Antepartum haemorrhage

Antepartum hemorrhage ( APH )

Definition:
APH defined as bleeding from the genital tract between 24th week of gestation and delivery of the fetus (24th indicate a lower limit of fetal viability).
Since the causes of bleeding during mid- pregnancy are very much the same as those of third trimester, it seems appropriate to consider APH as occurring from 20 weeks onwards.
APH is associated with higher maternal and fetal morbidity and mortality.
Maternal death:
In the developing countries today, high incidence of pre-existing anemia, difficulties with transport and restricted medical facilities make APH continues to be responsible for many maternal deaths.
Some avoidable factors are: lack of education of the patients to seek medical assistance early , inadequate resuscitation of the mother, inexperience of junior medical staff, & delay in seeking the assistance of more experienced doctors, unavailability of blood banking.

Fetal loss:

perinatal mortality is 12% mainly due to abruptio placenta, or extreme prematurity associated with APH of undetermined origin. In Placenta previa perinatal loss is mainly due to prematurity ,but it is much less than AP.

Causes of APH:

Placenta abruption.
Placenta previa
hemorrhage of undetermined origin:
bleeding from pathology of lower genital tract ( cervical carcinoma, cervical erosion, vaginal trauma ,vaginal infection).
The blood is fetal rather than maternal arises from torn vasa previa, bleeding from a velamantous insertion of the cord.


General principles of management of APH:

maternal and fetal conditions must be assessed

maternal resuscitation must be started promptly .
Early delivery if there is evidence of fetal distress and if the fetus of sufficient maturity to survive.
Vaginal examination, must be avoided until placenta previa has been excluded.
Anti-D immunoglobulin should be given to all (unsensitized) rhesus-negative woman.

Recommendations about the management of massive obstetrical hemorrhage:

All relevant staff should be notified immediately ,
( senior obstetrician, anaesthetist , blood bank personnels ,etc) .
blood should be taken for blood grouping, cross-matching .
coagulation profiles should be performed when indicated.
At least two IV lines with large bored cannulae should be set up. CVP monitoring is important .
Resusitaion should be started with crystalloid or colloid until a cross-matched blood is available
Immediate surgical intervention after restoration of the normovolaemia.

Placenta praevia

Definition:
it is a placenta that is implanted entirely or in part in the lower uterine segment. Bleeding resuls from separation of the placenta as the formation of the lower segment occur and the cervix effaces & start dilatation , this blood loss occur from the venous sinuses in the lower uterine segment


Grad 1, when the placenta implanted in the lower segment but does not reach the internal cervical os ,but in close proximity to it .
Grad 2, the placenta reachs the edge of the cervix but does not cover it ( marginal )
Grad 3, the placenta partially cover the internal os.
Grad 4, the placenta is symmetrically implanted in the lower segment so that it covers the cervix at full dilatation (central)
Placenta acceta , increta & percrita :
If placenta adherent to the uterua it is called accrete , when it penetrates the myometium it is increta , when it perforated the myometrium than it is percreta .

1 and 2 consider to be minor degree of PP

3 and 4 consider to be major degree of PP
Classification is important in relation to management because spontaneous delivery may occur with lateral or marginal implantation
Causes :
Are frequently unclear, may be due to delay in implantation of the blastocyst so that this occur in the lower part of the uterus .
-The accepted association ; older multiparous woman,
multiple pregnancy, due to large placental area, previous uterine damage as in previous CS or curettage.

Clinical presentation :

1. APH the 1st hemorrhage is usually not severe (warning hemorrhage ). The bleeding typically painless although, in some cases bleeding has probably been precipitated by a burst of Braxton Hicks contraction causing some cervical dilatation and stretching of the lower segment, in others the effect of blood lifting the placental membranes may produce uterine activity with the consequence of pain . Abdominal examination shows soft uterus and not tender, the fetal heart is usually heared .

2. Fetal malpresentation in late pregnancy - there is typically high cephalic presentation or fetal malpresentation due to the presence of the placenta in the lower uterine segment .


3. Asymptomatic PP :diagnosed by routine ultrasound examination

Diagnosis :

Clinical finding ;painless vaginal bleeding occur suddenly and tend to be recurrent , profuse hemorrhage may occur when labour started . the abdomen is soft and fetal parts are easy to palpate ,the lie may be oblique or transverse , there is mal -presentation or high cephalic presentation , fetal heart is usually normal
Diagnostic procedure;
Ultra-sound scanning, to localize the placenta.
Magnetic resonance image MRI; this is the most accurate method ,not always performed .
Doppler US can be useful to diagnose placenta acceta, increta & percreta .
EUA( examination under general anesthesia);
vaginal examination in a fully equipped and prepared operating theatre for immediate Caesarean Section ,may be attepted in minor degree PP in a well equipped OT with the availability of cross matched blood ,although it is much less practised nowadays .

Management:

Asymptomatic PP
Admit women with asymptomatic major PP from 32 week of gestation, anemia should be corrected, crossed matched blood should be available for immediate transfusion and facilities for immediate C/S.
Those with asymptomatic minor PP, can often be managed on an outpatient basis unless living far from the hospital. They should be advised to avoid travel and coitus.

Symptomatic PP;

The management of symptomatic PP, depend on the stage of pregnancy (gestational age) and the extent of bleeding.

If the woman presented with massive blood loss (severe APH ), the steps that recommended for the management of massive obstetrical hemorrhage should be considered .


If the bleeding is mild,
It is preferable to allow the pregnancy to continue to a point at which the baby is unlikely to have major complication of immaturity after birth.
The woman may be required to remain in hospital for long periods.
Anemia should be identified and corrected,
Blood should be available for immediate transfusion,
Facilities should be available for immediate C/S,
Fetal growth monitoring,
And termination of pregnancy at 36weeks of gestation.

Caesarean section

Epidural and spinal anesthesia can be used , and general anesthesia is peferred. the most commonly encountered difficulty is hemorrhage. After delivery removal of placenta from the lower segment may prove difficult. Because there is a relative lack of decidua, an abnormal degree of adherence often occurs.
An abnormal amount of bleeding can also occur because of poor contraction of the less muscular lower segment. If control of bleeding is inadequate, direct pressure with warm packs and the administration of oxytocics,oversewing placental bed , ligation of the internal iliac arteries and, ultimately, hysterectomy may be needed.