COLLEGE OF MEDICINE DEPT OF OBSTETRICS AND GYNECOLOGY ProfAyman Hussien Shaamash MBBCH MSc MD Egypt Professor of OBGyn Faculty of Medicine King khalid University ID: 775537
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Slide1
1
Antepartum Haemorrhage
COLLEGE OF MEDICINE
DEPT. OF OBSTETRICS AND GYNECOLOGY
Prof.Ayman
Hussien
Shaamash
MBBCH,
MSc
., MD. (Egypt)
Professor of OB./Gyn.
Faculty of Medicine.
King
khalid
University
Dr
Elsheikh
Amin
KKU,MD,ABHA
Slide2Definition
Bleeding
from or within
the genital tract after fetal viability (20weeks) and before fetal expulsion.
Complicates close to 4% of all pregnancies
Slide3Causes of ANTEPARTUM HAEMORRHAGE
1- Placenta praevia.2- Abruptio Placentae.3- Uterine Rupture4- Vasa Previa5- Unknown origin.6-Local causes.Bloody ShowVaginal Lesion/Injury• cervical lesion (cervicitis, polyp, ectropion, cervical cancer)• other: bleeding from bowel or bladder, abnormal coagulation
Placental
Extra placental
Slide4Definition: The placenta is partially or totally implanted in the lower uterine segment Classification or grades • Low lying-near the internal os (1st..dgree degree)• Marginal-the edge of placentas at the margin of the internal os (2nd.degree)• Partial-internal os partially covered by placenta (3rd.degree)• Total-internal os covered by placenta(4th.degree)
I- Placenta Previa
Slide55
Types of Placenta Previa
Slide6Slide7• Incidence at approximately 0.3-0.5% (1:200)• Occurs as consequence of abnormal zygote implantation at lower sgment.• Risk increased with: - Advanced maternal age - Prior C/S (1.5 times higher) - Defective decidualization - Smoking (risk doubled) - Multiple pregnancy- Prior placenta previa
Slide8Complications
A- Maternal
1- During pregnancy:
- Malpresentation, Non engagement,preterm labor
- Antepartum hag.(Sheehan”s syndrome)
2- During labor &puerperium
-
PROM, Cord prolapse, uterine inertia.
-
postpartum Hag., subinvolution, retained fragments
3 -
Placenta Previa-Accreta
- Risk 5% with unscarred uterus and 25% with previous CS
.
B- Fetal:
Mainly risk of prematurity, malpresentation, isoimmunization, fetal distress.
Slide9Clinical Findings:
•
Most common symptom is painless, causless and recurrent bleeding
(
inevitable bleeding
)
• Bleeding increases with labor, direct
trauma, or digital examination
• Initial bleeding is usually not catastrophic
• DIC is uncommon ,unless massive bleeding
Slide10Diagnosis
•
DO NOT DIAGNOSE via vaginal exam!
•
Ultrasound is the easiest, most reliable
way to diagnose (95-98% accuracy)
•
Transvaginal or often superior to transabdominal methods for posterior placenta
previa
Slide1111
Ultrasonographic Diagnosis of Placenta Previa
Slide12Placental Migration
•
Placental location may “change” during pregnancy.
•
25% of placentas implant as “low lying” before 20 weeks of pregnancy,Of those 25% -98% are not placenta previa at term
•
Clinically important bleeding is not likely before 24-26 weeks
•
The clinically important diagnosis of placenta previa is therefore a late second or early third trimester diagnosis
•
Migration is a misnomer
Slide1313
Management
Severe bleeding
Caesarean section
Moderate bleeding
Gestation
>34 WK
<34 WK
Resuscitate
Steroids
Unstable
Stable
Resuscitate
Mild
bleeding
Gestation
<36 WK
Conservative care
>36 WK
Slide14Management
A. Expectant Mangement
•
Bed rest probably indicated
•
Antenatal testing probably indicated
•
If environment is ideal, home care is acceptable
•
Evaluation for possibility of placenta accreta
•
Consideration for Rh IgM in rh negative
patients with bleeding
•
Episodic AFS testing with bleeding events
•
Follow up ultrasound if indicated
Slide15B. Active treatment
Resuscitate, monitor BP and amount of bleeding
Persistent bleeding requires delivery whatever the gestation
28- 34 weeks - time for steroids and prevent contractions with indocid, if no contraindications
Elective caesarean if ? 37 weeks
(Never cut through the placenta)
Expect
the intraparum and postpartum complications.
