bleeding in late px

Antepartum Hemorrhaged (APH)

Definition: Bleeding from the genital tract in late pregnancy after the 28th weeks(20 – 28) of gestation and before delivery of the baby is called APH.

Incidence:

• About 3% among hospital deliveries.

1BY GEBREMARYA TEMESGEN BSC MW

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Causes:

A. Maternal:– Placenta previa

– Apruptio placenta/placental abruption

– Incidental causes (Local causes in the vagina & cervix)

– Blood dyscrasias

– Causes never found

B. Fetal– Vasa previa

BY GEBREMARYA TEMESGEN BSC MW2

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Effects of APH:

A. On the mother:

• Shock.

• Disseminated Intravascular coagulation (DIC)

• Renal failure

• Permanent ill health

• Death


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B. On the fetus:

• Fetal hypoxiamentally & physically inspired baby

• Stillbirth

• Neonatal death


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Types:

1. Placenta praevia (Unavoidable hemorrhage) Definition: Placenta praevia is defined as a placenta which is partially or wholly attached on the lower pole of the uterus either anteriorly or posteriorly.

NB: The lower pole of the uterus is which:– Does not contract during labour but stretch in

response to contractions.

– Used to be the isthmus before pregnancy.


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• As the lower segment grows and stretches, placenta can be separated and bleeding can occur.

• The anterior location is less serious.

Incidence: 0.5% of all pregnancies, higher in multigavidae.


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Causes: The exact causes of implantation of the placenta in

the lower uterine segment are not known however, it is frequently associated with:

A. Endometrial scaring that can result from:– Previous placenta previa( 4-8%) recurrence after 1

placenta previa– Abortion– C/S– Increased parity– Closely spaced pregnancies


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B. Impended endometrial vascularization (inadequate blood supply) can be due to:

– Hypertension

– Diabetes mellitus

– Uterine tumor

– Smoking

– Advanced maternal age

– Drug addiction


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C. Increased placental mass

– Multiple pregnancy

– Syphilis infection


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Degrees of Placenta Previa

A. Type one/low laying/Lateral/Placenta previa

• Majority of the placenta is in the upper uterine segment

• Vaginal delivery is possible

• Blood loss is mild.

• Mother and fetus are in good health condition.

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BY GEBREMARYA TEMESGEN BSC MW

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B. Type II placenta previa/marginal/MarginalisThe placenta is partially located in the lower

uterine segment near the internal cervical os. • Vaginal delivery is possible particularly if the

placenta is anterior. • Blood loss is moderate. • Mother & fetus condition is varying. May be

mother is in shock and fetal hypoxia mayoccur. • Fetal hypoxia is more likely to occur than

maternal shock.


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C. TYPE III Placenta previa/Partial/Partialis

• The placenta is located over the internal os but not centrally.

• Vaginal delivery is inappropriate because of the placenta precedes the fetus.

• Blood loss is severe, particularly when lower segment stretches and cervix begins effacement and dilates in the pregnancy


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D. Type IV placenta previa/central/total/totalis

• The placenta is located centrally over the internal os.

• Vaginal delivery should not be considered.

• Blood loss is very severe.

• LSCS is essential in order to save the life of mother and fetus.


Degrees of Placenta Previa

Obstetrics II For Midwives By mukerem A. Oct 2014

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S/S of Placenta Previa:

• Vaginal bleeding:– The only symptom of placenta praevia is vaginal

bleeding.

– Vaginal bleeding is sudden onset, painless, and causeless.

– In about 5% 1st time during labor especially in primigravida

– Bleeding occurs before 38th wks and earlier, bleeding more likely to major degree.


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• General condition and anemia is according to visible blood loss.

• Uterus feels relaxed, soft and elastic without localized area of tenderness.

• Fetal heart rate usually present unless there is major separation of placenta.

• If bleeding is severe color is bright red blood loss.


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Indications:

• Fetal head remains unengaged in primigravida.

• Malpresentation especially breech.

• The lie is oblique or transverse

• The lie is unstable usually in a multigravida. (When after 36th wks of gestation remaining it varies from one examination to another between longitudinal and oblique


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Diagnosis & Investigations

• Localization of placenta and clinical Sonography:

– Simplest and fastest method of identifying placental localization

– Helpful to assess the fetal size and shape.

– Information of maturity

– Guidance of management

– Confirms the Dx and also grade the degree of previa.


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Assessing the Mothers Condition

• Amount of vaginal bleeding.

• Mother’s history of small repeated blood loss at interval through out the pregnancy.

• Sudden single blood loss after 28th weeks of gestation.

• Hemorrhage may be mild, moderate or severe according to activity and at rest.

