L11: Antepartum Hemorrhage Flashcards by Ahmed Farag

Q

Def of Antepartum Hemorrhage

A

Bleeding in or from genital tract from 20 weeks gestation (28 weeks previously) till birth (including 1st & 2nd stages of labor).

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Q

Etiology & DDx of Antepartum Hemorrhage

A

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Q

Def of Placenta Previa

A

Placenta is partially or totally implanted in LUS after fetal viability (≥ 20 weeks).

Before 20 weeks, it is termed low lying placenta.

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Q

Incidence of Placenta Previa

A

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Q

Etiology of Placenta Previa

A

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Q

RF for Placenta Previa

A

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Q

RF for Placenta Previa

Age

A

Old age (9 fold increase in women > 40 years)

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Q

RF for Placenta Previa

Parity

A

More common in multiparas

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Q

RF for Placenta Previa

Previous Uterine Scar

A

C.S (4 folds increase) / myomectomy / deep curettage

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Q

RF for Placenta Previa

Previous Placenta Previa

A

Commonest risk factor

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Q

RF for Placenta Previa

Commonest RF

A

Previous placenta previa

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Q

Classification of Placenta Previa

A

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Q

Pathophysiology of Placenta Previa

During 3rd trimester, LUS progressively enlarges but inelastic placenta can’t stretch to accommodate this enlargement → shearing action () placenta & LUS → inevitable separation of part of placenta → unavoidable bleeding.

A

…

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Q

Pathophysiology of Placenta Previa

Separation is aggravated during labor by progressive taking up of LUS combined è downward advancement of lower pole of intact sac of membranes making double shearing mechanism on placenta.

A

…

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Q

Pathophysiology of Placenta Previa

No mechanism to stop bleeding because:

A

LUS is non retractile.
Muscle fibers of LUS are atonic è absence of decussating muscle layer.

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Q

Pathophysiology of Placenta Previa

Source of Bleeding

A

Maternal blood.

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Pathophysiology of Placenta Previa

A

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Q

Pathophysiology of Placenta Previa

Amount of Bleeding

A

1st attack is variable but recurrent attack is dangerous.

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Q

Complications of Placenta Previa

A

Maternal & fetal

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Q

Maternal Complications of Placenta Previa

During Pregnancy

A

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Q

Maternal Complications of Placenta Previa

A

During Pregnancy
During Labor
During Puerperium

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Q

Maternal Complications of Placenta Previa

During labor

A

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Q

Maternal Complications of Placenta Previa

During Puerperium

A

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Q

Maternal Complications of Placenta Previa

During Puerperium (PPH)

A

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Maternal Complications of **Placenta Previa** - During Puerperium (Puerperal Sepsis)

Fetal Complications of **Placenta Previa**

Dx of **Placenta Previa** - Hx

Dx of **Placenta Previa** - Ex

- General, Abdominal, Speculum & Local

Dx of **Placenta Previa** - Abdominal Ex

Dx of **Placenta Previa** - general Ex

Signs of hypovolemic shock (according to amount of blood loss)

Dx of **Placenta Previa** - Local Ex

Dx of **Placenta Previa** - Speculum

For exclusion of local gynecological causes of bleeding.

Indications of Local Ex in **Placenta Previa**

It has no role in modern obstetrics however, it can be done only when active treatment is indicated.

Precautions of Local Ex in **Placenta Previa**

→ Done in operating room under complete aseptic precautions & everything is ready for immediate CS if needed. → Cross matched blood should be available for transfusion if needed.

Information gained in Local Ex in **Placenta Previa**

→ Amount of bleeding. → Degree of cervical effacement & dilatation. → Relation of placental edge to internal os. → Condition of membranes. → Presentation & Pelvic capacity.

Disadvantages of Local Ex in **Placenta Previa**

→ May initiate severe attack of bleeding. → False diagnosis (mistaken for blood clots).

Investigations for **Placenta Previa**

Main Tool for Dx of **Placenta Previa**

US

advantages of US in Dx of **Placenta Previa**

Safe, simple, rapid & accurate

Types of US in Dx of **Placenta Previa**

* TAS. * TVS (more accurate but risky). - Transperineal ultrasound.

US in Dx of **Placenta Previa** - value

* Diagnosis of placenta previa & determination of its type. * Determination of fetal age, viability, size, presentation & position. * Exclusion of multifetal pregnancy & congenital anomalies.

Dx of **Placenta Previa** - MRI

Safe but expensive.

Dx of **Placenta Previa** - Others

For maternal & fetal evaluation.

TTT of **Placenta Previa** Depend on .....

