Partum -Ante

Heamorrhage

•Dr Hisham Al-rahahla

Def. :

Bleeding from the genital tract

between 28th

weeks of preg. &

onset of labour .

(28 weeks was the limit of fetal

viability)

Causes :

- P.P.

- Accidental heamorrhage.

- Undetermined.

- Local Ca.

- Vasa praevia.

C.E.M.D.

M.M. :

- Inadequate resuscitation.

- Inexperienced doctors & delay

in senior staff responding to

calls for help.

Fetal Loss :

Commoner than M.M. in one study

14% of the losses were

associated with APH .

Mx. Of massive

obstetric Hge

1. Summond help.

2. Take bl. For xmatch, coag. Studies.

3. Transfusion of bl.

4. At least 2 periph. Lines.

5. Facilities that should be available

(CVP, intraant. press., ECG, ABG) .

6. Discuss with haemotologist.

7. Rapid infusion: compression calf,

blood warming. No need for

filtration.

General Principles of

Mx.

- Maternal & fetal condition must be

assessed.

- Maternal resuscitation must be

started promptly .

- Consideration must be given to early

delivery if there is evidence of fetal

distress & if baby is of sufficient

maturity to survive .

- V/E by speculum or digitaly must be

postponed till PP is R/O by U/S .

- Anti D .

Placenta Praevia

Def. :

Placenta situated wholly or

partially within the L. Segment

at or after 28 weeks.

Incidence :

0.55% range (0.29 – 1.24%)

follows def.

PNM 81/1000 . 22% due to

RDS. MM is rare but morbidity

hosp. & C/S.

Classification :

Helps in Mx. 6 types of class. But

follow U/S classification.

Types :

I Low lying, within 5 cm. of the OS

II Marginal

III Partial, partially covering the OS

IV Total , completely covering the OS

Etiology & Ass. Factor

• Cause unknown but certain factors

predispose to it :

1. Parity ranges from 0.2% to 5% .

2. Mat. Age increase with age 3

X > 35 yrs.

3. Ethnic origin: slightly higher

in blacks.

4. Placental size more in twin .

5. Endometrial damage .

6. Preterm del. 2.9% 28-37 weeks.

7. Previous C/S increased in linear way

mainly in the preg. Following.

8. Smoking & compersatory pl. enlargement.

9. Ut. Scars & path. Myomectomy, submuc.

Fibroid, ut. Adhesions.

10. Pl. pathology: marginal or vilamentous

cord insertion, succinaturate lobe

11. Previous p.p. recurrence 4 – 8% .

Associated Preg.

Complications

• Spont. Abs.

• PIH protective

(prematurity).

• Abn. Placentation (acreta).

Increased esp. with previous C/S

• Malpresentation (breech/TV lie)

• SGA conflicting !? No difference.

Diagnosis :

1/3 are asymptomatic.

Routine Dx. :

U/S abdo. 93-97% accuracy .

false -ve 7%

Vag. U/S Better resolution

less false -ve

rarely is essential (obesity-post

placenta)

MRI :

The most accurate costly, not

routine.

May be in special cases …

“Acreta”

Management

Basics :

- No V/E.

- Prolongation of preg till

maturity.

- Transfusion support .

- Delivery by C/S .

The av. time of complication is 35 wks.

* If starts earlier PNM

The Asymptomatic Pt.

1/3 of pts. with PP

1. ? Admission in the last trimester.

2. Serial rescanning till 38 wks.

Particularly I & II

3. Maintain Hb at higher N. limits.

4. Del. By C/S for all II, III, IV not

before 37 weeks.

Type I rescan at 36-37 wks. If BPD

is below loweredge of placenta

allow labour .

The Symptomatic Pt.

Depend on 2 factors :

* Fetal maturity .

* Degree of hge.

Deliver immediately :

Any bleeding at :

* Fetal maturity.

* Fetal distress at viable gest.

* Persistent hge.

Initial Mx.

• Assess maternal CVS followed

by fetal assessment .

• IV 16 gauge cannula .

• Hb., x match, clotting studies.

• Crystalloid, calloid if heavy loss.

• Fetal monitoring (at viable gestation

means possible C/S at fetal

compromise)

Tocolytics ?? Be careful time to give

steroids.

nefidipine MgSO4 NSAI

Cx. cerclage

• Vasa Praevia rare .

Vag. Blood can be tested for

fetal Hb.

Women stabilized following a

bleeding episode at any time should

be hospitalized for the rest of their

preg.

? Social stress

PPH Suspect, ut. Atony

synto, carboprost., ut. artery

lig. Hystrectomy.

transfusion

Anaesthesia : G.A.

LSCS : If placenta is ant. Avoid

cutting through it. No place for

double set up examination.

Abruptio Placenta

Def. :

Premature separation of a

normally sited placenta. It is a

self extending process.

Causes :

Unknown

Causes :

• Hypertension.

• The “sick placenta” .

mid trimester FP with fetal abn.

IUGR, prem labour & pl. abruption.

( uteropl. Doppler waveform )

not screening

3. Trauma , usually RTA

ECV & cordocentesis.

4. Fibroid

5. Cocaine still uncertain.

6. Rupture of memb. Esp. in

polyhydramnios .

7. F.A. def. : evidence not

convincing.

8. Multiple preg. Cause unclear.

9. Chorioamnioritis esp. with

PROM .

Clinical Presentation :

• Bleeding Concealed

revealed

• Pain Continuous

intermittent labour

Dx. :

Clinical

Confirmed after del.

U/S minimal role .

Mx.

• Early del.

• Adequate bl. Transfusion.

• Adequate analgesia.

• Monitoring of mat. Condition.

• Assessment of fetal condition.

Mat. Risks (hgic shock, ARF,

Coagulopath.)

Fetal hypoxia & sudden death.