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    Add as FriendAntepartum hemorrhage

    by: Saad

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    1 : Antepartum Haemorrhage Saad Bin Zafar Mahmood
    2 : Definition Hemorrhage from the vagina after the 24th week of gestation till end of pregnancy Blood loss of greater than 300mls Incidence : 3-5% of all pregnancies
    3 : Antepartum Haemorrhage: Types Simple: Local Vagina – Trauma Cervical – Infection or tumor - Blood dyscrasias Thrombocytopenia Anticoagulants Complicated: Abruptio Placentae Placental praevia Vasa Praevia
    4 : Abruptio Placentae Premature separation of the placenta. Pathophysiology of placental abruption: Bleeding into the decidua basalis layer Hematoma forms causing further placental separation Fetal blood supply is further compromised Complication - Couvelaire Uterus (Retroplacental blood goes into the peritoneal cavity)
    5 : Classification Clinical classification Class 0 - Asymptomatic Class 1 - Mild (represents approximately 48% of all cases) Class 2 - Moderate (represents approximately 27% of all cases) Class 3 - Severe (represents approximately 24% of all cases)
    6 : Placental abruption: types Placental abruption can be broadly classified into two types: Revealed Concealed Mixed
    7 : Presentation Symptoms Vaginal bleeding - 80% Abdominal or back pain and uterine tenderness - 70% Fetal distress - 60% Abnormal uterine contractions (eg, hypertonic, high frequency) - 35% Idiopathic premature labor - 25% Fetal death – 15%
    8 : Presentation Physical Examination Should be done after stabilizing the patient Ultrasound should be done first to assess the location of placenta. Only then should a digital pelvic exam be conducted Profuse bleeding in waves Uterine contraction / Uterine hypertonus Shock Absence of fetal heart sounds Increased fundal height (due to hematoma)
    9 : Risk factors of Abruptio Placentae Maternal hypertension Maternal trauma Cigarette smoking Alcohol consumption Cocaine use Short umbilical cord Maternal age <20 or >35 years Low socioeconomic status Elevated second trimester maternal serum alpha-fetoprotein (associated with up to a 10-fold increased risk of abruption) Previous placental abruption
    10 : Investigations Laboratory studies CBC PT & APTT Fibrinogen levels BUN / creatinine Imaging studies Transvaginal ultrasonography Transabdominal ultrasonography
    11 : Complications of Abruptio placentae - Maternal Can lead to DIC
    12 : Fetal complications include Hypoxia or hypoxic-ischemic encephalopathy (HIE) growth retardation CNS abnormalities Intra uterine death. Complications of Abruptio placentae – Fetal
    13 : Placenta praevia Implantation of placenta over the internal cervical os and therefore in front of the presenting part Pathophysiology Delay in implantation of blastocyst so that it occurs in the lower part of uterus In third trimester isthmus of uterus thins to form lower uterine segment Placental attachment is disrupted as the area gradually thins in preparation of the onset of labor This leads to bleeding from the venus sinuses
    14 : Placenta previa: types Complete placenta previa Partial placenta previa Marginal placenta previa (placenta approaching the border of os)
    15 : Grading of placenta previa: Grade I – The placenta is in the lower segment, but the lower edge does not reach the internal os. Grade II – The lower edge of the low-lying placenta reaches, but does not cover the internal os.  Grade III – The placenta covers the internal os.  Grade IV – The placenta covers and entirely surrounds the internal os
    16 : Presentation Symptoms Painless vaginal bleeding Bleeding stops spontaneously and recurs with labor Malpresentation (Breech, transverse lie) Physical Exam Digital exam is contraindicated Uterus is soft and non tender Concurrent contractions with bleeding are present
    17 : Placenta previa : Risk factors Previous placenta previa. Multiple pregnancies- due to the placenta occupying a large surface area. Cigarette smoking Increased maternal age Uterine scar (previous caesarean section) Endometritis
    18 : Investigations Laboratory studies CBC PT & APTT Imaging studies Transvaginal ultrasonography Transabdominal ultrasonography
    19 :
    20 : Differential Diagnosis
    21 : Non Placental causes of APH
    22 : Vasa previa: Vasa previa is a condition when fetal vessels traverse the fetal membranes over the internal os. These vessels course within the membranes (unsupported by the umbilical cord or placental tissue) and are at risk of rupture when the supporting membranes rupture.
    23 : Management of Antepartum Hemorrhage
    24 : Initial management Assessing the airways: Assessing the breathing: Assessing the circulation Cannula inserted for Drug adminstration Blood sampling IV fluid adminstration
    25 : Placenta previa If uncomplicated pregnancy no need of intervention Vitamins and Iron supplements should be taken If minimal bleeding expected management may be continued If needed tocolytics may be considered to administer antenatal steroids Before the delivery the following should be consulted Obstetric anesthesiologist Interventional radiologist General surgeon Urologist
    26 : Placenta previa If placental edge is more than 2cm from internal cervial os trial of labour can be offered. If the distance is less than 2cm cesarian section is done although an SVD can be done Delivery is mostly done at 36-37 weeks of gestation Low transverse uterine incision is used If the patient is at risk of invasive placentation than informed consent should be taken for cesarian hysterectomy
    27 : Abruptio placentae Vitamins and Iron supplements should be taken Initial management Transfusion, correction of coagulopathy and Rh immune globulin if needed Cesarian section preferable mode of delivery Vertical incision Hysterectomy might be needed if severe blood loss Tocolytics may be used in case of preterm delivery only if Hemodynamically stable No fetal distress Preterm fetus may benefit from corticosteroid therapy In case of fetal death mode of delivery is SVD
    28 : Types of tocolytics
    29 : Uterine rupture-management It is an emergency Laprotomy is urgently done Uterine rupture can be an antepartum or postpartum event
    30 : Vasa previa When vasa previa is diagnosed antenatally, an elective Caesarean section should be offered prior to the onset of labour. In cases of vasa previa, premature delivery is most likely, therefore, consideration should be given to administration of corticosteroids at 28 to 32 weeks
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    32 : THANKS
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