1 Antepartum Haemorrhage COLLEGE OF MEDICINE DEPT. OF OBSTETRICS AND GYNECOLOGY Prof.Ayman Hussien Shaamash MBBCH, MSc., MD. (Egypt) Professor of OB./Gyn. Faculty of Medicine. King khalid University Dr Elsheikh Amin KKU,MD,ABHA

Bleeding from or within the genital tract after fetal viability (20weeks) and before fetal expulsion. Complicates close to 4% of all pregnancies

Causes of ANTEPARTUM HAEMORRHAGE 1- Placenta praevia. 2- Abruptio Placentae. 3- Uterine Rupture 4- Vasa Previa 5- Unknown origin. 6-Local causes. Bloody Show Vaginal Lesion/Injury cervical lesion (cervicitis, polyp, ectropion, cervical cancer) other: bleeding from bowel or bladder, abnormal coagulation Placental Extra placental

Definition: The placenta is partially or totally implanted in the lower uterine segment Classification or grades Low lying-near the internal os (1 st.. dgree degree) Marginal-the edge of placentas at the margin of the internal os (2 nd. degree) Partial-internal os partially covered by placenta (3 rd. degree) Total-internal os covered by placenta (4 th.degree) I- Placenta Previa

5 Types of Placenta Previa

Incidence at approximately % (1:200) Occurs as consequence of abnormal zygote implantation at lower sgment. Risk increased with: - Advanced maternal age - Prior C/S (1.5 times higher) - Defective decidualization - Smoking (risk doubled) - Multiple pregnancy - Prior placenta previa Incidence at approximately % (1:200) Occurs as consequence of abnormal zygote implantation at lower sgment. Risk increased with: - Advanced maternal age - Prior C/S (1.5 times higher) - Defective decidualization - Smoking (risk doubled) - Multiple pregnancy - Prior placenta previa

A- Maternal 1- During pregnancy: - Malpresentation, Non engagement,preterm labor - Antepartum hag.(Sheehan”s syndrome) 2- During labor &puerperium - PROM, Cord prolapse, uterine inertia. - postpartum Hag., subinvolution, retained fragments 3 - Placenta Previa-Accreta - Risk 5% with unscarred uterus and 25% with previous CS. B- Fetal: Mainly risk of prematurity, malpresentation, isoimmunization, fetal distress. Complications A- Maternal 1- During pregnancy: - Malpresentation, Non engagement,preterm labor - Antepartum hag.(Sheehan”s syndrome) 2- During labor &puerperium - PROM, Cord prolapse, uterine inertia. - postpartum Hag., subinvolution, retained fragments 3 - Placenta Previa-Accreta - Risk 5% with unscarred uterus and 25% with previous CS. B- Fetal: Mainly risk of prematurity, malpresentation, isoimmunization, fetal distress.

Clinical Findings: Most common symptom is painless, causless and recurrent bleeding (inevitable bleeding ) Bleeding increases with labor, direct trauma, or digital examination Initial bleeding is usually not catastrophic DIC is uncommon,unless massive bleeding

Diagnosis DO NOT DIAGNOSE via vaginal exam! Ultrasound is the easiest, most reliable way to diagnose (95-98% accuracy) Transvaginal or often superior to transabdominal methods for posterior placenta previa

11 Ultrasonographic Diagnosis of Placenta Previa

Placental Migration Placental location may “change” during pregnancy. 25% of placentas implant as “low lying” before 20 weeks of pregnancy,Of those 25% -98% are not placenta previa at term Clinically important bleeding is not likely before weeks The clinically important diagnosis of placenta previa is therefore a late second or early third trimester diagnosis Migration is a misnomer

13 Management Severe bleeding Caesarean section Moderate bleeding Gestation >34 WK <34 WK Resuscitate Steroids Unstable Stable Resuscitate Mild bleeding Gestation <36 WK Conservative care >36 WK

 Management A. Expectant Mangement Bed rest probably indicated Antenatal testing probably indicated If environment is ideal, home care is acceptable Evaluation for possibility of placenta accreta Consideration for Rh IgM in rh negative patients with bleeding Episodic AFS testing with bleeding events Follow up ultrasound if indicated

B. Active treatment  Resuscitate, monitor BP and amount of bleeding  Persistent bleeding requires delivery whatever the gestation  weeks - time for steroids and prevent contractions with indocid, if no contraindications  Elective caesarean if ? 37 weeks (Never cut through the placenta)  Expect the intraparum and postpartum complications.

Delivery should depend upon type of previa and amount bleeding – Complete previa = C/section – Low lying = (attempted vaginal delivery) – Marginal/partial = (it depends on bleeding!) “double setup” for uncertain cases is no more applicable. ➔ Occasionally Caesarean hysterectomy necessary (bleeding, adherent placenta). Delivery should depend upon type of previa and amount bleeding – Complete previa = C/section – Low lying = (attempted vaginal delivery) – Marginal/partial = (it depends on bleeding!) “double setup” for uncertain cases is no more applicable. ➔ Occasionally Caesarean hysterectomy necessary (bleeding, adherent placenta).

