Bleeding in late px

Antepartum Hemorrhaged (APH)
Definition: Bleeding from the genital tract in
late pregnancy after the 28th weeks(20 – 28)
of gestation and before delivery of the baby is
called APH.
Incidence:
• About 3% among hospital deliveries.
1
BY GEBREMARYA TEMESGEN BSC MW

APH Cont..
Causes:
A. Maternal:
– Placenta previa
– Apruptio placenta/placental abruption
– Incidental causes (Local causes in the vagina &
cervix)
– Blood dyscrasias
– Causes never found
B. Fetal
– Vasa previa
2

APH Cont...
Effects of APH:
A. On the mother:
• Shock.
• Disseminated Intravascular coagulation (DIC)
• Renal failure
• Permanent ill health
• Death
3

APH Cont…
B. On the fetus:
• Fetal hypoxia mentally & physically inspired
baby
• Stillbirth
• Neonatal death
4

APH Cont...
Types:
1. Placenta praevia (Unavoidable hemorrhage)
Definition: Placenta praevia is defined as a
placenta which is partially or wholly attached on
the lower pole of the uterus either anteriorly or
posteriorly.
NB: The lower pole of the uterus is which:
– Does not contract during labour but stretch in
response to contractions.
– Used to be the isthmus before pregnancy.
5

APH Cont…
• As the lower segment grows and stretches,
placenta can be separated and bleeding can
occur.
• The anterior location is less serious.
Incidence: 0.5% of all pregnancies, higher in
multigavidae.
6

APH Cont...
Causes:
The exact causes of implantation of the placenta in
the lower uterine segment are not known
however, it is frequently associated with:
A. Endometrial scaring that can result from:
– Previous placenta previa( 4-8%) recurrence after 1
placenta previa
– Abortion
– C/S
– Increased parity
– Closely spaced pregnancies
7

APH Cont…
B. Impended endometrial vascularization
(inadequate blood supply) can be due to:
– Hypertension
– Diabetes mellitus
– Uterine tumor
– Smoking
– Advanced maternal age
– Drug addiction
8

APH Cont…
C. Increased placental mass
– Multiple pregnancy
– Syphilis infection
9

APH Cont...
Degrees of Placenta Previa
A. Type one/low laying/Lateral/Placenta previa
• Majority of the placenta is in the upper
uterine segment
• Vaginal delivery is possible
• Blood loss is mild.
• Mother and fetus are in good health
condition.
10

APH Cont...
B. Type II placenta previa/marginal/Marginalis
The placenta is partially located in the lower
uterine segment near the internal cervical os.
• Vaginal delivery is possible particularly if the
placenta is anterior.
• Blood loss is moderate.
• Mother & fetus condition is varying. May be
mother is in shock and fetal hypoxia mayoccur.
• Fetal hypoxia is more likely to occur than
maternal shock.
11

APH Cont...
C. TYPE III Placenta previa/Partial/Partialis
• The placenta is located over the internal os
but not centrally.
• Vaginal delivery is inappropriate because of
the placenta precedes the fetus.
• Blood loss is severe, particularly when lower
segment stretches and cervix begins
effacement and dilates in the pregnancy
12

APH Cont...
D. Type IV placenta previa/central/total/totalis
• The placenta is located centrally over the
internal os.
• Vaginal delivery should not be considered.
• Blood loss is very severe.
• LSCS is essential in order to save the life of
mother and fetus.
13

Degrees of Placenta Previa
Obstetrics II For Midwives By mukerem A.
Oct 2014
14

APH Cont...
S/S of Placenta Previa:
• Vaginal bleeding:
– The only symptom of placenta praevia is vaginal
bleeding.
– Vaginal bleeding is sudden onset, painless, and
causeless.
– In about 5% 1st time during labor especially in
primigravida
– Bleeding occurs before 38th wks and earlier, bleeding
more likely to major degree.
15

APH Cont…
• General condition and anemia is according to
visible blood loss.
• Uterus feels relaxed, soft and elastic without
localized area of tenderness.
• Fetal heart rate usually present unless there is
major separation of placenta.
• If bleeding is severe color is bright red blood
loss.
16

APH Cont...
Indications:
• Fetal head remains unengaged in
primigravida.
• Malpresentation especially breech.
• The lie is oblique or transverse
• The lie is unstable usually in a multigravida.
(When after 36th wks of gestation remaining it
varies from one examination to another
between longitudinal and oblique
17

APH Cont...
Diagnosis & Investigations
• Localization of placenta and clinical Sonography:
– Simplest and fastest method of identifying placental
localization
– Helpful to assess the fetal size and shape.
– Information of maturity
– Guidance of management
– Confirms the Dx and also grade the degree of previa.
18

APH Cont...
Assessing the Mothers Condition
• Amount of vaginal bleeding.
• Mother’s history of small repeated blood loss at
interval through out the pregnancy.
• Sudden single blood loss after 28th weeks of
gestation.
• Hemorrhage may be mild, moderate or severe
according to activity and at rest.
• Color: bright red
19