1. Severity of bleeding. 2. Patient is in labor or not. 3. Type of placenta previa. 4. Fetal are & maturity.

Plan of TTT in **Placenta Previa** - Severe bleeding

Resuscitation then immediate CS.

Plan of TTT in **Placenta Previa** - Mild to Moderate Bleeding

in Labor or not?

Plan of TTT in **Placenta Previa** - Mild to Moderate Bleeding while Patient is in labor

Plan of TTT in **Placenta Previa** - Mild to Moderate Bleeding while patient is NOT in labor

Lines of TTT of in **Placenta Previa**

- 1st aid measures & resuscitation - Expectant treatment - Termination of pregnancy

Lines of TTT of in **Placenta Previa** - 1st Aid measures & resucitation

1st Aid measures & resucitation in **Placenta Previa** - Antishock Measures

a) Cross matched fresh blood transfusion. b) IV fluids (crystalloid solutions as Ringer's lactate & saline). c) Corticosteroids.

1st Aid measures & resucitation in **Placenta Previa** - IV lines

Insert 2 large wide pore cannulas & CVP catheter.

1st Aid measures & resucitation in **Placenta Previa** - Labs

CBC, coagulation profile, arterial blood gases & serum creatinine.

1st Aid measures & resucitation in **Placenta Previa** - Confirmation of diagnosis & detection of type of placenta previa

By ultrasound & double setup vaginal examination.

1st Aid measures & resucitation in **Placenta Previa** - Evaluation of Fetus

Living or dead, age, maturity & wellbeing.

Expectant TTT in **Placenta Previa** - Aim

delay TOP till fetus is mature enough (till end of 37* week).

Expectant TTT in **Placenta Previa** - Prerequiseties

Expectant TTT in **Placenta Previa** - Measures

TOP in **Placenta Previa** - Indications

1. Severe bleeding. 2. Patient is in labor. 3. Mature fetus (patient 1st seen after 37 weeks).

Methods of TOP in **Placenta Previa**

- CS - Vaginal

Indications of CS in **Placenta Previa**

Why is Placenta previa type Il posterior (More dangerous)?

Type of CS in **Placenta Previa**

LSCS (allows better control of bleeding).

CS in **Placenta Previa** - fetal Approach

CS in **Placenta Previa** - Precautions

1. Operation should be managed by senior obstetrician & anesthetist. 2. Care from PPH.

Vaginal delivery in **Placenta Previa** - Prerequisities

Vaginal delivery in **Placenta Previa** - Precautions

1. Continuous fetal & maternal monitoring. 2. Care from PPH.

Vaginal delivery in **Placenta Previa** - Old Vaginal Methods

**Used only in dead or hopeless fetus è severe bleeding:** 1. Willett's scalp forceps. 2. Bipolar podalic version & bringing down leg to compress placenta by 1/2 breech.

Another name of **Placental Abruption**

Accidental Hemorrhage

def of **Placental Abruption**

APH due to separation of normally implanted placenta before 3rd stage of labor.

Incidence of **Placental Abruption**

1% of deliveries.

Etiology of **Placental Abruption**

Compare between HTN **Placental Abruption** & Non-HTN **Placental Abruption** in terms of: - Historic Name - Incidence - Parity - Causes

Causes of Non-HTN **Placental Abruption**

Pathogenesis of HTN **Placental Abruption**

Pathogenesis of Non-HTN **Placental Abruption**

Classification (Types) of **Placental Abruption**

- Clinical & Severity

Classification (Types) of **Placental Abruption** - Clinically

1) Revealed accidental Hge 2) Concealed accidental Hge 3) Mixed (combined) accidental Hge

Classification (Types) of **Placental Abruption** - Severity (Sher's)

Sher's Classification **Placental Abruption** - Grade 0

Small retroplacental hematoma discovered on maternal surface of placenta after delivery (no APH)

Sher's Classification **Placental Abruption** - Grade I

Mild revealed or mixed Hge + uterine tetany & tenderness + no fetal distress + no maternal shock.

Sher's Classification **Placental Abruption** - Grade II

Moderate revealed or mixed Hge + uterine tetany & tenderness + fetal distress + no maternal shock.

Sher's Classification **Placental Abruption** - Grade III

Assessment of severity of Bleeding in **Placental Abruption**

Complications of **Placental Abruption**

Fetal & Maternal

Fetal Complications of **Placental Abruption**

Maternal Complications of **Placental Abruption**

Maternal Complications of **Placental Abruption** - Shock

Partly hypovolemic (Hge) & partly neurogenic (ry to peritoneal irritation).