• Color: bright red


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General Examination

• If hemorrhage is slight - Bp, respiration, pulse may be normal

• If hemorrhage is severe - Bp will be low; pulse is increased due to shock, respiration is increased

• Mothers color will be pale and clammy extremities.

• Skin is cold and clammy.

• Temperature is usually normal.

• Degree of shock correlates with amount of blood lost per vaginaum


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Abdominal Examination

• Normal uterine consistency.

• Lie of fetus is oblique or transverse.

• Fetal head may be high in primigravida

• No pain

NB: NEVER ATTEMPT TO DO PV!!!!!!!!!!


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Assessing Fetal Condition:

• Mother should be asked about fetal activity.

• She may be aware of diminish of fetal movement which may occur if fetal hypoxia is severe.

• Use Doppler

• Call pediatrician.


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Complications of Placenta previa:

A. Maternal:

i. During pregnancy:

• APH with varying degree of shock.

• Malpresentation is common and increased incidence of breech and transverse lie.

• Premature labor either spontaneous or induced.


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ii. During Labour: • Early rupture of membranes. • Cord prolapsed is due to abnormal attachment of

cord. • Slow dilatation of the cervix because of placenta

in lower position. • Intrapartum hemorrhage due to further

separation of placenta. • Retained placenta increased incidence of manual

removal.


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ii. During puerperium:

• Sepsis is increased due to anemia.

• Increased operative interference

• PPH


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B. Fetal Complications:

• Low birth weight due to premature labor.

• Asphyxia due to early separation of placenta.

• IUFD due to severe degree of separation of placenta and due to maternal shock


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Management of Placenta Previa :

• Depends upon the:

1. Amount of bleeding

2. Condition of mother and fetus.

3. localization of placenta

4. Stage of the pregnancy


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A. Conservative Management: is appropriate if:

• Bleeding is slight

• Mother and the fetus are well


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If bleeding is slight • The mother and fetus are well, immediately admit to

hospital at rest until bleeding is stopped. • Assess the blood loss • Vital sings are checked• Blood samples are taken for blood group & Rh type. Hb. • IV line should be started with 5% dextrose. • Blood transfusion should be arranged. • Gentle abdominal palpation & note uterine tenderness and

auscultated fetal heart rate. • Inspection of vulva, presence of bleeding dark or fresh.


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Mode of Delivery

Vaginal bleeding is usual with type one placenta previa and possible with type two placenta previa which is situated anteriorly.


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B. Active Management

• Severe vaginal bleeding will necessities immediate C/S regardless of the location of the placenta.

• Blood should be checked for cross matching, IV infusion will be in progress.

BY GEBREMARYA TEMESGEN BSC MW 31

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Note: In major cases of placenta previa( type III & IV),C/S is required even if the fetus has died in utero in order to prevent torrential hemorrhage and possible maternal death!!!!

Home work

What is

1. placenta acreta?

2. Placenta Increta?

3. Placenta Percreta?

BY GEBREMARYA TEMESGEN BSC MW 32

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2. Abruptio Placenta/Placental Abruption/Accidental Hemorrhage

Definition: Premature separation of normally situated placenta occurring after 28th (20 –28)wks of pregnancy is known as placental abruption.

Incidence:

• 1 in 50 deliveries


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Causes:It is not always clear but it is associated with • PIH(The most common cause of sever hypertension) . • Toxemia of pregnancy • Poor socioeconomic condition & malnutrition. • Trauma • Attempt external cephalic version especially under anesthesia. • Fall or blow on the abdomen.

• SUDDEN UTERINE CONTRACTION • Sudden escape of liquor amni in hydramnoius • Short cord

• Can bring about placental separation. • FOLIC ACID DEFICIENCY , smoking

• Previous abruption


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Types of Placental Abruption: A. Based on Blood lost from Abruption: 1. Revealed:

Following separation of placenta the blood is downwards between the membranes and deciduas. Blood comes out the cervical canal to the visible externally. This is commonest type. Complications are fewer. Retro placental clot is NOT formed. DIC may occur.

2. Concealed: Blood is collected behind the separated placenta or collected in between the membranes or deciduas. The collected blood is prevented from coming out of the lower segment. This type is rare.

3. Mixed: Some of the part of the blood is collected inside (concealed) and

some part is expelled (revealed). This type is very rare.


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B. Based on Degree of abruption(Clinical classification) :

1. Mild Separation

2. Moderate Separation

3. Severe Separation

Mild Separation:

• Placenta Separation and bleeding are slight

• Mother and fetus are in good condition.


