Anticoagulant therapy intrauterine growth restriction Polyhydramnios cocaine usage

Clinical presentation Abdominal pain Sudden onset , constant & severe Uterine contraction Vaginal bleeding is usually dark & non – clotting Uterus tender on palpation & later become hard ( woody) Maternal signs of shock

Fetal distress is common & precedes fetal death Coagulation disorder possibly DIC Remember , extent of the maternal haemorrhage may be much than apparent vaginal loss Diagnosis : clinically . Ultrasound use to confirm fetal wellbeing & exclude placenta previa

complication Effect on the mother : Hypovolaemic shock DIC Acute renal failure feto-maternal Hge Maternal mortality Recurrence ( 10 %)

Effect on the fetus Perinatal mortality IUGR

management Admission Resuscitation Immediate fetal well -being by CTG Fetal distress or maternal compromise → resuscitate & deliver No fetal distress & bleeding & pain cease →expectant MX till term

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