Associated with velamentous insertion of the umbilical cord (1% of deliveries) Bleeding occurs with rupture of the amniotic membranes (the umbilical vessels are only supported by amnion Bleeding is FETAL (not maternal as with placenta previa) Fetal death may occur with trivial symptom Associated with velamentous insertion of the umbilical cord (1% of deliveries) Bleeding occurs with rupture of the amniotic membranes (the umbilical vessels are only supported by amnion Bleeding is FETAL (not maternal as with placenta previa) Fetal death may occur with trivial symptom II- Vasa Previa

Definition: It occurs when all or part of the placenta separates from the underlying uterine attachment. Incidence-approx 1/100 -1/200 deliveries Common cause of IUFD ( 119 per 1000 births compared with 8.2 per 1000 for all others conditions) Recurrence rate is 1 in 8 pregnancies. III- Abruptio Placenta

►Hypertension/chronic hypertension -1/2 of fetally fatal abruptions were associated with HTN ►PPROM-abruptio may be a manifestation of rapid decompression ofu ►Smoking (and/or ethanol consumption) ►Cocaine abuse-2-15% rate of abruption in patients using cocaine ►Uterine leiomyoma-risk increased if fibroid is behind implantation site ►Trauma-relatively ►Cigarette smoking ►Thrombophilias ►Prior abruption ►Increased age and parity ►Multifetal gestation ►Hydramnios Abruptio Placenta-Associating Factors

22 Pathology ➔ Placental abruption is initiated by hemorrhage into the decidua basalis. ➔ The decidua then splits, leaving a thin layer adherent to the myometrium. ➔ Development of a decidual hematoma that leads to separation, compression, and destruction of the placenta adjacent to it. ➔ Bleeding with placental abruption is almost always maternal. ➔ Significant fetal bleeding is more likely to be seen with traumatic abruption

23 classification Total (fetal death inevitable) vs. partial External/revealed/apparent: blood dissects downward toward cervix Internal/concealed (20%): blood dissects upward toward fetus Mostly are mixed

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Pain and tenderness Often I.U.F.D Bleeding from abruption may be all intrauterine-vaginally detected bleeding may be much less than with placentaprevia DIC occurs as a consequence of hypofibrino- genemia-in chronic abruption, this process may be indolent Hypotension on hypertension” Renal impairment Pain and tenderness Often I.U.F.D Bleeding from abruption may be all intrauterine-vaginally detected bleeding may be much less than with placentaprevia DIC occurs as a consequence of hypofibrino- genemia-in chronic abruption, this process may be indolent Hypotension on hypertension” Renal impairment Abruption Placenta- Clinical picture

26 Abruptio Placentae -Diagnosis Abruptio Placentae - Diagnosis  Abruption may no be immediately apparent  Ultrasound has 15% of sensitivity

27 1. Term gestation, maternal and fetal hemodynamic stability. 2. Term gestation, maternal and fetal hemodynamic instability. Once maternal stabilization is achieved, cesarean section should be performed unless vaginal delivery is imminent. 3. Preterm gestation, maternal and fetal hemodynamic stability. 82% of patients who are at less than 20 weeks' gestation can be expected to have a term delivery despite evidence of placental separation. a. Preterm, absence of labor. patients followed closely with serial US for fetal growth. Steroids is administered. If at any time maternal instability arises, delivery should be performed. b. Preterm, presence of labor. If both maternal and fetal hemodynamic stability are established, tocolysis may be used in selective cases,. Magnesium sulfate is preferred over the b- sympathomimetic agents 4. Preterm gestation, maternal and fetal hemodynamic instability.

►Check Abdomen - previous C/S scar, fundal height and uterine tenderness. ► Resuscitate - FDP, whole blood. ► Monitor BP and urine output. ► Check FHR and ► detailed U/S examination ► Vaginal examination and ARM (Vaginal delivery should be tried) ► Give oxytocin infusion or prostaglandin if necessary to induce contractions ► Avoid Caesarean Section unless living baby, or no progress or continuous heavy bleeding ► Watch out for PPH ► ►Check Abdomen - previous C/S scar, fundal height and uterine tenderness. ► Resuscitate - FDP, whole blood. ► Monitor BP and urine output. ► Check FHR and ► detailed U/S examination ► Vaginal examination and ARM (Vaginal delivery should be tried) ► Give oxytocin infusion or prostaglandin if necessary to induce contractions ► Avoid Caesarean Section unless living baby, or no progress or continuous heavy bleeding ► Watch out for PPH ► Rho(D) immunoglobulin should be administered to Rh- negative mothers within 72 hours of a bleeding episode.Management

1- Shock 2- Labor-1/5 initially present with “labor” 3- Renal failure-may be pre-renal, due to underlying process (preeclampsia) or due to DIC 4- Uteroplacental apoplexy (Couvelaire uterus) 5- cerebral and pituitary Shock 2- Labor-1/5 initially present with “labor” 3- Renal failure-may be pre-renal, due to underlying process (preeclampsia) or due to DIC 4- Uteroplacental apoplexy (Couvelaire uterus) 5- cerebral and pituitary (Sheehan syndrome), 6- fetal complications: perinatal mortality 25-60%, prematurity, intrauterine hypoxia 7- amniotic fluid embolus 8- <1 % MMR. Complications

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