APH lecture.ppt ad it's surgical management
- 2. 2 Definition of APH This is defined as bleeding from the genital tract between the 28th week of pregnancy and the onset of labour.
- 3. 3 Causes of APH Placenta praevia Placental abruption Local causes Undetermined origin Vasa praevia
- 4. 4 Placenta Praevia A placenta that is implanted entirely or in part, in the lower uterine segment.
- 5. 5 Grades of Placenta Praevia Type I- placenta encroaches on the lower uterine segment but does not reach the internal cervical os. Type II- placenta reaches the edge of the cervix, but does not cover it. Type III-placenta covers the cervix but not at full cervical dilatation.
- 6. 6 Grades of Placenta Praevia Type IV- placenta is symmetrically implanted in the lower uterine segment and covers internal os at full dilatation Types I & II are minor praevias - as the lower segment develops, may become normally situated. Types III & IV are major praevias
- 7. 7 Placenta Praevia Causes are frequently unclear and the low site of implantation may merely represent an accident of nature Associations include: older multiparous women, multiple pregnancy and previous uterine damage such as C/S
- 8. 8 Clinical presentation of Placenta Praevia Two classical presentation are of APH or as fetal malpresentation in late pregnancy. Can be asymptomatic and routinely picked up on U/S. Recurrent painless bleeding is the typical history Patient is usually stable unless there has been a major bleed
- 9. 9 Clinical presentation of Placenta Praevia The uterus is soft and non tender High head on presentation or malpresentation- breech, transverse or oblique lie FHHR
- 10. 10 Diagnosis of Placenta Praevia History Clinical examination U/S EIT-examination in theatre -full preparation for C/S
- 11. 11 Management of Placenta Praevia Depends on stage of pregnancy and extent of haemorrhage Minor praevia with minimal or no bleeding -conservative management. Aim to deliver at 38 weeks gestation. Mode of delivery will depend on EIT findings. If minor, then vaginal delivery can be attempted unless it’s a posterior placenta praevia.
- 12. 12 Management of Placenta Praevia Major placenta praevia, if asymptomatic or minimal bleeding - then aim to deliver at 38 weeks gestation. EIT? Delivery is by C/S. Any type of praevia associated with severe haemorrhage should be delivered by the quickest mode - C/S- regardless of gestation age.
- 13. 13 Placental Abruption The premature separation of a normally situated placenta The basic cause is unknown Is a self extending process with the accumulating blood clot causing more separation and thus more haemorrhage, until the edge of the placenta is reached
- 14. 14 Placenta Abruption cont’d Blood then escapes through the potential space between the chorion and decidua until it reaches the cervix Blood can also reach the amniotic cavity (by disrupting the placenta, producing blood- stained liquor) and the myometrium (causing a couvelaire uterus)
- 15. 15 Complications of Abruption Fetal hypoxia or death - because of the extent of placental separation Haemorrhagic shock Renal damage - acute tubular or cortical necrosis DIC PPH
- 16. 16 Associations of Abruption Hypertension-cause or consequence? Sick placenta-excessive fetomaternal transfer of AFP in mid pregnancy & diminished ‘adhesiveness” Previous history of abruption-risk of recurrence ten fold Trauma-RTA, assault, ECV, cordocentesis
- 17. 17 Associations of Abruption cont’d Fibriods - where site of placental attachment covers a fibroid, increased risk of abruption PROM esp with sudden decompression as with polyhydramnios Multiple pregnancy - cause is unclear
- 18. 18 Clinical presentation of Abruption Bleeding may be concealed or revealed Pain over the uterus with no associated periodicity Uterus is extremely hard and tender & it does not relax. The HOF is large for dates in concealed haemorrhage
- 19. 19 Clinical presentation of Abruption cont’d Fetal parts are difficult to palpate and the FH may be inaudible Faintness & collapse may occur, as may signs of shock
- 20. 20 Diagnosis of Abruption History Examination & demonstration after delivery, of a retroplacental clot indenting the placental surface U/S - has a minimal role in placental abruption
- 21. 21 Management of Abruption cont’d Principles of management are: « early delivery « adequate blood transfusion « adequate analgesia « detailed monitoring of maternal & fetal condition
- 22. 22 Management of Abruption cont’d Early delivery is vital & if the baby is alive and the gestation age favors extra uterine survival, delivery should be by C/S even if the fetus is not hypoxic. If the fetus is dead, vaginal delivery is preferred unless there is severe haemorrhage and mother’s life is at stake.
- 23. 23 Management of Abruption cont’d X-match at least 4 units of whole blood, FFP Clotting profile - bedside clotting - fibrinogen levels - platelets Active management of third stage
- 24. ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR This has three components: 1. Administration of Oxytocin – to enhance uterine contractions 2. Clamping the cord early – usually before, alongside, or immediately after giving the Oxytocin 24
- 25. 3. Controlled cord traction is applied with counter-pressureon the uterus in order to deliver the placenta 25