Maternal Complications of **Placental Abruption** - Renal failure

Maternal Complications of **Placental Abruption** - Sheehan Syndrome

Due to ischemic necrosis of anterior pituitary.

Maternal Complications of **Placental Abruption** - DIC

Maternal Complications of **Placental Abruption** - Couvelaire uterus (uteroplacental apoplexy)

Maternal Complications of **Placental Abruption** - PPH

Compare between **Revealed PA** - **Concealed PA** - **Mixed PA** in terms of: - Incidence - Placental Separation - Pathway of Blood - Bleeding - Symptoms (Vaginal Bleeding, Pain, Cause) - General Signs (Shock, Cause) - Abdominal Signs (Uterus, Fetal Parts, FHS) - Local Signs (Vaginal Bleeding, Placenta, Membranes)

Compare between **Revealed PA** - **Concealed PA** - **Mised PA** in terms of: - Incidence

Compare between **Revealed PA** - **Concealed PA** - **Mised PA** in terms of: - palcental Separartion

Compare between **Revealed PA** - **Concealed PA** - **Mised PA** in terms of: - Blood Pathway

Compare between **Revealed PA** - **Concealed PA** - **Mised PA** in terms of: - Bleeding

Compare between **Revealed PA** - **Concealed PA** - **Mised PA** in terms of: - Symptoms

Compare between **Revealed PA** - **Concealed PA** - **Mised PA** in terms of: - General Signs

Compare between **Revealed PA** - **Concealed PA** - **Mised PA** in terms of: - Abdominal Signs

Compare between **Revealed PA** - **Concealed PA** - **Mised PA** in terms of: - Local Signs

Investigations in **Placental Abruption**

- US - Labs - Others

US in **Placental Abruption**

For exclusion of placenta previa, detection of retroplacental hematoma & determination of fetal age, viability, size, presentation & position.

Labs in **Placental Abruption**

CBC, coagulation profile & renal function tests.

Other INVx in **Placental Abruption**

For detection of the cause (as PET) & for maternal & fetal evaluation

TTT of **Placental Abruption** Depends on .....

1. Fetus is living or dead. 2. Severity of bleeding. 3. Fetal wellbeing, age & maturity (if fetus is living). 4. Patient is in labor or not.

Bleeding in concealed types is Concealed due to:

DDx of **Placental Abruption**

Plan of TTT of **Placental Abruption** - Dead Fetus

Resuscitation then vaginal delivery

Plan of TTT of **Placental Abruption** - Living Fetus

Plan of TTT of **Placental Abruption** - Living fetus with severe abruption

Resuscitation then immediate CS.

Plan of TTT of **Placental Abruption** - Living fetus with non severe abruption

Lines of TTT of **Placental Abruption**

- 1st Aid Measures - Expectant TTT - TOP - TTT of Cause - TTT of Complications

Lines of TTT of **Placental Abruption** - 1st Aid Measures

As in placenta previa + Exclusion of placenta previa & detection of retroplacental hematoma.

Lines of TTT of **Placental Abruption** - Expectant TTT

As in placenta previa.

Lines of TTT of **Placental Abruption** - TOP

Vasginal & CS

Indications of TOP in **Placental Abruption**

Usually, pregnancy is terminated in all cases except cases fulfilling criteria for expectant treatment

Methods of TOP in **Placental Abruption**

Vaginal & CS

Indications of Vaginal Delivery in **Placental Abruption**

Method of Vaginal Delivery in **Placental Abruption**

AROM + Oxytocin drip or PGs according to situation.

Value of AROM in Vaginal Delivery in **Placental Abruption**

Advantages of Vaginal Delivery over CS in **Placental Abruption**

1. Less blood loss. 2. Avoidance of coagulopathy during CS (in vaginal delivery, bleeding stops by uterine contractions while in CS, bleeding stops by coagulation mechanism which is deficient).

Vaginal Delivery in **Placental Abruption** - Precautions

1. Abdominal binder. 2. Continuous fetal & maternal monitoring. 3. Care from PPH.

CS in **Placental Abruption** - Indications

1. Severe bleeding. 2. Deteriorating maternal condition. 3. Living fetus (rarely found) è fetal distress. 4. Failed vaginal delivery (for 8 hours). 5. Other indications for CS.

CS in **Placental Abruption** - Precautions

Lines of TTT of **Placental Abruption** - TTT of the Cause

TTT of preeclampsia.

Lines of TTT of **Placental Abruption** - TTT of Complications

TTT of renal failure & DIC.

Compare between placenta previa centralis & placental abruption

OSCE