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OBSTETRIC HEMORRHAGES

OBSTETRIC HEMORRHAGES. ANTEPARTUM HAEMORRHAGE (APH) Definition Bleeding from the genital tract after 24 weeks and before delivery Classification: * Placental Abruption * Placenta Praevia * Incidental APH Placental Abruption: Definition: separation of a normal situated placenta

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OBSTETRIC HEMORRHAGES

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  1. OBSTETRIC HEMORRHAGES

  2. ANTEPARTUM HAEMORRHAGE (APH) Definition Bleeding from the genital tract after 24 weeks and before delivery Classification: * Placental Abruption * Placenta Praevia * Incidental APH Placental Abruption: Definition: separation of a normal situated placenta (upper segment of the uterus) before delivery * Incidence: 1/80 to 1/200 Recurrence rate 6-10% Pathogenesis: The precise cause of the insecure placental attachment which predisposes to abruption is uncertain

  3. Precipitating factors: Trauma; External cephalic version; Amniocentesis; Smoking; Uterine decompression (PROM) in polyhydramnios; H/O Pl. abruption (rec.6-10%); Grandparity (x3); ?Hypertensive disorders (! Cause or consequence); Folic acid deficiency. Placental separation Intravasation of the blood through the myometrium to serosal Surface  Couvelaire uterus Types: *Revealed Hrrge: Blood escape by dissecting between the membranes and uterine wall leading to vaginal bleeding and sometimes getting into the amniotic sac giving blood stained liquor.

  4. * Concealed Hrrge: Blood extend into uterine wall with little or no external bleeding. Clinical condition is out of proportion of the loss Clinical Features: Symptoms: Bleeding per vagina (revealed) Pain:esp in concealed type where the bleed occur through the myometrium (couvelaire uterus) increasing uterine tone Signs: * General signs of shock; (Concealed type: out of proportion of external loss); BP is poor guide to

  5. the extent of bleeding because of association of with hypertension. * Abdominal exam: tenderness; uterus is hard wooden in consistency (esp. in concealed) * Uterus size:> dates (in concealed) or =dates (in revealed) * Fetal parts difficult to palpate * FSH: +(fetal bradycardia)/ - fetal death) * Avoid P/V exam if placental site bec Placenta praevia is a D.D

  6. Differential Diagnosis: * Placenta praevia (painless bleeding) * Uterine rupture (pain +bleeding;H/O C.S or other uterine scar) * Degenerating Fibroid * Ovarian Cyst (torsion;ruptured) * Surgical causes : intestinal obstruction; appendicitis * Rectus sheath Haematoma Complication: * Coagulopathy: Thromboplastin released from the damaged myometrium cause consumption coagulopathy * Hypovolemic shock Renal insufficiency

  7. Management: Admission Initial assessment: mild/moderate/severe Mild bleeding: * Ultrasound to localize the placenta and to rule out retroplacental clots. * Expectant management till maturity: If no retroplacental clots, CTG reactive, and non- progressive. * Rule out local causes by speculum exam Moderate/severe: * Resuscitation: ABC (Airways/Breathing/Circulation)

  8. Establish intravenous: CBC, Blood group, cross matching, Coagulation profile • CVP • Urinary catheter for output measurement(>30 ml/hour indicate adequate renal perfusion) • CTG monitoring • Mode of delivery • Depend on : fetal maturity, fetal heart trace /fetal presentation / severity of bleeding • ARM / Syntocinon:- If CTG is reactive / reasonable fetal maturity / cephalic; if fetus dead allow vaginal delivery • Shorten second stage VE/forceps • Active management of third stage: high risk of PPH

  9. Immediate C.S: - If fetus alive and CTG show fetal • Bradycardia - Breech • - Premature fetus • EUA: Severe bleeding / Placental site is unknown • Management of complications: • * Consumption coagulopathy: adequate blood • transfusion/ FFP/ avoid epidural • * PPH: Avoid by active management of third stage • * Renal failure: from inadequate perfusion/rarely from • fibrin deposit in DIC • Usually recover after adequate blood and fluid replacement. Rarely permanent seek nephrologist help • Maternal / Perinatal Mortality: • MM <1% • PNM 30% to  15%

