1. Abnormal Bleeding in Pregnancy and Labour
Dr. Chitra Setya MD
Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida

2. Definition
Antepartum haemorrhage---It is bleeding from the genital tract after the 28th week of pregnancy and before the end of the second stage of labour .
Postpartum haemorrhage– haemorrhage following delivery.

3. Antepartum Bleeding Causes Abruptio Placentae Placenta praevia
Rupture of  uterus
Carcinoma of cervix
Trauma
Cervical polyp
Unknown origin

4. Placenta praevia
Definition : The placenta is partially or totally attached to the lower uterine segment.
Incidence : 0.5% , more common in multiparas and in twin pregnancy due to the large size of the placenta.

5. Placenta praevia Types: 1. Total : internal os completely covered.
2. Partial : internal os partially covered
3. Marginal : edge of placenta at the margin of int. os
4. Low lying placenta

6. Placenta praevia

7. Placenta praevia

8. Placenta praevia Risk factors Chronic hypertension
Multiparity (second or succeeding pregnancy)
Multiple gestations (i.e., twins, etc.)
Older maternal age
Previous cesarean delivery
Tobacco use
Prior uterine curettage (D&C)

9. Placenta praevia Diagnosis Symptoms:
Causeless, painless and recurrent bright-red vaginal bleeding;
It is causeless, but may follow sexual intercourse or vaginal examination.
It is painless, but may be associated with labour pains .
It is recurrent, but may occur once in slight placenta praevia lateralis.

10. Placenta praevia Signs: General examination:
Depends on extent of blood loss
Abdominal examination:
The uterus is corresponding to the period of amenorrhoea, relaxed and not tender.

11. Placenta praevia
The foetal parts and heart sound (FHS) can be easily detected.
Malpresentations, particularly transverse and oblique lie and breech presentation are more common as well as non-engagement of the head.

12. Placenta praevia Arrange for immediate transfer to the hospital.
Treatment
At Home
Arrange for immediate transfer to the hospital.
No vaginal examination and no vaginal pack, only a sterile vulval pad is applied.

13. Placenta praevia No oral intake as anaesthesia may be required.
Antishock measures as pethidine IM, fluids and blood transfusion may be given in the way to the hospital if bleeding is severe.

14. Placenta praevia At Hospital
Assessment of the patient's condition, general and abdominal examination and resuscitation if needed.
At least 2 units of cross matched blood should be available.

15. Placenta praevia If the patient is not in labour
If the bleeding is severe, continue antishock measures and do immediate caesarean section .
If the bleeding is slight, look to the gestational age :

16. Placenta praevia
If completed 37 weeks (36 weeks by some authors) or more, pregnancy is terminated by induction of labour or caesarean section
If less than 37 weeks (36 weeks by others), conservative treatment is indicated till the end of 37 (or 36) weeks but not more.

17. Placenta praevia Conservative treatment:
The patient is kept hospitalized with bed rest and observation till delivery.
Anaemia should be corrected if present.
Observation of foetal wellbeing.
Anti-D immunoglobulin is given for the Rh-negative mother.

18. Placenta praevia If the patient is in labour:
Vaginal examination is done using precautions. According to the findings, the patient will be delivered either vaginally or by caesarean section.

19. Placenta praevia Vaginal delivery is allowed if the
following findings are fulfilled:
Placenta praevia is lateralis or marginalis anterior,
bleeding is slight,
vertex presentation,
adequate pelvis with no soft tissue obstruction.
Caesarian section--- normal mode of delivery

20. Placenta praevia Complications of Placenta Praevia
Maternal: mortality rate: 0.2%.
Foetal:
Foetal mortality rate is 20 %.
Prematurity.
Asphyxia.
Malformations (2%).

21. Abruptio placenta
Placental abruption is the premature separation of a normally-implanted placenta from the uterine wall.
Risk factors :
Older maternal age
Hypertension (high blood pressure)
Tobacco, cocaine, or methamphetamine use
Clotting abnormalities
Abdominal trauma
Previous placental abruption
Uterine fibroids

22. Abruptio placenta Signs and symptoms of placental abruption:
Vaginal bleeding
Sudden onset of labor, with persistent pain between contractions
Tenderness over uterus
Back pain
Signs of shock if blood loss is significant

23. Abruptio placenta
Management -- Depends on gestational age and status of mother & fetus
- live& mature fetus– immediate caesarian section with fluid & blood replacement
- maternal condition stable with premature fetus – expectant management under close supervision
- severe placental abruption with a dead fetus – vaginal delivery preferred

