1. Antepartum haemorrhage

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

3. 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.

4. 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

5. 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)

6. 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

7. 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

8. 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 .

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

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

11. 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

12. 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

13. 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

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

15. 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

16. 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

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

18. Effect on the fetus
Perinatal mortality
IUGR

19. 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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