1. *Abdominal pain in pregnancy :
-Common complain
-specific causes of bleeding in pregnancy
*-uterine fibroid degeneration :
-Myoma
-acute abdominal pain
-nausea& vomiting – mild pyrexia
-occur between weeks gestation
-diagnosis: by u/s
RX: bed rest –analgesia

2. -sever uterine torsion :
-uterus rotate more than 90
-abdominal pain
-predisposing factors :
-fibroid –congenital malformation of the uterus
-adenxial mass –pelvic fracture –pelvic surgery
Rx:-bed rest
-change maternal position to correct torsion
-administer analgesia
-rare cases .laparatomy
c.s delivery

3. *pelvic girdle pain
-suprapubic dysfunction (SPD)
-abnormal relaxation of the ligament supporting the pubic pain
-causes :
1-high level of pregnancy hormone especially relaxin
2-biomechanical factors
3-Genetic factors
Incidence 1\300
Out come of this problem :
1-increase mobility of the joint
2-pubic bone move up & down when woman walk
3-strain sacroiliac joint

4. c\p:
-grand multigravida
-pain in the pubic region
-backache
-occur 28 weeks or in postnatal
-abdominal pain ( muscular action )
-tenderness over the symphysis pubis

5. Management :
-explanation to decrease anxiety
-bed rest on firm mattress
-avoid straddle movement
-decrease non essential wt bearing activities
-avoid abduct the hip
-avoid squatting position
-use supportive panty girdle (tubgrip ) -.

6. use comfortable shoes
-increase risk for venous thrombosis
-physio- therapies
-postnatal ligament gradually return to its normal position so arrangement for physiotherapy is important to strength & stabilize joint

7. Ante partum hemorrhage :
Bleeding from the genital tract in late pregnancy after 24th weeks gestation and before the onset of labor.
* effect on fetus:
Fetal mortality
Fetal morbidity.
Still birth .
Neonatal death.
Hypoxia to baby.
Neurological damage to baby.

8. effect on the mother :
(sever bleeding)
shock: hemorrhagic.
DIC
permanent illness.
maternal death.

9. *Types of ante partum hemorrhage :
1. placenta previa.
2. placenta abruption.
Initial intervention ApHge :
reduce anxiety both parents.
Assess the situation.
History and details to know the cause of bleeding.
Nature type of ApHge.
?? D.D : cause of bleeding.

10. Maternal condition:
Assessment :
- observe Pallor breathlessness - signs of shock .
Tachycardia , tachypnea - subnormal temperature and hypotension.
Assess amount of blood loss
gentle abd . examination.
Observe signs of labor.
Don’t do vaginal or rectal examination.
Avoid use of enema or suppositries,This will exacerbate the condition.

11. fetal condition:
ask about movement of the baby.
Auscultation FHR by CTG.
U/S
? D.D

12. 1-location of the placenta.
2-pain "continuous intermittent , painless.
3-onset of bleeding after trauma , sexual inter course .
4-Amount of visible blood ,.
5-color of blood [Bright ,red , dark]
6-degree of shock.
7-consistency of abdomen "tense, tender , soft , board like"
8-lie ,presentation, engagement.
9-F.H.R –positive –ve.
10-uls – site of placenta.

13. Supportive treatment:
Emotional support.
Fluid replacement , plasma ,blood.
Strong analgesia.
Bed rest.
Prepare for emergency ambulance.

14. Placenta previa:
The placenta is partially or wholly implanted in the lower uterine segment either anterior or posterior wall.
Lower uterine segment stretch and grow after 12 weeks
later weeks ,placenta separate and cause sever bleeding.
-Cause of bleeding:
Shearing stress between placental trophoblast and maternal venous blood sinus.
separation of placenta previa put mother and her fetus on risk.

15. degree of placenta previa:
type I-
Majority of placenta in uus.
Vaginal birth.
Mild blood loss .
Mother and fetus in good condition.

16. Type II :
partially in lower uterine segment.
Near the cervical os.
Called placenta previa marginal's
Vaginal birth possible " placenta anterior"
Moderate blood loss.
Maternal shock.
Fetal hypoxia

17. Type III
– placenta located over the internal cervical os ,but not centrally
-Sever bleeding
-C.S delivery better

18. Type IV
placenta located centrally over the internal cervical os
– torrential Hge
C .S delivery.

19. Pictures of previa:
painless vaginal bleeding.
soft uterus.
abd lax.
lie unstable.
presenting part above the pelvic brim.
uls confirm the DX and determine degree, vaginal bleed
this type never bleed . type I
early pregnancy heavy bleeding.