24. Antepartum bleeding Rupture of uterus Carcinoma of cervix Trauma
Cervical polyp
Unknown origin

25. Post partum haemorrhage
Defined as the loss of 500ml or more of blood after completion of the third stage of labour
Causes:
-- Uterine atony
-- Retained placenta
-- Genital lacerations- vaginal, cervical tears

26. Post partum haemorrhage
Uterine atony : Causes
Large infant, forceps delivery, intrauterine manipulation, use of anaesthetic agents, multiple fetuses.
Treatment:
Manual removal of the placenta
Oxytocin- 20 units in 1000ml fluid IV
Methylergonovine 0.2 mg IM
Prostaglandins 0.25mg IM

27. Post partum haemorrhage
Retained placenta > 30 minutes seen in ~ 6% of deliveries.
Risk increased with: prior C/S, curettage , uterine infection, increased parity.
Most patients have no risk factors.
Occasionally succenturiate lobe left behind.
Attempt to remove the placenta by usual methods.
Excess traction on cord may cause cord tear or uterine inversion.

28. Post partum haemorrhage
Birth trauma
Vaginal, cervical tears --- to be repaired
Hematoma --- drain

29. THANK YOU

30. Absent fetal movements
Dr. Chitra Setya MD
Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida

31. Fetal Movements First fetal movement occurs around 8-9 weeks
For primiparas fetal movement often not felt till 18wks or later
For multiparas fetal movement is felt around 15 –16 wks
Simplest and oldest form of fetal welfare assessment

32. Fetal movements Procedure:
The test is valid after 30 weeks of pregnancy.
The mother counts the fetal movements in 3 hours during the period of 12 hours e.g. from 9 am to 9 p.m , - The count is multiplied by 4 to get the fetal movements in 12 hours. If count < 10 – further testing

33. Fetal movements Count-to -ten Cardiff system : 10 movements in 12 hrs
Cessation of the fetal movement hours before stoppage of the heart ---"movement alarm signal".

34. Fetal movements - Pregnant woman can monitor herself. - No cost.
Advantages:
- Informative and non-invasive.
- Pregnant woman can monitor herself.
- No cost.                                
- Accurate gestational age not required.

35. Fetal movements Drawbacks:
- Awareness of the fetal movement differs from mother to mother.
- Cessation of fetal movement may occur due to intrauterine sleep.
- Sedation of the fetus occurs if mother is on sedatives.
- Sudden death of the fetus may occur without preceding slowing of the fetal movement as in abruptio placenta or it may be preceded by increased flurry movements.

36. Fetal movements Assessment of fetal activity Maternal perception
Tocodynamometer
Ultrasound
Fetuses have sleep- activity cycles with sleep cycles extending upto 23 min.
Activity decreases with decreased amniotic fluid volume

37. Fetal movements Electronic monitoring Non Stress test
Done with 2 transducers placed to assess fetal heart
and uterine contractions

38. Fetal movements

40. Fetal movements NST Reactive test:
Two or more fetal movements are accompanied by acceleration of FHR of 15 beats/ minute for at least 15 seconds’ duration. Reactive test means that the fetus can survive for one week, so the test should be repeated weekly.
Non -reactive test:
No FHR acceleration in response to fetal movements so contraction stress test is indicated.
   

41. Fetal movements Ultrasound Doppler monitoring Pregnancy outcome
Check the FHR, Fetal movements and the blood flow to the uterus and the baby
Pregnancy outcome
Pregnancy outcome was the same for mothers who measured fetal movements and those who did not but it is still considered good for early detection of fetal well being as well for mother– baby bonding

42. Fetal Movements ACOG recommendations
Daily fetal kick count to be maintained in
the 3rd trimester
Notify the health provider if the count is
decreased

43. Fetal Movements Summary
Fetal movement record is a simple ,harmless & cost effective way to assess fetal well – being
Pregnancies with decreased fetal movements are at an increased risk of adverse pregnancy outcome
It also helps in “Bonding” between the mother and fetus

44. Thank you

45. Premature rupture of membranes
Dr. Chitra Setya MD
Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida

46. Premature rupture of membranes
Rupture of membranes before the onset of labour
at any stage of gestation
Occurs in 3% of all pregnancies
Responsible for 1/3rd causes of preterm birth
Causes significant fetal complications– sepsis,
prematurity, cord prolapse, abruptio placenta, fetal
death

47. Premature rupture of membranes
Risk Factors
Lower socioeconomic class
Previous preterm birth
H/O STD
Multiple pregnancy
Polyhydramnios
Procedures– cervical encirclage,amniocentesis

48. Premature rupture of membranes
Diagnosis
History
Examination
Vaginal swab
Ultrasound assessment
- amniotic fluid
- fetal assessment