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Moderate Separation:

• Placental separation of about 1/4th

• Up to 1 liter of blood may be lost

• The mother will be shocked

• The fetus may be dead of alive

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BY GEBREMARYA TEMESGEN BSC MW

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Severe Separation: • Is an acute obstetric emergency• At least 2/3rd of the placenta has been detached. • Up to 2 litter of blood may be lost• The fetus will almost certainly died.• The woman will have severe abdominal pain• The uterus will have board like

consistency(Covelaure uterus, uterine apoplexy)• Renal failure, coagulation defects & pituitary

failure( Sheehan’s synderome) may occur.


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Complications of Placental Abruption:

• DIC ( Disseminated intravascular coagulation)

• PPH due to DIC. Inj. Ergometrine 5mg IV at delivery

• Renal failure as a result of Hypovolaemia

• Pituitary necrosis(Sheehan’s Syndrome) due to severe Hypotension.


Obstetrics II For Midwives By mukerem A. Oct 2014

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Prevention:

• Prevention and early detection and effective therapy of PIH.

• Avoidance of trauma - especially forceful external version under anesthesia.

• Avoid sudden decompression of uterus due to acute or chronic hydramnoius.

• Routine administration of folic acid supplement from early stage of pregnancy


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Management of placental abruption: • Urgently to arrange for medical alerts. • Transfer to obstetrics unit and give treatment • Assessment of the blood loss, maturity of the fetus &

whether the patient is in labor or not. • Blood is sent for Hb%, ABO, Rh and Urine. • 5% dextrose is started and arrangement for blood

transfusion • If necessary oxytocin drip may be started. • If after 38th wks of gestation induction of labour to be done

by artificial rupture of membranes or with oxytocin


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• If before 38th wks of gestation if bleeding is sever LSCS to be done

• If Bleeding is less or shght or stopped only oxytcoin may be started.

• Sedation is ensured by giving inj. morphine 15mg IM or Inj. Pethedin 100-150mg.

• Blood sample is taken for Hb. Rh & Urine protein.

• Correct hypovolemic shock 5% dextrose should be started

• Arrangement made for urgent fresh blood transfusion to be done.

• Urine output should be monitored carefully & output should be at least 30-40ml/hrs.


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Management cont…

• Oxytocin drip should be started.

• If spontaneously the membranes ruptured normal vaginal delivery to be conducted with or without oxytocin drip

• AMTSL to prevent PPH

• To improve the uterine tone oxytocin should be used along with blood transfusion.


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Management Cont…• If concealed abruption placenta baby is invariably dead

in severe case and or premature vaginal delivery is possible than LSCS.

In early stage vaginal delivery is possible. In later stage • The progress of labor is delayed 6-8 hrs • General condition poor with appearance of

complication factor like oblique or faulty of fibrinogen level may be taken to LSCS because to save the life of mother and baby.


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Care of the baby:

• Preparation should be made for an asphyxiated baby.

• Pediatrician must be present during LSCS.

• Baby transfer to ICU(Intensive care unit)


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Nursing Care:

• Bp, pulse, respiration taken frequently.

• If Pyrexia is present temperature may be recorded every 1 or 2hrs.

• Urine output is accurately assessed by the insertion of an indwelling catheter.

• Urine should be send to lab for protein.


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• Fluid intake must be recorded accurately to assess the fluid balance.

• Fundal height and abdomen girth are measured hourly (Why?)

• If fetus is alive the fetal heart rate should be monitored continuously

• If there is any abnormalities in mother and fetus immediately reported to obstetricians.


Comparison Placenta previa and abruptio placenta

Abruptio Placenta

1. Severe constant pain often with loss of FHR

2. Bleeding: severe, less or absent (Concealed)

3. Shock & anemia even if the bleeding has bee slight

4. Hypertension & proteinuriais common

5. Uterus hard or tender

6. Fetal parts difficult to feel

Placenta Previa

1. Painless bleeding

2. Bleeding: severe, less or slight

3. Shock & anemia if bleeding has been severe

4. No hypertension or protienuria

5. Utersu soft & not tender

6. Presenting part is high/malpresentation


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Abruptio placenta

7. FHB is absent usually

8. Clotting defect is present usually (DIC)

Placenta previa

7. FHB is present usually

8. No clotting defeat


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3. Incidental cause/Local Causes in the vagina & Cervix):

• Crvicitis

• Vaginitis

• Cervical Polyps

• Cervical erosion

• Varicosities of the vulva

• Cervical cancer


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4. Blood Dyscrasias

• Rare: e.g. Leukaemia

5. Causes not found

• E.g. Placenta circumvallta


bleeding in late px

Healthcare

aph contc

effects of aph

degrees of placenta

previous placenta previa4

lower segment

lower uterine segment

lower pole

fetal hypoxia