20. Assessing of mother condition:
Amount of vaginal bleeding.
Hx of small repeated blood loss (intervals)
After 20th weeks gestation.
Common after 34th weeks.
Degree of the Hge : mild, moderate, sever.
Occur when doing activity, or even on bed rest.
Bright red color bleeding (fresh) .
Retro placental blood clot not formed "So no pain.

21. General examination:
V/S – stable , signs of shock .
According to amount of blood loss.
Air hunger - RBCs carrying o2
pale skin – cold moist .
lose of consciousness.

22. *Abd examination:
-lie—oblige, Transverse.
Head high not engaged. (PG)
-abdomen lax not tender
-contraindication to do vaginal examination, it will worse the condition
-quantify blood loss ,blood soaked material for fluid replacement

23. -assessing fetal condition :
-fetal activity
-cessation of fetal movement
-signs of hypoxia, bad CTG
-excessive fetal movement : signs of fetal hypoxia
-u\s ,CTG ,pinards

24. Management depends on:
amount of bleeding
-mother &fetus condition
Location of placenta
Stage of pregnancy

25. Conservative management :
-slight bleeding
-mother and fetus in well condition
-bed rest (hospitalization many weeks until bleeding stop)
-fetal kick chart
-CTG

26. -u\s
repeated, site of placenta
-fetal growth
-placental perfusion
-IUGR
-Psychological &social care
-group education
-parent education
-visit special care baby unit
-answering question ?preterm birth
-sever bleeding ,reach maturity NVD
-37 weeks IOL

27. -risk of ppHge :placenta lower uterine segment ,living ligature action is broken
-active management :
Sever vaginal bleeding :c.s regardless location of placenta ( preterm baby )
-CBC ,blood group ,cross match , clotting studies
-IV fluid rapidly ,several unit of blood may need infused rapidly
-consent form
-emergency blood group o –ve -

28. anesthetics consultation
-intake & output
-,epidural or general anesthesia
-comforting mother & sharing information
-support partner
-placenta anterior
-type 3,4 require c.s even the baby died to stop hemorrhage & prevent maternal death

29. Incidence :
-comes after 20 weeks
-complicate 3-6 \1000
-multigravida 1\90
-increasing age – increase parity
-little percentage occur in prima gravida
Etiology : unknown
-?smoker
-previous c.s
-recurrence 4-8 %

30. Complications :
-maternal shock, resulting from blood loss and hypovolaemia
• anesthetic and surgical complications, which are more common in women with major degrees of placenta praevia.
• placenta accreta, in up to 15% of women with placenta praevia
• air embolism, an occasional occurrence when the sinuses in the placental bed have been broken
• postpartum hemorrhage: occasionally uncontrolled hemorrhage will continue, despite the administration of uterotonic drugs at delivery – even following the best efforts to control it, and a ligation of the internal iliac artery,

31. a caesarean hysterectomy may be required to save the woman's life
• maternal death, a very rare outcome
• fetal hypoxia and its sequelae due to placental separation
• fetal death, depending on gestation and amount of blood loss

32. A placental abruption:
- pre-mature separation of normally situated placenta after 22 weeks of pregnancy.
- etiology unclear.
- associated factors.
1. sever pre-eclampsia, not chronic HTN.
2. after delivery of 1st twins ,and occurrence ROM .
3. direct trauma to the abdomen RTA.
4. seat belt injury

33. 5. violence.
6. previous c.s
7. High parity.
8. cigarette smoking.
9. ECV.
- incidence %

34. * partial separation:
- bleeding from maternal venous sinus.
apparent bleeding from vaginal due to .
retained bleeding behind placenta and forced into the myometrium, and infiltrate between muscle fibers [bruised, edematous uterus]
-couvelaire uterus
-uterine apoplexy .

