OBSTETRIC HAEMORRHAGE

JAYAKUSUMAFETOMATERNAL DIVISION

OBSGYN DEPTFAC,MED UDAYANA UNIVERSITY

DEFINITION ABORTION IS THE TERMINATION OF

PREGNANCY,EITHER SPONTANEUSLY OR INTENTIONALY , BEFORE THE FETUS DEVELOPS SUFFICIENTLY TO SURVIVE.

USUALY DEFINE AS PREGNANCY TERMINATION PRIOR TO 20 WEEKS GESTATION OR LESS THAN 500 GRAM BIRTH WEIGHT

DEFINITION VARY, ACCORDING TO ABILITY TO TREAT THE EXTREMELY PRETERM UNBORN BABY.

SPONTANEOUS ABORTION Abortion occurring without medical or

mechanical means to empty the uterus. Etiology : - > 80% occur in the first 12 weeks of

pregnancy and the etiology is chromosomal anomalies

- after 12 weeks incidence of abortion and chromosomal anomalies are decrease .

etiology1. Fetal factors : - abnormal zygotic development - aneupoid abortion2. Maternal factors : - infections - endocrines disorders( progesterone def, diabetes

mellitus) - nutrition - drug use ( tobacco,alcohol,radiation,toxins) - immunological factors ( APA) - trauma - uterine defects - cervix incompetence

Etiology (2) 3. Paternal factors : - sperm chromosomal anomalies.

Spontaneus Abortion ( cont)

Pathology : early abortion : beginning with bleeding

into the decidua basalis necrosis of tissues adjacent the bleeding conceptus detaches uterine contraction expulsion

Later abortion : retained conceptus maceration the skull bone collapse,abdomen distended when amniotic fluid absorbed fetus become compressed fetus compresus fetus become dry fetus papyraceus.

Subgroup of spontaneus abortion

Clinically spontaneous abortion separate into 3 subgroup :

1. Threatened abortion 2. Inevitable abortion 3. Complete abortion or incomplete

Threatened abortion Bleeding appears through a closed cervical os Bleeding maybe spooting or heavier, may persist

for days-weeks Half of this condition will abort, especially if fetal

cardiac activity is absent Clinic manifestations : bleeding and abdominal cramping ( dull, midline

and supra pubic discomfort) DD/ : polyps, cx erosions, ectopic pregnancy√ R/ : bed rest Analgesics follow up : USG, bHCG levels

Inevitable Abortion Rupture of membrane, followed by escape of

amniotic fluid, bleeding, pain, fever. Clinical manifestations : - rupture of membrane - evidence of leaking amniotic fluid - bleeding and pain - cervical dilatation - feverManagement : bed rest, observed for 2-3 days

usual activities (+), except for vaginal examination

Incomplete abortion Expulsion of the fetus, placenta in part from the

uterus or the conceptus remain entirely in utero may partially extrude through the cervical dilated os.

Bleeding may severe Clinical manifestations : - bleeding, pain, abdominal cramp - cervical os remain open - retained placental tissue lies in cervical canalManagement : - stabilize hemodynamic by fluid replacement - extracting the retain placenta by ring forceps - if bleeding occur heavily suction curettage ASAP

Complete abortion Expulsion of the fetus, placenta in whole

from the uterus or the conceptus escape completely from uterus

Clinical manifestations : - cervical os closesManagement : -observed

Ectopic pregnancy Implantation of the conceptus anywhere

out of endometrial lining of the uterine cavity

Could be uterine or extra uterine Uterine : cervical Extra uterine : fallopian tube, fimbriae,

broad ligament, ovarial or abdominal Almost 95% occurred in the fallopian

tube. The chance of successful pregnancy after

ectopic pregnancy decreased

Ectopic pregnancy (cont) Risk : 1. Pelvic inflammatory diseases 2. Tubal surgery 3. infertility Pathogenesis : the fertilized ovum, implanted in ectopic place ( fallopian

tube )the tube lacks of submucosal layer zygote comes to lie in the muscular wall tropoblast rapidly growing and invades/ erodes the muscular wall bleeding to the tube canal to abdominal cavity or backward to the uterine cavity ( TUBAL ABORTION)

Location of tubal abortion : ampulla if the tube ruptured abdominal bleeding ( TUBAL RUPTURED) Location of tubal ruptured : istmic

Ectopic pregnancy ( cont 3)

Clinical manifestations and Diagnosis : - Clinical manifestation is depend on whether rupture has occurred or not - early and prompt diagnosis identify the tube before rupture - pelvic or abdominal pain - amenore - spotting or bleeding - abdominal or pelvic tenderness - uterine changes push to one side by ectopic mass - passes of uterine decidual cast bleeding - Blood pressure and pulse - Pelvic mass -- > pain and tenderness - Culocentesis to identify the hemoperitoneum by inserted the needle

through the posterior fornix into the cul de sac. - Laboratory : B HCG and USG

Ectopic pregnancy (cont 4) Treatment :1. Surgical : Conservative surgery : tubal salvage (salphyngostomy) Radical Surgery : Salphyngectomy2. Medical : Methotrexate : highly effective against active tropoblast dose : Mtx Variable dose : 1 mg/kg IM, days 1,3,5,7 3. Expectant Management :- criteria : tubal pregnancy only, b HCG decreased, no

abdominal bleeding, diameter of ectopic mass < 3,5 cm

Placenta previa Placenta is located over or very near the internal os. Four degrees of placenta previa : 1. Total Placenta previa: the internal cervical os is

covered completely by placenta 2. Partial placenta previa : the internal os is

partially covered by placenta 3. Marginal placenta previa : the edge of

placenta is at the margin of internal os 4. Low lying placenta : the placenta is implanted

in the lower uterine segment such that the placental edge actually doesn’t reach the internal os but in close proximity to it

Placenta previa (cont 2) Etiology : 1. Advance maternal age 2. Multiparity 3. Previous CS Clinical findings : painless hemorrhage at the of the 2 trimester

or 3 rd trimester its onset without warning initial bleeding is not previous, subsequent

bleeding heavier

Placenta previa (cont 3) Management : --> depend on : 1. fetus preterm or aterm 2. bleeding severe or not management with preterm fetus and no active bleeding is

Conservative, bed rest to prolong pregnancy until the fetus mature

informed the family regarding the problem of placenta previa

every placenta previa should be manage in the tertiary hospital.

- delivery by CS : term baby and or active bleeding !!! Don’t perform the vaginal examination can cause severe

bleeding .

Placental abruption Separation of the placenta from its normal

site of implantation before delivery If bleeding escapes through the cervix

external hemorrhage If bleeding retained in uterus concealed

hemorrhage. Etiology : primary causes is unknown risk factors : increased age and parity,

preeclampsia, PROM, hydramnios .

Placenta abruption (cont 2)

Pathogenesis: initially there is hemorrhage into the

decidua basalis decidual hematoma separation and compression of the placenta.

Signs and symptoms depend on the size of the hematoma.

Placental abruption ( cont 3)

Clinical diagnosis : 1. external bleeding can be profuse

compromise mother and fetus directly 2. abdominal cramp and pain 3. Blood pressure and pulse shock 4. blood loss anemia USG to confirm diagnosis

Placental abruption ( cont4 )

Complication : Maternal : shock, consumptive

coagulopathy ,uterine couvelar, and renal failure

Fetal : intra uterine fetal death MANAGEMENT : 1, Expectant : delaying delivery when

fetus preterm and maternal hemodynamic stable

2, delivery : vaginal delivery if bleeding so severe n fetus is dead. If fetal distress CS

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