  10. Retrouterin Clot

  11. Couvelaire uterus

  12. Placenta Praevia: Definition The placenta is partly or wholly inserted in the lower uterine segment Types: - Grade (lateral PP): Placenta encroach lower uterus segment - Grade II (Marginal PP): Placenta reaches int. os but does not cover it a  anterior b  posterior - Grade III (Partial PP) - Grade IV (Compete PP/P) Centralis Incidence: 0.8-1%

  13. Etiology Surface area of placenta:Twins, succenturate lobe - Age / parity: placenta praevia  with age and parity - Previous C/S: Implantation on the scar Clinical feature: Symptoms: Painless vaginal bleeding; usually in third trimester / unprovoked / recurrent Signs:general  depend on amount of loss Abd.  soft not tender High presenting part FSH usually normal Vaginal exm. Is C/I in placenta praevia

  14. Diagnosis Ultrasound ? Speculum exam  for local causes for fetal Hb  Vasa praevia Management: Depend on: Fetal maturity / severity of bleeding If severe: resuscitate and deliver by CS If mild/moderate: conservative till reasonable maturity. keep patient in hospital. Two units of blood always ready. serial fetal surveillance At 37-38 weeks: Grade I-II a: EUA  if placenta not felt---  ARM / Syntocinon if bleeding  CS Grade II b & III& IV  elective CS

  15. Prognosis: MM  Low PNM  2% depend on gestational age at delivery Postpartum: Watch for PPH. Active Mg. Of third stage Vasa Praevia: Definition Velamentous insertion of the cord and the fetal vessels lies on the membranes covering the internal os. The blood is fetal in origin. A small amount of bleeding is serious. Diagnosis Kleihauer test Management : CS Incidental APH: Bleeding from local causes e.g. Cervical erosion; cervical polyp;cervical varicosities;??? Cervical cancer Management: Treat cause

  16. Velamentous insertion of the cord

  17. *Prolonged labour: *Mismanagement of third stage: Trauma: Unsutured episiotomy, multiple laceration, cervical tear Coagulation disorders: Chronic: Von Willebrand’s disease, idiopathic thrombocytopenia Acute: Amniotic fluid embolism Causes of secondary PPH: Retained product of placenta/ Endometritis

  18. Prevention of PPH: • Identification of high risk patients; multiparity; multiple • pregnancy; HO PPH; Anemic patient tolerate blood • loss poorly so ensure good Hb level at labour and treat • anaemia • Proper management of third stage: • * Delivery of placenta (CCT) • * Drugs • 0.5 mg ergometrine I.m • Syntometrine (0.5mg ergometrine+5 units • syntocinone) • Syntocinone • Management of PPH: • IF MAJOR PPH INVOLVE: • Senior Anaesthetist • Obstetric Consultant /SR • Haematologist

  19. RESUSCITATE • * Adequate venous access • * CBC • * X match 6 units minimum • * Clotting / FDPs • * Insert urinary catheter • * If hypotensive: • Head down tilt • Oxygen • IV fluid • hartmann’s • haemaccel unless • crossmatched blood available • If unavailable • uncrossmatched blood (patient’s group) • As a last resort group O Rh negative

  20. Diagnosis and Treatment: Is the placenta complete? If placenta is retained or incomplete .. For manual removal under G anaethesia. Atonic uterus: Uterine massage/Bimanual compression Oxytocin 5U IV OR Ergometrine 500 mg IV caution in: PIH, cardiac disease, hypertension If no response: IV Oxytocin infusion (20u in 500ml Hartmann’s)

  21. If no response PGF2 (Hemabate) 250 µ I.M 1.5 hrly to max. of 5 doses Caution in : Asthma If bleeding persist: Arrange theatre Prepare for EUA: check cervix / vagina / perineum / retained products Internal iliac ligation Hysterectomy

  22. *** always check for DIC coagulopathy and correct it *** Watch for complication after acute event: DIC,renal failure, Anaemia, Sheehan syndrome ………………………………………………. Treatment of secondary PPH: If retained product ---  evacuation under antibiotics If endometritis --------  Triple antibiotics

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