Lecture 16 APH.pptx. power point lecture
- 1. Antepartum Hemorrhage MR CHIBUYE MPH,BsCM & Dip CM Chreso University
- 2. Introduction • Bleeding from the genital tract in pregnancy from age of viability 24 week’s gestation ( according to WHO) and the onset of labour. • It affects 4% of all pregnancies. • It is associated with increased risks of fetal and maternal morbidity and mortality
- 3. Causes • Placental: Non-placental 1. Abruptio placenta. 1. Vasa previa 2. Placenta previa 2.Bloody show. - 3.Uterine rupture. - 4.Cervicitis. - 5.Carcinoma. - 6.Trauma. • - 7.Idiopathic
- 5. Introduction Definition: Abruptio placentae is defined as the premature separation of the placenta from the uterus • Also called placental abruption • Abruptio placentae also occurs in about 1% of all pregnancies throughout the world.
- 6. Risk Factors • Increased age & parity. • Hypertensive disorders. • Preterm ruptured of membranes. • Multiple gestation. • Polyhydramnios. • Smoking. • Cocaine use. • Prior abruption. • Uterine fibroid. • Trauma
- 7. Types • Revealed- • Concealed • Mixed
- 8. Presentation • Vaginal bleeding/ no bleeding if its Concealed • Tense, tenderness Uterine or back pain. • Fetal distress. • High frequency contractions. • Uterine hyper tonus. • Decreased/absent fetal movements (IUFD.)
- 9. Classification Grade 0. Asymptomatic, small retroplacental clot after delivery Grade 1. External vaginal bleeding • Uterine tetany and tenderness may be present • No signs of maternal shock • No evidence of fetal distress
- 10. Grade 2. • External vaginal bleeding may or may not be present • Uterine tender and tetany. • No signs of maternal shock • Signs of fetal distress present Grade 3. • External bleeding may or may not be present • Marked uterine tetany • Maternal shock • Fetal death or distress • Coagulopathy in 30% of the cases
- 11. complications • Shock • Consumptive Coagulopathy • Renal Failure • Fetal Death
- 12. Diagnosis of Abruptio • The diagnosis is clinical. • U/S: to Confirm fetal viability, assess fetal growth & normality, measure liquor, do umbilical artery Doppler velocities. • U/S to exclude placenta praevia
- 13. Principles of management 1. Early delivery (50% of abruption present in labour). 2. Adequate blood transfusion. 3. Adequate analgesia. 4. Detailed maternal and fetal monitoring. 5.Coagulation profile (30% develop DIC). 6. C/S: distressed baby, severe bleeding, alive baby & not in advanced labour. 7. Vaginal delivery: very low gestation, dead baby, cervix is fully dilated. Anti-D if the mother is rhesus negative.
- 14. PLACENTA PREVIA
- 15. Introduction Definition: The presence of placental tissue overlying or proximate to the internal cervical os after viability. OR - This is when the placental is lying on the lower segment of the uterine Incidence: Complicates approximately 1 in 300 pregnancies
- 16. Risk factors • Multiparty • Increased maternal age • Previous placenta previa, recurrence rate 4-8% • Multiple gestation • Previous cesarean section • Uterine anomalies • Maternal smoking
- 17. Types of Placenta Previa • Type I: The placental edge is in the lower uterine segment but does not reach the internal os • Type II: The placental edge reaches the internal os but does not cover it. • Type IIA- Placenta is anterior • Type IIB - placenta is posterior • Type III: The placenta covers the internal os when it is close and is asymmetrically situated (partial). • Type IV: The placenta covers the internal os and is centrally situated (complete)
- 18. Clinical presentation of Placenta Praevia • Bleeding: usually mild but it could be severe; recurrent, painless. • Soft uterus. • Normal fetal heart rate (unless there is severe bleeding or associated abruption). • High presenting part. • Fetal malpresentation (breech/transverse/oblique). • Vaginal examination is contraindicated.
- 19. Investigations • U/S: Transvaginal is better than transabdominal • U/S shows low lying placenta • Complete blood count
- 20. Complications of Placenta praevia • Preterm delivery. • Preterm premature rupture of membranes. • IUGR (repeated bleeding). • Malpresentation; breech, oblique, transverse. • Fetal abnormalities (double in PP). • ↑ number of C/S. • Postpartum haemorrhage: lower segment not contract and retract
- 21. Management of Placenta Praevia • Depends on gestational age (GA), severity of APH and the type of placenta praevia: • Placenta praevia at term has to be delivered • If heavy APH, then take theatre for caesarean section • If minimal/moderate APH and preterm, then admit to antenatal ward, keep X-matched, keep IV access with large-bore cannulae at all times and do OB ultrasound (US). • Steroids if GA 26-34 wks: dexamethasone 6 mg IM every 12 hrs x 4 doses. • If no heavy bleeding, then wait and do elective caesarean delivery at 37 wks gestation.
- 22. VASA PREVIA
- 23. Introduction • Vasa previa is a very rare condition refers to vessels that traverse the membranes in the lower uterine segment in advance of the fetal head. • Rupture of these vessels can occur with or without rupture of the membranes and result in fetal exsanguination.
- 24. UTERINE RUPTURE
- 25. Introduction • Def: dissolution in continuity of the uterine wall anytime beyond 28/40,before this called perforation • Uterine rupture in pregnancy is often catastrophic complication with a high incidence of fetal and maternal morbidity. • Abdominal pain or free fluid • Tender abdomen • Easily palpable fetal parts • Absent fetal movements • Absent fetal heart sounds • NO abdominal contractions • Treatment is repairing the rupture or hysterectomy
- 26. Risk factors of uterine rupture • Previous operations on the Uterus like C/S, Myomectomies • Classical C/S carries a high risk than lower transverse C/S • The higher the number of C/S the higher the risk of rupture • Grand multiparty • Induction of labor • Augmentation of labor with oxytocics • Obstructed labor • Use of forceps delivery • Direct trauma
- 27. THANKS FOR YOUR ATTENTION