Ante-partum Hemorrhage Dr.MSc. Raul Hernandez Canete.

Hemorrhage from the vagina after 24 week of gestation is classified as Antepartum Hemorrhage The factors which cause antepartum hemorrhage may be present before 24 weeks, but …..

Threatened miscarriage (up to 24 w) APH (from 24 w-onset of labour): Placenta Praevia, Placental abruption. Intrapartum hemorrhage (from the onset of labour-the end of 2nd stage): Uterine rupture, Vasa praevia. Postpartum hemorrhage (from the 3rd stage of labour-end of the puerperium)

Cause of third-trimester hemorrhage: Nonobstetric causes: Cervicitis, cervical eversion, erosion, polyps, malignant and benign neoplasms, vaginal lacerations, varices.

Obstetric causes: Placenta praevia, Abruptio placentae, Uterine rupture, Rupture of Vasa praevia.

Placenta Previa Placenta praevia is a condition in which the placenta attaches to the uterine wall in the lower portion of the uterus and covers all or part of the cervix.

Placenta Previa: Risk factors for placenta praevia Previous cesarean section Multiparity Advanced maternal age Multiple gestation Erythroblastosis fetalis

Clinical features: Painless vaginal bleeding Abnormal fetal presentation High presenting part Soft abdomen No precipitating factor Maternal cardiovascular compromise Fetal condition satisfactory until severe maternal compromise

Management: Bed rest IV line Normosaline or Ringer Vital sign, and fallow it Estimated the blood loosed. Hb and group + match Call the consultant or transfer to hospital as soon as possible.

cont.. Early hospital admission Inductors of fetal lung maturation No digital examination USG Possible CS

Abruptio Placentae The premature separation of the placenta is termed Abruption, Could be: - With revealed haemorrhage. - With concealed haemorrhage.

Predisposing and precipitating factors: Previous abruptio Hypertensive states of pregnancy Advanced maternal aged Multiparity Uterine distention Trauma Sudden reduction in uterine volume.

Pathophysiology: Local vascular injury that results in vascular rupture into the decidua basalis, bleeding and hematoma formation. The hematoma shears off adjacent denuded vessels, producing further bleeding and enlargement of the area of separation.

Cont.. Another mechanism is initiated by an abrupt rise in uterine venous pressure transmitted to the intervillous space. This results in engorgement of the venous bed and the separation of all or a portion of the placenta

Clinical features: Painful vaginal bleeding Sometimes precipitating factor Agitated and distressed Tender, tense abdomen Normal lie and presentation Coagulation defect sooner

Release of thromboplastins from the damaged placenta may lead to disseminated intravascular coagulation with depletion of platelets, fibrinogen and other clotting factors.

Management: Bed rest Vital sign IV line Hb and group + match If is possible rupture the membranes Transfer the patient to the hospital as soon as possible Oxygen by catheter.

USG if is possible With fetus alive CS is indicated If there is not fetal heartbeat, vaginal delivery is indicated Blood transfusion should be consider Be ready for PPH, due to Uterine atony (Couvelaire Uterus)

Uterine Rupture Risk Factor: Gynecological: -Multiparity, -Multiple pregnancy, -Uterine tumor, -Uterine scar.

In relation with obstetric attention: -Obstructed labor, -Incorrect use of oxytocin, -Fetal macrosomia, -Kristeller maneuver, -Others maneuvers(internal version, difficult forceps, destructive operations,and maneuvers to relieve shoulder dystocia) Abdominal Trauma.

Uterine Rupture could be: -Occult or Incomplete rupture. -Complete rupture: - Traumatic. - Spontaneous

Clinical Features: Suprapubic pain and tenderness Cessation of uterine contractions Disappearance of fetal heart tones Recession of the presenting part Vaginal hemorrhage Signs and symptoms of hypovolemic shock

Prevention: Identify the patient with risk of uterine rupture Early diagnosis of abnormal presentation Correct administration of oxytocin during labour Good obstetric assessment and technique Correct use of PARTOGRAPH

Management: 2 IV line Group + match Vital sign Oxygen by catheter Normosaline or Ringer Urine catheter Blood transfusion Record of vital sign each 15 minutes and fluid given. Prepare the patient for urgent surgical treatment

JERE -JEFF