Ante partum hemorrhage :

Islamic University of Gazafaculty of Nursing Ante partum hemorrhage :

Bleeding from the genital tract in late pregnancy after 24th weeks gestation and before the onset of labor.

* effect on fetus: • Fetal mortality • Fetal morbidity. • Still birth . • Neonatal death. • Hypoxia to baby. • Neurological damage to baby.

effect on the mother : • (sever bleeding) • shock: hemorrhagic. • DIC • permanent illness. • maternal death

*Types of ante partum hemorrhage : 1. placenta previa. 2. placenta abruption. • Initial intervention ApHge : • reduce anxiety both parents. • Assess the situation. • History and details to know the cause of bleeding. • Nature type of ApHge. • ?? D.D : cause of bleeding.

Maternal condition • Assessment : • - observe Pallor breathlessness - signs of shock . • Tachycardia , tachypnea - subnormal temperature and hypotension. • Assess amount of blood loss • gentle abd . examination. • Observe signs of labor.

. Don’t do vaginal or rectal examination. • Avoid use of enema or suppositries,This will exacerbate the condition

fetal condition • ask about movement of the baby. • Auscultation FHR by CTG. • U/S • ? D.D • 1-location of the placenta. • 2-pain "continuous intermittent , painless.

3-onset of bleeding after trauma , sexual inter course . • 4-Amount of visible blood • 5-color of blood [Bright ,red , dark]

6-degree of shock. • 7-consistency of abdomen "tense, tender , soft , board like" • 8-lie ,presentation, engagement. • 9-F.H.R –positive –ve. • 10-uls – site of placenta.

Supportive treatment: • Emotional support. • Fluid replacement , plasma ,blood. • Strong analgesia. • Bed rest. Prepare for emergency ambulance

Placenta previa: • The placenta is partially or wholly implanted in the lower uterine segment either anterior or posterior wall. • Lower uterine segment stretch and grow after 12 weeks • later weeks ,placenta separate and cause sever bleeding

-Cause of bleeding: • Shearing stress between placental trophoblast and maternal venous blood sinus. • separation of placenta previa put mother and her fetus on risk. • degree of placenta previa

type I- • Majority of placenta in uus. • Vaginal birth. • Mild blood loss . • Mother and fetus in good condition

Type II : • partially in lower uterine segment. • Near the cervical os. • Called placenta previa marginal's • Vaginal birth possible " placenta anterior" • Moderate blood loss. • Maternal shock. • Fetal hypoxia

Type III • – placenta located over the internal cervical os ,but not centrally • -Sever bleeding • -C.S delivery better

Type IV • placenta located centrally over the internal cervical os • – torrential Hge • C .S delivery.

Pictures of previa: • painless vaginal bleeding. • soft uterus. • abd lax. • lie unstable.

presenting part above the pelvic brim. • uls confirm the DX and determine degree, vaginal bleed • this type never bleed . type I • early pregnancy heavy bleeding

Assessing of mother condition: • Amount of vaginal bleeding. • Hx of small repeated blood loss (intervals) • After 20th weeks gestation. • Common after 34th weeks.

Degree of the Hge : mild, moderate, sever. • Occur when doing activity, or even on bed rest. • Bright red color bleeding (fresh) . • Retro placental blood clot not formed "So no pain

General examination: • V/S – stable , signs of shock . • According to amount of blood loss. • Air hunger - RBCs carrying o2 • pale skin – cold moist . • lose of consciousness

Abdominal examination • -lie—oblige, Transverse. • Head high not engaged. (PG) • -abdomen lax not tender • -contraindication to do vaginal examination, it will worse the condition • -quantify blood loss ,blood soaked material for fluid replacement

assessing fetal condition : • -fetal activity • -cessation of fetal movement • -signs of hypoxia, bad CTG • -excessive fetal movement : signs of fetal hypoxia • -u\s ,CTG ,pinards

Management depends on • amount of bleeding • -mother &fetus condition • Location of placenta • Stage of pregnancy

Conservative management : • -slight bleeding • -mother and fetus in well condition • -bed rest (hospitalization many weeks until bleeding stop) • -fetal kick chart • -CTG

-u\s • repeated, site of placenta • -fetal growth • -placental perfusion • -IUGR • -Psychological &social care • -group education

-parent education • -visit special care baby unit • -answering question ?preterm birth • -sever bleeding ,reach maturity NVD • -37 weeks IOL • -risk of ppHge :placenta lower uterine segment ,living ligature action is broken

-active management : • Sever vaginal bleeding :c.s regardless location of placenta ( preterm baby ) • -CBC ,blood group ,cross match , clotting studies

-IV fluid rapidly ,several unit of blood may need infused rapidly • -consent form • -emergency blood group o –ve • -anesthetics consultation • -intake & output

-,epidural or general anesthesia • -comforting mother & sharing information • -support partner • -placenta anterior • -type 3,4 require c.s even the baby died to stop hemorrhage & prevent maternal death

Incidence : • -comes after 20 weeks • -complicate 3-6 \1000 • -multigravida 1\90 • -

increasing age – increase parity • -little percentage occur in prima gravida • Etiology : unknown • -?smoker • -previous c.s • -recurrence 4-8 %

Complications : • -maternal shock, resulting from blood loss and hypovolaemia • • anesthetic and surgical complications, which are more common in women with major degrees of placenta praevia. • • placenta accreta, in up to 15% of women with placenta praevia

air embolism, an occasional occurrence when the sinuses in the placental bed have been broken • • postpartum hemorrhage: occasionally uncontrolled hemorrhage will continue, despite the administration of uterotonic drugs at delivery

– even following the best efforts to control it, and a ligation of the internal iliac artery, a caesarean hysterectomy may be required to save the woman's life • • maternal death, a very rare outcome • •

fetal hypoxia and its sequelae due to placental separation • • fetal death, depending on gestation and amount of blood loss

Ante partum hemorrhage :