Antepartum haemorrhage Flashcards
Antepartum hemorrhage
- Definitions
- Causes
Definition:
Hemorrhage from vagina after 24th week of gestation.
Causes:
1. Hemorrhage from placenta and uterus
a. Placenta previa
b. Placental abruption
c. Uterine rupture
- Genital tract lesions
a. Cervical carcinoma
b. Cervicitis
c. Polyps
d. Infections - trichomatosis - Fetal vessels bleeding
a. Vasa previa - unprotected (no placental tissue) fetal
vessels traverse the fetal membranes over the
internal cervical os and below the presenting part of
the fetus.
Velamentous cord insertion –
a condition when part of the umbilical
cord traverse through the fetal
membranes (chorion and amnion) to
the placenta and not normally
directly to the placenta. In this
condition the cord is not protected by
Warthon’s jelly. Painless! Usually
suddent onest or after rupture of
membrane
Placenta Previa
Definition
Definition:
Mal-implentation (sometimes also maldevelopment) of the placenta where it attaches near or over the
cervical opening due to delayed blastocyst implantation.
When lower segment occurs (uterine
stretching) and cervix effaces this causes bleeding. Can have sudden onset or prior to rupture of membranes.
Placenta Previa
Types
Classification (marginal or complete):
1. Grade I (low lying) – less than 2cm from internal os
2. Grade II (marginal) – reaches internal os (usually ends up in normal delivery).
a. Posterior grade II – when the placenta Infront of sacrum and prevents fetal descent.
3. Grade III (partial) – partially covering internal os (require C section).
4. Grade IV (complete) – completely covers internal os, all placenta in lower segment (require C
section).
Placenta Previa
Rx, Sx, Dx
Risk factors:
1. Previous pregnancies
2. Previous surgeries
3. Previous placental previa
4. Smoking and cocaine
5. Maternal age
Symptoms:
1. Painless bleeding
2. Malpresentation of fetus
3. Normal uterine tone
Diagnosis:
1. Visual examination
2. Ultrasound
a. Transabdominal
b. Transvaginal – for posterior placentas. Determine distance from cervical os to lower
placental margin.
Placenta Previa
Management
- No active bleeding and no fetal distress
a. Hospitalization and 48h observation
b. Conservative treatment of resting, manage bleeding (iron and transfusion when
necessary) and CTG → get close to due day as possible.
c. If <37 weeks use corticosteroid (betamethasone) and tocolysis (MgSu) in mild uterine
contractions
- Acute bleeding or fetal distress
a. If <37 weeks
i. Vaginal examination - done in operating room prepared for C section.
ii. Stabilization and emergency C-section.
b. If >37 weeks immediate delivery
Placenta Previa
Complications
Complications:
1. Fetal hypoxia
2. Maldevelopment
a. Placenta accerta – attached to myometrium)
b. Placenta increta – invades myometrium)
c. Placenta precreta – invades parametrium
Placental abruption
Definition:
Hemorrhage from premature separation of the placenta from the uterus.
Risk factors:
1. Dietary deficiency (especially folic acid)
2. Smoking
3. HTN
4. Thrombophilia
5. Trauma
Classification (clinically unimportant):
1. Revealed
2. Concealed
3. Mixed
Placental abruption DD from
placenta previa
Symptoms:
Painful vaginal bleeding
Increased uterine contractions
Longitudinal lie of fetus
Placental abruption pathogenesis
Blood in the uterine wall causes increase in resting tone and onset of contractions as well as clot
formation (consumption of maternal clotting factors which promotes further bleeding).
Placental abruption
Management
- General approach
a. Blood transfusion and IV fluids
b. Monitor vital signs
c. Clotting factors
d. Maintain airway
e. Anti-D Ig antibodies in Rh(-) mother
f. Ultrasound – assess fetal growth and placental site - Normal findings:
a. <34 weeks
i. Observe and monitor
ii. Use corticosteroids and tocolytics to aim for normal delivery
b. >34 weeks
i. If active uterine contractions attempt vaginal delivery
ii. If no contractions and no fetal distress and no bleeding → conservative
treatment (as in placental previa) - Acute symptoms and live fetus:
a. Induction of labor with syntocinon and vaginal delivery – only when close to term
b. Otherwise, emergency C-section regardless of gestational age
- Acute symptoms and dead fetus:
a. Induction of delivery or emergency C-section in case of maternal risk due to bleeding or
slow labor progression.
General approach Placental abruption
a. Blood transfusion and IV fluids
b. Monitor vital signs
c. Clotting factors
d. Maintain airway
e. Anti-D Ig antibodies in Rh(-) mother
f. Ultrasound – assess fetal growth and placental site
Normal findings management
Placental abruption
a. <34 weeks
i. Observe and monitor
ii. Use corticosteroids and tocolytics to aim for normal delivery
b. >34 weeks
i. If active uterine contractions attempt vaginal delivery
ii. If no contractions and no fetal distress and no bleeding → conservative
treatment (as in placental previa)
Placental abruption
Acute symptoms and live fetus
a. Induction of labor with syntocinon and vaginal delivery – only when close to term
b. Otherwise, emergency C-section regardless of gestational age
Placental abruption
Acute symptoms and dead fetus
Acute symptoms and dead fetus:
a. Induction of delivery or emergency C-section in case of maternal risk due to bleeding or
slow labor progression.
