antepartum haemorrhage titus june 26 2013 - cmnrp · 2014-01-20 · antepartum haemorrhage: an...
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June 26, 2013
Antepartum Haemorrhage: An Overview
T. Titus MFM Fellow
June 26, 2013
� To understand the major and minor causes of APH
� To identify risk factors for major causes of APH
� To understand the complications and management options for patients
� Review of the management for emergency cases
� Bleeding w/c occurs after the 20wks GA but prior to the onset of labour
� Exact Incidence unknown (unrecognised; unreported)
� Incidence ~ 3-5%
� Maternal –placental
� Fetal
� Majority cases = minor
� Major = clinically significant
� Consequences – mother, fetus or both
� Placenta Previa
� Placental Abruption
� Vasa Praevia
� Marginal
� Cervicitis
� Trauma (ex. MVA)
� Vulvovaginalvaricosities
� Genital Tract Tumours
� Haematuria
� Other (ex. Intercourse)
June 26, 2013
Antepartum Haemorrhage: An Overview
� SOGC – placenta implanted in the lower segment of the uterus, presenting ahead of leading pole of the fetus
� Occurrence: 2.8/1000 singleton; 3.9/1000 twin
� Maternal Age: <20 y.o. and >35 y.o.
� Parity
� Previous Caesarean section (C/S)
� Previous uterine surgery (sx): D&C
� Smoking
� Cocaine
� Previous placenta praevia
� U/S: Transvaginal (TV) more accurate c.f. Transabdominal (TA)
� When placenta lies b/w 0 and 20mm from internal cervical os
� If U/S done b/w 18 – 24 wks, repeat in 3rd
TM
� Overlap of (> 0mm) after 35 wks GA indicates C/S as route of delivery.
� Bleeding – Usually “painless” (classic)
� PTD & PTB
� � risk of abruption
� Blood transfusion (10 fold �)
� PeripartumHysterectomy (33 fold �)
� �PPH (uterine atony)
� �Adherent placenta (accreta, increta or percreta)
� Fetal malpresentation
� Allow progress close to term as possible
� Inpt vs. Outpt (controversial) – outcomes are same
June 26, 2013
Antepartum Haemorrhage: An Overview
� Premature separation of the placenta before birth, after 20 wks GA.
� 1% pregnancies affected
� Degree of abruption varies- minor to major (fetal death, maternal morbidity)
� If placentas examined routinely –
� evidence of abruption found ~4%
� Many unrecognised
� Concealed (10%) vs. Revealed
� Classically –Painful, pale, tender “woody hard”uterus +/- contractions
� FHR absent in severe cases +/- coagulopathy
� Most often dx based on history & exam
� U/S poor for dx (50% cases no findings)
� CTG important – contractions may not be appreciated clinically (ex. MVA)
� Previous abruption: ◦ 10% recurrence risk◦ if 2 previous episodes =25% recurrence risk
� Smoking- dose response relationship; if quit before pregnancy still � risk
� Hypertension & Hypertensive disorders of pregnancy (pre-eclampsia)
� Cocaine
� Trauma ex. MVA
� PPROM
� ECV
� Multiple gestation
June 26, 2013
Antepartum Haemorrhage: An Overview
� 10% of PTB
� � rates of perinatal asphyxia, IVH, CP
� Assocn with IUGR
� Fetal death
� Coagulation ex. DIC
� Haemorrhagic shock
� PPH
� Clinical situation – degree of bleeding, GA, Fetal status
� If maternal/ fetal compromise & fetal viability = delivery
� C/S unless labour well advanced
� If fetus dead = vaginal delivery preferred
� Asymptomatic, no maternal/fetal compromise = conservative mx (20-34 wks GA)
� Defn:
� Fetal vessels coursing via membranes over internal cxcal os
� Below fetal presenting part
� Unprotected by placental tissue /umbilical cord
� Incidence:
� Varies b/w 1 in 2000 to 1 in 6000 pregnancies (1)
� May be under reported
23
Placenta praevia, placenta praeviaaccreta & vasa praevia: diagnosis &
management (Green top 27) January 2011
� Placenta with a succenturaiate lobe
� Multiple pregnancies
� IVF
June 26, 2013
Antepartum Haemorrhage: An Overview
� Often dx first made by
� Vessels felt during vaginal exam
� Presentation –unanticipated bleeding at amniotomy
� Fetal vs. maternal origin
� If bleeding due to fetus – CTG changes :
� Tachy� decels �brady
� Immediate C/S
� Admit b/w 28 to 32 wks GA
� Steroids b/c � risk PTB
� Planned C/S b/w 34-37 wks GA
� Multidisciplinary approach (haem)
� ABC’s of resuscitation
� 2 large bore IV (12 or 14G)
� IV Fluids -2L;
� GXM O neg
� CBC, U&E, T&S, PT/PTT
� Urinary catheter
� Anaesthesia
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