APH Cont...
General Examination
• If hemorrhage is slight - Bp, respiration, pulse may be
normal
• If hemorrhage is severe - Bp will be low; pulse is
increased due to shock, respiration is increased
• Mothers color will be pale and clammy extremities.
• Skin is cold and clammy.
• Temperature is usually normal.
• Degree of shock correlates with amount of blood lost
per vaginaum
20

APH Cont...
Abdominal Examination
• Normal uterine consistency.
• Lie of fetus is oblique or transverse.
• Fetal head may be high in primigravida
• No pain
NB: NEVER ATTEMPT TO DO PV!!!!!!!!!!
BY GEBREMARYA TEMESGEN BSC MW 21

APH Cont...
Assessing Fetal Condition:
• Mother should be asked about fetal activity.
• She may be aware of diminish of fetal
movement which may occur if fetal hypoxia is
severe.
• Use Doppler
• Call pediatrician.
22

APH Cont...
Complications of Placenta previa:
A. Maternal:
i. During pregnancy:
• APH with varying degree of shock.
• Malpresentation is common and increased
incidence of breech and transverse lie.
• Premature labor either spontaneous or
induced.
23

APH Cont...
ii. During Labour:
• Early rupture of membranes.
• Cord prolapsed is due to abnormal attachment of
cord.
• Slow dilatation of the cervix because of placenta
in lower position.
• Intrapartum hemorrhage due to further
separation of placenta.
• Retained placenta increased incidence of manual
removal.
24

APH Cont...
ii. During puerperium:
• Sepsis is increased due to anemia.
• Increased operative interference
• PPH
25

APH Cont...
B. Fetal Complications:
• Low birth weight due to premature labor.
• Asphyxia due to early separation of placenta.
• IUFD due to severe degree of separation of
placenta and due to maternal shock
26

APH Cont...
Management of Placenta Previa :
• Depends upon the:
1. Amount of bleeding
2. Condition of mother and fetus.
3. localization of placenta
4. Stage of the pregnancy
27

APH Cont…
A. Conservative Management: is appropriate if:
• Bleeding is slight
• Mother and the fetus are well
28

APH Cont...
If bleeding is slight
• The mother and fetus are well, immediately admit to
hospital at rest until bleeding is stopped.
• Assess the blood loss
• Vital sings are checked
• Blood samples are taken for blood group & Rh type. Hb.
• IV line should be started with 5% dextrose.
• Blood transfusion should be arranged.
• Gentle abdominal palpation & note uterine tenderness and
auscultated fetal heart rate.
• Inspection of vulva, presence of bleeding dark or fresh.
29

APH Cont…
Mode of Delivery
Vaginal bleeding is usual with type one placenta
previa and possible with type two placenta
previa which is situated anteriorly.
30

APH Cont…
B. Active Management
• Severe vaginal bleeding will necessities
immediate C/S regardless of the location of
the placenta.
• Blood should be checked for cross matching,
IV infusion will be in progress.

APH Cont..
Note: In major cases of placenta previa( type III &
IV),C/S is required even if the fetus has died in
utero in order to prevent torrential hemorrhage
and possible maternal death!!!!
Home work
What is
1. placenta acreta?
2. Placenta Increta?
3. Placenta Percreta?

APH Cont...
2. Abruptio Placenta/Placental
Abruption/Accidental Hemorrhage
Definition: Premature separation of normally
situated placenta occurring after 28th (20 –
28)wks of pregnancy is known as placental
abruption.
Incidence:
• 1 in 50 deliveries
33

APH Cont...
Causes:
It is not always clear but it is associated with
• PIH(The most common cause of sever hypertension) .
• Toxemia of pregnancy
• Poor socioeconomic condition & malnutrition.
• Trauma
• Attempt external cephalic version especially under anesthesia.
• Fall or blow on the abdomen.
• SUDDEN UTERINE CONTRACTION
• Sudden escape of liquor amni in hydramnoius
• Short cord
• Can bring about placental separation.
• FOLIC ACID DEFICIENCY , smoking
• Previous abruption

APH Cont ....
Types of Placental Abruption:
A. Based on Blood lost from Abruption:
1. Revealed:
Following separation of placenta the blood is downwards between
the membranes and deciduas. Blood comes out the cervical canal
to the visible externally. This is commonest type. Complications are
fewer. Retro placental clot is NOT formed. DIC may occur.
2. Concealed:
Blood is collected behind the separated placenta or collected in
between the membranes or deciduas. The collected blood is
prevented from coming out of the lower segment. This type is rare.
3. Mixed:
Some of the part of the blood is collected inside (concealed) and
some part is expelled (revealed). This type is very rare.
35

APH Cont…
B. Based on Degree of abruption(Clinical
classification) :
1. Mild Separation
2. Moderate Separation
3. Severe Separation
Mild Separation:
• Placenta Separation and bleeding are slight
• Mother and fetus are in good condition.
36

