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

2. 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 …..

3. 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)

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

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

6. 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.

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

9. 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

10. 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.

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

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

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

14. 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.

15. 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

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

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

18. 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.

19. 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)

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

21. 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.

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

23. 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

24. 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

25. 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

26. JERE -JEFF