35. -clp
-no vaginal bleeding.
-Signs of hypovolemic shock (concealed Hge )
uterine enlargement.
Extreme pain.
3) Mixed Hge:
- bleeding per vagina.
- concealed Hge. In the uterine muscle.
- revealed , concealed , mixed

36. * according to mother and baby condition
mild
moderate.
sever Hge.
assessing mother condition.
Hx: pre eclampsia.\recent hx of N ,V headache , blurred vision.
Physical domestic violence appear .
ECV RTA.
Delivery of first twins
Loss of copious amount of amniotic fluid .
Slight localize pain – revealed.
- concealed (sever abd. pain.)

37. General examination:
Anxious , abd pain, pallor
edema of the face, fingers, pretibial area.
Alteration of v/s, except Bp in case of PIH
Respiration & pulse within normal.
Temp. :normal – air hunger
if sever infection developed fever.
Brown dark blood .
Fresh bright.

38. Abd examination.
More than expected gestational age concealed .
Hard uterus.
Rigid uterus, painful.
Gaurading on palpation of abdomen
Us CTG
Fetal death is common out come

39. assessing fetal condition : -fetal movement -CTG -U\s management:
I Vcanula , CBC , blood group , cross match ,clotting factors.
psychological care.
analgesic for pain morphine 15 mg , pethidine mg.
differentiate between pain from concealed hemorrhage, or pain from uterine contraction.

40. source of pain:
bleeding between muscle and membrane of placenta
labor pain
sub capsular hemorrhage ( pre -eclampsia)
management of shock (hypovolemic shock ,hemorrhagic
plasma or blood transfusion
haemacele :-doesn't alter platelet functions ,improve renal function
position left side ,sever shock elevate legs ,semi recumbent position

41. -midwifery role :
Resuscitate mother before surgery
Check v\s regularly
Cvp
Canula in place
I&o recorded by indwelling catheter
Urinanalysis for proteinuria
Fluid requirement should record
Fundal height checked regularly
Continuous CTG if baby living
Anti D for mother RH –ve

42. *management of different degree of placental abruption :
1-mild (incidental ):
Mild separation of placenta ( partial )
Slight vaginal bleeding
Mother &fetus in stable condition

43. -no signs of shock
-abdomen lax
-soft uterus
-??pp
Dx: u/s
Rx:u/s
-v/s
-fetal condition monitoring by CTG
-if mother not in labor ,< 37 weeks follow up
->37 weeks IOL

44. *IOL:done in case of :
1-mild episode of bleeding
2-no evidence of fetal compromise
Nb: anemic mother with mild abruption placenta need more concern

45. Moderate:
Separation of placenta 1\4
-vaginal bleeding
-formation of retro placental blood clot
C/p:
-uterine tenderness
-increase pulse rate
-decrease blood pressure
-hypoxic baby
-IUFD

46. Management :
-manage shock
-analgesic
-fluid & blood transfusion
-cvp monitoring
-continuous CTG
-vaginal birth : contracted & stop bleeding after birth
-psychological support
* augmentation of labor :1-amniotomy ROM
2-oxytocin infusion

47. - sever type :
-acute emergency condition
-detachment of placenta 2\3
-life threatening condition
-most of blood concealed
-sever shock decrease blood pressure ,if normal suspect pre-eclampsia cases
-fetus almost died
-sever abdominal pain
-board like abdomen

48. * Complications:- - DIC -RF
Pituitary dysfunction
-The same as moderate treated by blood transfusion, cs delivery in case of sever bleeding
cvp
pain relief

49. *Care of the baby:
Asphyxia (pediatrician, equipment well prepared)
may need neonatal ICU
physical care :
full information and explanation to the family.
Partner support.
If baby go neonatal ICU "visit her"
Let mother to handle her baby before going to nursery.
N.B abruption placenta has a risk factor for recurrence in the next pregnancy.

50. Complications
• DIC is a complication of moderate to severe placental abruption.
• Postpartum hemorrhage may occur as a result of the Couvelaire uterus and disseminated intravascular coagulation, or both. Intravenous ergometrine 0.5 mg is given at birth as a prophylactic measure. •

51. Renal failure may occur as a result of hypovolaemia and consequent poor perfusion of the kidneys.
• Pituitary necrosis is another possible consequence of prolonged and severe hypotension (also known as Sheehan's syndrome; see medical texts for details of this rare condition).
• The maternal mortality rate due to placental abruption is 1%