Slide16•
Delivery should depend upon type of previa and amount bleeding
– Complete previa = C/section
– Low lying = (attempted vaginal delivery)
– Marginal/partial = (it depends on bleeding!)
“double setup” for uncertain cases is no more applicable
.
➔
Occasionally Caesarean hysterectomy necessary (bleeding, adherent placenta).
Slide17• Associated with velamentous insertion of the umbilical cord (1% of deliveries) • Bleeding occurs with rupture of the amniotic membranes (the umbilical vessels are only supported by amnion • Bleeding is FETAL (not maternal as with placenta previa) • Fetal death may occur with trivial symptom
II- Vasa Previa
Slide18Slide19Definition: It occurs when all or part of the placenta separates from the underlying uterine attachment. • Incidence-approx 1/100 -1/200 deliveries • Common cause of IUFD (119 per 1000 births compared with 8.2 per 1000 for all others conditions) • Recurrence rate is 1 in 8 pregnancies.
III- Abruptio Placenta
Slide20Slide21►Hypertension/chronic hypertension -1/2 of fetally fatal abruptions were associated with HTN ►PPROM-abruptio may be a manifestation of rapid decompression ofu►Smoking (and/or ethanol consumption) ►Cocaine abuse-2-15% rate of abruption in patients using cocaine ►Uterine leiomyoma-risk increased if fibroid is behind implantation site►Trauma-relatively►Cigarette smoking►Thrombophilias►Prior abruption►Increased age and parity►Multifetal gestation►Hydramnios
Abruptio Placenta-Associating Factors
Slide2222
Pathology
➔
Placental abruption is initiated by hemorrhage into the decidua basalis.
➔
The decidua then splits, leaving a thin layer adherent to the myometrium.
➔
Development of a decidual hematoma that leads to separation, compression, and destruction of the placenta adjacent to it.
➔
Bleeding with placental abruption is almost always maternal.
➔
Significant fetal bleeding is more likely to be seen with traumatic abruption
Slide2323
classification
Total (fetal death inevitable) vs. partial
External/revealed/apparent: blood dissects downward toward cervix
Internal/concealed (20%): blood dissects upward toward fetus
Mostly are mixed
Slide2424
Slide25• Pain and tenderness• Often I.U.F.D • Bleeding from abruption may be all intrauterine-vaginally detected bleeding may be much less than with placentaprevia • DIC occurs as a consequence of hypofibrino-genemia-in chronic abruption, this process may be indolent • Hypotension on hypertension”Renal impairment
Abruption Placenta- Clinical picture
Slide2626
Abruptio Placentae - Diagnosis
Abruption may no be immediately apparent
Ultrasound has 15% of sensitivity
Slide2727
1.
Term gestation, maternal and fetal hemodynamic stability
.
2.
Term gestation, maternal and fetal hemodynamic instability
.
Once maternal stabilization is achieved, cesarean section should be performed unless vaginal delivery is imminent.
3.
Preterm gestation, maternal and fetal hemodynamic stability
.
82% of patients who are at less than 20 weeks' gestation can be expected to have a term delivery despite evidence of placental separation.
a.
Preterm, absence of labor
.
patients followed closely with serial US for fetal growth. Steroids is administered. If at any time maternal instability arises, delivery should be performed.
b.
Preterm, presence of labor
.
If both maternal and fetal hemodynamic stability are established, tocolysis may be used in selective cases,. Magnesium sulfate is preferred over the b-sympathomimetic agents
4.
Preterm gestation, maternal and fetal hemodynamic instability
.
Slide28►Check Abdomen - previous C/S scar, fundal height and uterine tenderness.► Resuscitate - FDP, whole blood.► Monitor BP and urine output.► Check FHR and ► detailed U/S examination ► Vaginal examination and ARM (Vaginal delivery should be tried)► Give oxytocin infusion or prostaglandin if necessary to induce contractions► Avoid Caesarean Section unless living baby, or no progress or continuous heavy bleeding► Watch out for PPH ► Rho(D) immunoglobulin should be administered to Rh-negative mothers within 72 hours of a bleeding episode.
Management
Slide291- Shock2- Labor-1/5 initially present with “labor”3- Renal failure-may be pre-renal, due to underlying process (preeclampsia) or due to DIC 4- Uteroplacental apoplexy (Couvelaire uterus) 5- cerebral and pituitary (Sheehan syndrome), 6- fetal complications: perinatal mortality 25-60%, prematurity, intrauterine hypoxia7- amniotic fluid embolus 8- <1 % MMR.
Complications
Slide3030
(Couvelaire uterus)
Slide3131
Slide3232
Slide33T
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