(BLEEDING IN LATE PREGNANCY)

Question 1

• Bleeding in late pregnancy is a common and major cause of…….

It includes— & —

• Both APH and PPH are associated with………

Answer 1

• Bleeding in late pregnancy is a common and major cause of maternal morbidity and mortality

Includes APH—ANTEPARTUM HAEMORRHAGE
and PPH—POST PARTUM HAEMORRHAGE

• Both APH and PPH are associated with hemodynamic compromise of the woman, and consequently foetal compromise as well

Question 2

APH is………..

Ante means ?
Partum. Means?

APH is a major cause of.,…..

Answer 2

ANTEPARTUM HAEMORRHAGE (APH)
⎯ Is bleeding from the genital tract of a pregnant woman after the 28th week of pregnancy and before delivery of the baby

• Ante= before; partum= birth of baby

• A major cause of maternal mortality and morbidity

Question 3

Causes of APH

Answer 3

Causes of APH
I. Bleeding from the placental site
1. Placenta praevia (abnormally situated placenta)—bleeding occurs when such abnormally situated placenta separates
2. Abruptio placenta—premature separation of a normally situated placenta.
II. Bleeding from local lesions in the genital tract
1. Carcinoma of the cervix
2. Cervical erosion
3. Cervical polyp
4. Acute cervicitis and vaginitis, espacially from Trichomonas vaginalis
infection

III. Ruptured uterus
⎯ Uterine rupture usually occur during labour but can occur antenatally (especially if a weak uterine scar is present)
IV. Bleeding from vasa praevia
• This is the condition which foetal blood vassels traverse the lower uterine segment in advance of the presenting part.
• Can occur in the following situations if the placenta is low-lying and:
⎯ The cord does not insert into the central part of the placenta, but inserts in the membranes at some distance from the margin of the placenta.

• In this case the vessels must traverse the membranes. This is velamentous insertion of the cord. If the vessels run in the membranes over the internal os to reach the placenta, the vessels are called vasa praevia
⎯ If the placenta is bilobed (i.e., there are two separate placentas which are roughly equal in size), or multipartite (i.e., more than 3), and the vessels of one placenta run through the membranes overlying the os
⎯ If there is a succenturiate lobe, (i.e., there are two separate placentas,
with one much smaller than the other), and the vessels supplying the
succenturiate lobe run in between the membranes overlying the os

Question 4

Risk factors for vasa praevia

Clinical features

Answer 4

Risk factors for vasa praevia
ØBilobed and succenturiate placentas ØLow-lying placentas
ØMultiple pregnancies
ØPregnancies resulting from IVF ØMarginal insertion of the cord

Clinical features
• Depends on the cause
1. Bleeding per vaginum with likely shock (commonest cause)
2. Foetal compromise if bleeding is severe
3. Discharge per vagina (especially if there are local causes such as Cervical Ca)
4. Abdominal pain (especially if uterine rupture)
5. Other features

Question 5

Treatment

Investigations

Answer 5

Investigations
• Mainly USG
vMedical
⎯ Resuscitation

Treatment
⎯ Blood transfusion
⎯ Bed rest
⎯ Avoid digital vaginal examination (for fear of placenta praevia) ⎯ Pain relief
⎯ Others, depending on the cause
vEmergency delivery (surgery)

Question 6

POST PARTUM HAEMORRHAGE (PPH)

PPH is Genrally divided into 2 ? Explain each

Answer 6

POST PARTUM HAEMORRHAGE (PPH)
• Genrally divided into early (primary) and late (secondary)

• Primary PPH—
⎯ bleeding from the genital tract in excess of 500ml and within 24hr of delivery of the baby, or any amount of bleeding within that period which is enough to compromise the health or haemodynamic state of the woman
⎯ May also be defined interms of the haematocrit levels

• Secondary PPH—bleeding occuring between 24hr and 6 weeks of
delivery.
• >99% of PPH are early (primary)

Note! Acceptable blood loss during C/S may be higher than that of vaginal delivery.

Question 7

Causes of Primary PPH

Answer 7

Causes of Primary PPH
• 4Ts + others
1. Tone (uterine atony)—commonest cause
2. Trauma—lacerations and haematomas of the lower genital
tract (2nd commonest)
3. Tissue (retained placenta)—may be caused by uterine atony and morbidly adherent placenta
4. Thrombin (clotting defects)
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• Others
vRuptured uterus
vAcute inversion of the uterus

• Secondary
• Retained placental tissue
• Infection
• Subinvolution of the placental site

Question 8

Clinical features

Investigations

Treatment

Answer 8

Clinical features
• Bleeding per vaginum
• Features of shock
• Fever
• Other signs and symptoms
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Investigations
• Diagnosis is mainly clinical, often using a speculum examination
• But other investigations that may be relevant: • Clotting profile
• USG
• CT Scan
• MRI
• Blood culture • FBC
• BUE&CR
• LFT
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Treatment
• Medical
• Resuscitation
• Blood transfusion
• Pain relief
• Manual removal of retained placenta
• Surgery
4-Feb-202

Question 9

CONCLUSION

Answer 9

CONCLUSION
• APH and PPH are the most common cause of maternal mortality in developing countries
• APH-–bleeding from the genital tract of a pregnant woman after the 28th week of pregnancy and before delivery of the baby
• PPH—bleeding from the genital tract in excess of 500ml and within 24hr of delivery of the baby, or any amount of bleeding within that period which is enough to compromise the health or haemodynamic state of the woman
4-Feb-2022