49. Premature rupture of membranes
Treatment depends on
- gestational age,
- amount of amniotic fluid
- fetal state
- infection

50. Premature rupture of membranes
Expectant management
Antibiotic therapy -- Ampicillin with Metronidazole
Corticosteroid therapy- to accelerate lung maturity
Betamethasone 12mg I/M 24hrs apart –2 doses
Dexamethasone 5mg 12 hrly - 4 doses
Tocolytics- to delay onset of labour
Risks
Maternal risks– infection
Fetal risks– pulmonary hypoplasia, limb
abnormalities,infection

51. Premature rupture of membranes
Summary of treatment
History, examination, USG
24 – 31 wks – 33 wks – 36 wks
Bed rest Bed rest Antibiotics
Antibiotics Antibiotics Deliver
Steroids Steroids
Deliver 34 wks Deliver 34 wks

52. Premature rupture of membranes
Complications
Delivery within one week
Respiratory distress syndrome
Cord compression
Cord prolapse
Chorioamnionitis
Abruptio placentae
Antepartum fetal death

53. THANK YOU

54. Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida
Molar Pregnancy
Dr. Chitra Setya MD
Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida

55. Molar Pregnancy Definition and Etiology
Hydatidiform mole is a pregnancy characterized by vesicular swelling of placental villi and usually the absence of an intact fetus.
The etiology -- unclear, but appears to be due to abnormal gametogenesis and fertilization
Incidence-- 1 out of

56. Molar Pregnancy Risk factors < 15 years
1. Maternal age  > 40 years
             < 15 years 
2. Paternal age  > 45 years  
3. Previous hydatidiform mole  1st: 1% , 2nd 15-28% 
4. Vitamin A deficiency 
5. Consanguinous marriages
6. Previous spontaneous abortion
7. More common in orients

57. Molar Pregnancy Molar pregnancy - Complete - Partial
Complete mole - Mass of tissue is completely made up of abnormal cells
There is no fetus and nothing can be found at the time of the first scan.
 Partial mole - Mass may contain both these abnormal cells and often a fetus that has severe defects.

58. Molar Pregnancy History Examination Amenorrhoea Vaginal bleeding
Excessive nausea & vomiting
Passage of vesicles
Examination
Uterine size> period of pregnancy
Soft boggy feel of uterus- with no fetal parts felt
Signs of anaemia

59. Molar Pregnancy Diagnosis of hydatidiform mole
Quantitative beta-HCG – value > 10,000mIU/ml
Ultrasound is the standard criterion for identifying both complete and partial molar pregnancies. The classic image is of a “snowstorm” pattern

60. Molar Pregnancy Signs and Symptoms of Complete Hydatidiform Mole
Vaginal bleeding
Hyperemesis ( severe vomiting)
Size inconsistent with gestational age( with no fetal heart beating and fetal movement)
Preeclampsia
Theca lutein ovarian cysts

61. Molar Pregnancy Signs and Symptoms of Partial Hydatidiform Mole
Vaginal bleeding
Absence of fetal heart tones
Uterine enlargement and preeclampsia is reported in only 3% of patients.
Theca lutein cysts, hyperemesis is rare.
     

62. Molar Pregnancy Differential diagnosis Abortion Multiple pregnancy
Polyhydramnios
   

63. Molar Pregnancy Treatment Suction dilation and curettage :
Complete evacuation of the uterus
USG to confirm complete evacuation
Serum β-HCG weekly till undetectable & monthly for 6 months
Serum β- HCG expected to be undetectable by8-12 wks
Advise contraception till then– condoms, OC pills after HCG negative

64. Molar Pregnancy Indications for chemotherapy
Serum B-HCG >20,000IU/L or urinary B-HCG > 30,000 IU/L 4 wks post evacuation
Rising level of B- HCG anytime post evacuation
Positive B-HCG levels 6 mths post evacuation
Evidence of metastasis
Persistant vaginal bleeding with +ve B- HCG
Methotrexate is the drug used

65. Grade C recommendation
RCOG Recommendations
Ultrasound has limited value in detecting partial molar pregnancies.
In twin pregnancies with a viable fetus and a molar pregnancy, the pregnancy can be allowed to proceed.
Surgical evacuation of molar pregnancies is advisable.
Routine repeat evacuation after the diagnosis of a molar pregnancy is not warranted.
Registration of any molar pregnancy is essential.
The combined oral contraceptive pill and hormone replacement therapy are safe to use after hCG levels have reverted to normal.
Women should be advised not to conceive until the hCG level has been normal for six months or follow-up has been completed (whichever is the sooner).
Grade C recommendation

66. THANK YOU