APH Cont…
Moderate Separation:
• Placental separation of about 1/4th
• Up to 1 liter of blood may be lost
• The mother will be shocked
• The fetus may be dead of alive
37

APH Cont….
Severe Separation:
• Is an acute obstetric emergency
• At least 2/3rd of the placenta has been detached.
• Up to 2 litter of blood may be lost
• The fetus will almost certainly died.
• The woman will have severe abdominal pain
• The uterus will have board like
consistency(Covelaure uterus, uterine apoplexy)
• Renal failure, coagulation defects & pituitary
failure( Sheehan’s synderome) may occur.
38

APH Cont...
Complications of Placental Abruption:
• DIC ( Disseminated intravascular coagulation)
• PPH due to DIC. Inj. Ergometrine 5mg IV at
delivery
• Renal failure as a result of Hypovolaemia
• Pituitary necrosis(Sheehan’s Syndrome) due
to severe Hypotension.
39

Obstetrics II For Midwives By mukerem A.
Oct 2014
40

APH Cont...
Prevention:
• Prevention and early detection and effective
therapy of PIH.
• Avoidance of trauma - especially forceful
external version under anesthesia.
• Avoid sudden decompression of uterus due to
acute or chronic hydramnoius.
• Routine administration of folic acid
supplement from early stage of pregnancy
41

APH Cont...
Management of placental abruption:
• Urgently to arrange for medical alerts.
• Transfer to obstetrics unit and give treatment
• Assessment of the blood loss, maturity of the fetus &
whether the patient is in labor or not.
• Blood is sent for Hb%, ABO, Rh and Urine.
• 5% dextrose is started and arrangement for blood
transfusion
• If necessary oxytocin drip may be started.
• If after 38th wks of gestation induction of labour to be done
by artificial rupture of membranes or with oxytocin
42

APH Cont...
• If before 38th wks of gestation if bleeding is sever LSCS to be
done
• If Bleeding is less or shght or stopped only oxytcoin may be
started.
• Sedation is ensured by giving inj. morphine 15mg IM or Inj.
Pethedin 100-150mg.
• Blood sample is taken for Hb. Rh & Urine protein.
• Correct hypovolemic shock 5% dextrose should be started
• Arrangement made for urgent fresh blood transfusion to be
done.
• Urine output should be monitored carefully & output should
be at least 30-40ml/hrs.
43

APH Cont...
Management cont…
• Oxytocin drip should be started.
• If spontaneously the membranes ruptured
normal vaginal delivery to be conducted with
or without oxytocin drip
• AMTSL to prevent PPH
• To improve the uterine tone oxytocin should
be used along with blood transfusion.
44

APH Cont...
Management Cont…
• If concealed abruption placenta baby is invariably dead
in severe case and or premature vaginal delivery is
possible than LSCS.
In early stage vaginal delivery is possible.
In later stage
• The progress of labor is delayed 6-8 hrs
• General condition poor with appearance of
complication factor like oblique or faulty of fibrinogen
level may be taken to LSCS because to save the life of
mother and baby.
45

APH Cont...
Care of the baby:
• Preparation should be made for an
asphyxiated baby.
• Pediatrician must be present during LSCS.
• Baby transfer to ICU(Intensive care unit)
46

APH Cont...
Nursing Care:
• Bp, pulse, respiration taken frequently.
• If Pyrexia is present temperature may be
recorded every 1 or 2hrs.
• Urine output is accurately assessed by the
insertion of an indwelling catheter.
• Urine should be send to lab for protein.
47

APH Cont…
• Fluid intake must be recorded accurately to
assess the fluid balance.
• Fundal height and abdomen girth are
measured hourly (Why?)
• If fetus is alive the fetal heart rate should be
monitored continuously
• If there is any abnormalities in mother and
fetus immediately reported to obstetricians.
48

Comparison Placenta previa and
abruptio placenta
Abruptio Placenta
1. Severe constant pain often
with loss of FHR
2. Bleeding: severe, less or
absent (Concealed)
3. Shock & anemia even if the
bleeding has bee slight
4. Hypertension & proteinuria
is common
5. Uterus hard or tender
6. Fetal parts difficult to feel
Placenta Previa
1. Painless bleeding
2. Bleeding: severe, less or
slight
3. Shock & anemia if bleeding
has been severe
4. No hypertension or
protienuria
5. Utersu soft & not tender
6. Presenting part is
high/malpresentation
49

APH Cont…
Abruptio placenta
7. FHB is absent usually
8. Clotting defect is present
usually (DIC)
Placenta previa
7. FHB is present usually
8. No clotting defeat
50

APH Cont…
3. Incidental cause/Local Causes in the vagina &
Cervix):
• Crvicitis
• Vaginitis
• Cervical Polyps
• Cervical erosion
• Varicosities of the vulva
• Cervical cancer
51

APH Cont…
4. Blood Dyscrasias
• Rare: e.g. Leukaemia
5. Causes not found
• E.g. Placenta circumvallta
52

Bleeding in late px

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