ANTEPARTUM HAEMORRHAGE

Definition: Bleeding from the genital tract after 22 weeks of pregnancy or during the 1st stage of labor.

Classification: Placental Site Bleeding: Extra-Placental Bleeding: Placenta previa Accidental haemorrhage. Extra-Placental Bleeding: Cervical erosion Polyp Carcinoma Rupture of V. vein in the cervix Rupture of Vasa Praevia – which is rare.

Placenta Praevia AE: DEFINITION: INCIDENCE: 1:200 The placenta is implanted partially or totally on L.U.S. INCIDENCE: 1:200 AE: Implantation of fertilized ovum in the isthmus. Development of chorion in the decidua capsularis. Abnormal large placenta.

DEGREES: 1st degree: The lower edge of placenta reach the upper part of lower uterine segment. Lateralis 2nd degree: The edge of the placenta reaches the int. OS but does not cover the partially dilated cervix. Marginalis 3rd degree: Placenta is covered OS while the cervix partially dilated. Incomplete centralis. 4th degree: Placenta is covered OS while cervix is completely dilated. Complete centralis.

MECHANISM OF BLEEDING: During labour  sheering of placenta. due to uterine contraction. CLINICAL PICTURE: Painless Causeless Recurrent bleeding after 28 weeks. SIGNS General examination Depend on severity of bleeding ± anaemia

Abdominal examination Nothing characteristic Maybe  malpresentation – non engagement head  Uterus is not tender  Supra pubic fullness Vaginal examination Should not be done except in theatre Vaginal examination is done when active treatment is indicated Active Treatment will be done: Fetal maturity During labor (patient in labour) Severe bleeding.

INVESTIGATION: Ultrasound – accurate Radiology – this is in the past Soft tissue placentography Amniography – radio opaque substance Detection of fetal head displacement Public angiography Cystography – inject sodium iodide 12.5. IV radio active istope Thermography

At home: In case of emergency TREATMENT At home: In case of emergency Cervix generally – no PV Sterile vulval pad Morphine + transfer to hospital At Hospital: Antenatal record – all investigation should be done including coagulation profile Blood transfusion if needed Abdominal examination Not in Labour: Severe bleeding – Cesarean section. Mild bleeding. Expect ttt less than 37 weeks do U/S

IN LABOUR: ARM & Syntocinon. Cesarean Section 1. Vertex. 1. G IN LABOUR: ARM & Syntocinon Cesarean Section 1. Vertex 1. G. III, IV 2. Engaged head 2. Post p.p. 3. Degree I – III ant 3. Sever bleeding 4. OS opened 4. Not stop with ARM 5. Mild or moderate bleeding 5. Others as CPD MANAGEMENT OF 3RD STAGE Careful observation due to p.p. haemorrhage.

COMPLICATION: Maternal:. During pregnancy. - ant. P. haemorrhage COMPLICATION: Maternal: During pregnancy - ant. P. haemorrhage - malpresentation - prematurity During labour 1st stage: - haemorrhage - slow dilatation of cervix - inertia - PRM 2nd stage: - laceration of cervix 3rd stage: - p.p. haemorrhage - retain part of placenta

DURING PEURPERIUM: FOETAL: Puerperal sepsis Sub involution Perinatal mortality 10 – 15% Prematurity Fetal malformaiton 3-4% Asphyxia due to: Anaemia hypoxia Separation of placenta Compression of placenta Prolapse cord

ACCIDENTAL HAEMORRHAGE (Abruptio Placenta) DEFINITION Separation of normally situated placenta after 22 weeks gestation. TYPES: Ext. (Revealed) Mild Concealed Severe Combined Moderate

Toxaemia increased in patient with severe type INCIDENCE About 1% Severe form are seen more in primigravida AE: Toxaemia: 25 – 60% Spasm of vessel  degenerage change. Rupture  Hge Toxaemia increased in patient with severe type

NON-TOXAEMIA: Trauma as  ECV Circumrellate placenta Traction on cord Sudden increased in IUP as R.M. in case of hydramnios Vit. C, K, E, deficiency Folate deficiency Detachment of placenta after delivery of 1st twin.

Utero-placenta apoplexy (couviar’s ut) Coagulation Defect PATHOLOGY: All degree of placenta separation can occur from few millions to whole placenta Degeneration change in the decidual  rupture  haemorrhage in the decidual basalis 1. Decidual than splits  Leaving then layer adherent to myometrium  Decidual haematoma  separation  compression Utero-placenta apoplexy (couviar’s ut) Coagulation Defect DIC  low thromboplastin + fibrimolysin high FDP Fibrinolysis

Vaginal bleeding – dark, not severe Tender abdomen History of trauma INVESTIGATION: Urine analysis  albumin PET Fibrinogen  FDF  Reveled Clinical Picture Symptoms: Vaginal bleeding – dark, not severe Tender abdomen History of trauma

Sign: General examination – hypertensive ± shock  amount of blood. Sign of hypertensive state of pregnancy Shock if present Abdominal examination Nothing Uterus is normal in size and consistency Fetal parts are easily felt F.H.S positive.

CLINICAL PICTURE Concealed antepartum haemorrhage SYMPTOMS Severe abdominal pain = abdominal dist. Shock  N + He

 Shock – concealed blood - partly due to over distended uterus SIGN: General Examination  Shock – concealed blood - partly due to over distended uterus Pulse rapid, BP subnormal, Temp. subnormal, Oedema Abdominal examination: Large uterus Uterus hard & tender & rigid F.H.S. are not heart Vaginal examination: No bleeding Cervix is dilated

TREATMENT REVEALED Not in labor In labor Before 37 After 37 active treatment OR CS in severe bleeding Expected treatment - RM uterine distension CS in cases of Prevent utero-renal reflex severe bleeding Fetal distress Oxytocin CONCEALED Living Dead – promote early CS vaginal delivery by: * RM & Oxytocin * Clot observation

PROGNOSIS Maternal In the past, the maternal mortality was high now 1% The maternal prognosis depend on: Extent of placenta separation Degree of coagulation defect Degree of utero pl. apoplexy Revealed or concealed haemorrhage Adequacy of treatment B. Fetal 100%  in severe type 30 – 50% in revealed type

THANK YOU