ANTEPARTUM HAEMORRHAGE

Sources :Textbook of Obstetrics ; D.C Dutta

Definition Causes Evaluation Management Complications

Definition

Bleeding from the genital tract from 22 weeks POA until delivery of the fetus

Why 22 weeks POA?This is because fetus is considered to be

salvageable at this gestation(WHO= 22 weeks/ 500g or more)

**Lower segment starts to form at 28 weeks until 34 weeks

CAUSES :Placental causes (70%) Placenta previa 34.5% Abruptio placenta 34.5% Vasa previa/circumvallate placenta 1%

Unexplained causes (25%)

Extraplacental causes (5%) Cervical polyp Ca cervix Local trauma Cervical or vaginal lesion/ infection

EvaluationQuick HistoryType of bleeding ? Discharge per vagina

POG Past obst history

Fetal movement Blood group

Previous scan

Quick Maternal AssessmentPulse,BP,Uterine enlargement

Quick Fetal AssesmentUSG,CTG

ManagementRx follows into 2 categories1.MINOR BLEEDING :without compromised

mother and fetus USG to rule out PP, Fetal well being If no bleeding ascertain cervical causes, Bishop’s

score P/S and High vaginal swab Investigations: FBC,GXM,BUSE,PT/PTTConservative approach Bed rest Anticipate future bleeding Regular fetal well being tests, fetal growth Keep 3 pint blood ready

2.SEVERE BLEEDING :Compromised mother and fetus Treat as major hemorrhage( altered consciousness

state,SBP< 100mmHg, Pulse >120/min, Blood loss > 1.5L, Decreased peripheral perfusion

Activate Red Alert,Call help ABC -O2 10L/min 2 IV 16 G cannula Foley’s catheter no 16 G 30 ml blood investigation (FBC,PP/PTT,BUSE,GXM) Commence IV Fluids (NS,HM then blood if available) Once hemodynamically stable transfer to HDU

Bleeding PV > 24 weeks

Placenta previa Abruptio placenta

Painless bleeding Painful bleedingSoft uterus Hard uterusMalpresentation Longitudinal lie

Placenta previa- placenta located at the lower segment after 20wks of POG

Placenta Previa

Risk Factors Increased age, parity, Previous scar: LSCS, Myomectomy, MRP Prior placenta previa Tobocco use Multiple pregnancy Previous induced abortion

TREATMENTPreterm with hemodynamic stable mother < 32 POG: Give Dexamethasone 12 mg 12 hrly x 2 doses Expectant management: Bed rest TILL TERM Fetal well-being and growth tests Anticipate bleeding. Keep blood kit ready Correction and prevention of anemia

At Term : Deliver depending on type of placenta previa If bleeding : recurs or persists,mother is

hemodynamically compromised terminate pregnancy by LSCS

Term Delivery either vaginally or LSCS.

Vaginal delivery LSCS Type 1 and Type 2 anterior Type 3,4 Cephalic presentation Fetal

distress Hemodynamically stable

Malpresentation

Keep blood ready Anticipate PPH Anticipate adherent placenta If LSCS consent for Cesarean Hysterectomy

Abruptio placenta-Premature separation of normally situated placenta after the period of viability but before delivery of baby

REVEALED CONCEALED MIXED

Etiology/Risk factorsHigh risk factors Gest Hpt/Pre-eclampsia Trauma Sudden uterine decompression Short cord Obstetric procedures like ECV Multiple pregnancy Polyhydramnios High parity

Management

Trendelenberg position & Oxygen

Obtain immediate Intravenous Access Two large bore IV (16-18 gauge) Collect blood for investigation Initiate Isotonic crystaloid bolus

Call for immediate Obstetric and neonatal support ARM and oxytocin/ Induce labor Consider Cesarean Section if fetal distress

Vasa previa

Fetal vessels travel within the membranes before valementous insertion

Crosses internal os Fetal distress LSCS Fetal mortality is > 50%

Vasa previa,circumvallate placenta

Other causes of APH

CERVICAL BLEEDING; Infectious cause Bleeding is controlled by cauterisation

CERVICAL POLYP Self limiting Local infection Polypectomy Histological diagnosis

BLOODY SHOW

Complications of APH

Couvelair uterus DIVC Amniotic fluid

embolism Acute renal failure PPH Hypovolemic shock Maternal and fetal

death