Antepartum hemorrhage Flashcards
Definition of antepartum hemorrhage
- PV bleed after 22 weeks till birth of baby
Cause of antepartum hemorrhage
> Maternal
- Indeterminate 45%
- Abrruptio placenta 30%
- Placenta praevia 20%
- Local cause 5% (eg: vaginitis, cervical polyp, extropion, carcinoma)
> Fetal
- Vasa praevia
Definition of placenta praevia
- Placental lying partly or wholly within the lower uterine segment (>28 weeks)
- <28 weeks = low lying placenta
- Confirm at 32 weeks of gestation as the formation of lower uterine segment is complete
- Bleeding is from mother
Types of placental praevia
> Major - >2cm from os
- Type 1 (Lateral): edge 5cm from internal os
- Type 2 (Marginal): edge of placenta at the margin of internal os
> Minor - <2cm from os
- Type 3 (Partial): partially cover internal os
- Type 4 (Central): completely cover internal os
Risk factor of placental praevia
> Maternal
- Advance maternal age
- Grandmultipara
- Smoking
- Previous C-section
- Uterine structural abnormalities
- Assisted conception
> Fetus
- Multiple pregnancy
Diagnosis of placental praevia
- Ultrasound: localization of placenta
Management of placental praevia
> Before 32 weeks
- F/u at 32 weeks to confirm placental location
> At 32 weeks
- Confirm PP
- If Hx of APH -> admitted to ward
- Not complicated -> outpatient mx (weekly FBC & GSH, 2 weekly ultrasound scan) till 36 weeks -> admit ward
> At 38 weeks
- Best timing for ELSCS
- Earlier if IUGR/ placental accrete
Mode of delivery for PP
> Minor - SVD
- Type 1
- Type 2 anterior
> Major - ELSCS
- Type 2 posterior
- Type 3, 4
Indication that allow SVD for PP minor
- Placental to os distance: anterior >2.5cm; posterior >3cm
- Head must be engaged
- No active PV bleeding during labor
Complication of placental praevia
> Maternal
- PPH
- Placental abruption
- Caesarean hysterectomy
- Placenta accrete in next pregnancy
> Fetus
- Prematurity/ Preterm delivery
- IUGR
- Abnormal lie
Definition of placental abruption
- Premature separation of placenta prior to the 3rd stage of labor
- Bleeding is from both mother and fetus
Risk factor of placental abruption
> Maternal
- Defective trophoblastic invasion (eg: preeclampsia, PIH)
- Direct abdominal trauma
- Sudden decompression of uterus (eg: after delivery of 1st twin, release of polyhydramnios)
- History of placenta abruption
- Smoking, alcohol
> Fetus
- Uterine overdistension (eg: multiple pregnancy, polyhydramnios)
Investigation for placental abruption
- FBC: reduce Hb, platelet and hematocrit, fibrinogen; increase fibrinogen degradation product, D-dimer
- Coagulation profile: increase PT/aPTT
- GXM
Management of placental abruption
> Fetus alive
- Severe preterm -> conservative mx
- ARM + oxytoxin
- Continuous CTG monitoring
- LSCS is any of them compromised
- Peads for neonatal resuscitation
- Watch for PPH
> Fetus dead
- Assess maternal stability and coagulopathy
- Vigorous replacement of fluid and blood products
- Correct any coagulopathy
- Vaginal delivery unless severe hemorrhage
- Watch for PPH
Complication of placental abruption
> Maternal
- Couvelaire uterus (blood seeping into uterus myometrium causing atony)
- DIC (due to profuse bleeding + thromboplastin release from decidua)
- PPH
> Fetus
- IUGR
- Preterm delivery
- Perinatal death
