Antepartum hemorrhage

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ANTEPARTUM HAEMORRHAGE(APH)

• MD III Lecture
• 2023
• Dr. M. Chiduo

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CASE STUDY

• Madame Mba is a 29-year old woman Para 4, was
  admitted at 32 weeks gestation in her fifth
  pregnancy with a history of sudden onset of
  fresh, red vaginal blood loss not associated with
  pain. O/E A Breech presentation was noted and
  the fetal heart beat was present. Ultrasound scan
  showed an anterior placenta extending down, and
  covering the internal os. The bleeding settled
  and the mother was delivered by Elective
  Caesarean section at 37 weeks.

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Antepartum Haemorrhage .

• APH Is bleeding from or into the genital tract
  after 28th week of pregnancy and before the onset
  of labour.
• Obstetric Causes
• Placenta praevia,
• Abruptio placentae ,
• Vasa praevia
• Heavy/bloody show
• Uterine Rupture

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Antepartum Haemorrhage ...

• Non obstetric causes
• Cervicitis
• Cervical polyps
• Cervical dysplasia or cancer
• Varicose veins
• Vaginal lacerations
• Vaginitis

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PLACENTA PRAEVIA

• Definition Placenta praevia is the implantation
  the placenta wholly or partially in the lower
  segment of uterus.
• Incidence Occurs in approximately 1200 births

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Aetiology

• Unknown
• Predisposing factors
• Age
• High parity
• Multiple pregnancy
• Previous Uterine scar(Caesarean section), Chronic
  Endometritis, Repeated DC
• Uterine myomas(fibroids)

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Causes of bleeding

• Mechanical separation of the placenta during the
  formation of the lower segment, effacement of the
  cervix, dilatation of cervix during labour and
  intravaginal manipulation
• Placentitis
• Rupture of poorly supported venous lakes in the
  decidua basalis that has been engorged with blood

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Types

• I- Lateral Low lying and a small part dips into
  the lower segment
• II- Marginal Touches/encroaches the internal
  os of the cervix
• III- Central Incomplete or Partial Covers
  partially the cervix
• IV- Central Complete Covers completely the
  cervix

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Clinical Features Diagnosis

• Painless vaginal bleeding
• May be a single or repeated episodes
• Mild moderate or severe
• The blood is fresh, bright red
• On abdominal examination
• Lie Oblique or transverse and unstable lie
• Malpresentation Breech
• High presenting part , NOT ENGAGED free and mobile

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Clinical Features Diagnosis.

• WARNING NO DIGITAL VAGINAL EXAMINATION. Where
  there is no Ultrasound, Examination can be done
  with the theatre ready in case of the need for
  Emergency Caesarean section.
• Speculum examination to rule-out incidental
  causes
• Diagnosis Ultrasound scanning , placental
  location on lower segment

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Management

• Depends on
• The amount of blood loss
• The condition of the mother and fetus
• Location of the placenta/type
• The gestational age

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I- Conservative Management

• Asymptomatic, slight bleeding
• Mother and fetus are well
• Preterm pregnancy lt37 weeks
• Type I II

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Conservative Management

• Type I II and Asymptomatic
• Bed rest at home and follow up every 2 weeks
• Type III IV
• Admit for close monitoring and observation
• Perform ultrasound to confirm localization the
  placenta

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Conservative Management

• Check FBP, Coagulation tests, Blood grouping and
  cross matching. Keep at least 2 units of blood
  ready in the bank for transfusion in case of
  acute bleeding
• Consider Blood transfusion if indicated
• Avoid vaginal digital examination

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Conservative Management

• lt34 weeks
• Dexamethasone Inj. (IM) 6mg 12hourly for 48 hours
  for fetal lung maturation
• Nifedipine tabs(PO) 20mg 8hourly until symptoms
  subside
• gt34 weeks and no PV bleeding or
  contraction(expectant management)
• Deliver by Cesarean section preferably at 3738
  weeks of gestation

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II Active management

• Recurrence of bleeding
• Severe bleeding
• Onset of labour
• Type III IV
• Independent of the Gestational Age
• Deliver by Emergency Caesarean Section
• Type I II Carefully Perform Amniotomy(artificial
  rupture of membranes) for Vaginal Delivery if the
  head is Engaged.

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The EndThank You for your attention!