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ANTEPARTUM HAEMORRHAGE.pptx

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This document discusses two causes of third trimester bleeding - placenta previa and abruptio placenta. It defines each condition and provides details on incidence, risk factors, clinical presentation, diagnosis and management. Placenta previa occurs when the placenta is implanted over or near the cervical os, and can be classified based on how much it covers the os. Abruptio placenta is the separation of a normally implanted placenta, and can be revealed, concealed or mixed. Both conditions require careful monitoring and management to prevent maternal hemorrhage and improve fetal outcomes.

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ANTEPARTUM HAEMORRHAGE (THIRD TRIMESTER BLEEDING) MS. MILAN SAWANT
Third-trimester bleeding, ranging from spotting to massive hemorrhage, occurs in 2% to 6% of all pregnancies. The differential diagnosis includes: Bloody show from labor Abruptio placentae (AP) Placenta previa (PP) Vasa previa (VP) Cervicitis, postcoital bleeding, trauma, uterine rupture, and carcinoma.
PLACENTA
ANTEPARTUM HAEMORRHAGE.pptx
DEFINITION When the placenta is implanted partially or completely over the lower uterine segment(over and adjacent to the internal os)it is called placenta previa.
INCIDENCE O.5 1% among hospital deliveries 80% cases found in multiparous women Increase incidence beyond 35yrs Increase incidence with high birth order and multiple pregnancy 1 in 300- 400 pregnancy .
MECHANISM OF BLEEDING Progressive stretching of the lower uterine segment normally occurs during the 3rd trimester and labour, but the inelastic placenta cannot stretch with it. This leads to inevitable separation of a part of the placenta with unavoidable bleeding. The closer to term, the greater is the amount of bleeding.
ETIOLOGY THEORIES POSTULATED Dropping down theory Persistence of chorionic activity Defective decidua Big surface area of the placenta
HIGH RISK FACTORS Multiparity Increased maternal age Previous cesarean section or any other scar in the uterus ( fibroids myomectectomy ) Placental size and abnormality ( twin) Smoking( due to defective decidual vascularisation) Prior curettage
BROWNE`S CLASSIFICATION 1. TYPE I Low lying Major part of the placenta is attached to the upper segment Only the lower margin encroaches to the lower segment But not up to the os 2. TYPE II Marginal Placenta reaches the margin of the internal os But does not cover it 3. TYPE III Incomplete or partial central Placenta covers the internal os partially 4. TYPE IV Central or total Placenta covers the internal os even after it is fully dilated Type 1 and type 2 are minor degree. Type 3 and 4 are major degree.
ANTEPARTUM HAEMORRHAGE.pptx
ANTEPARTUM HAEMORRHAGE.pptx
CLINICAL FEATURES & SYMPTOMS VAGINAL BLEEDING The classical presentation is painless antepartum haemorrhage. Causeless Recurrent SIGNS General condition and anemia are proportionate to the visible blood loss ABDOMINAL EXAMINATION The size of the uterus proportionate to the period of gestation The uterus feels relaxed, soft and elastic without any localised area of tenderness Persistence of malpresentation ( breech) Head is floating Fetal heart sound heard usually Stallworthys sign VAGINAL EXAMINATION SHOULD NOT BE DONE IN SUSPECTED
CONFIRMATION OF DIAGNOSIS LOCALISATION OF PLACENTA SONOGRAPHY TAS TVS Color Doppler flow study MAGNETIC RESONANCE IMAGING CLINICAL By internal examination(double set up examination) Direct visualization during caesarean section Examination of the placenta following vaginal delivery
MANAGEMENT There are two types of management for placenta previa based on certain criteria They are : Expectant management Active management The most important guiding principle is when the mothers life is at risk dont think about saving the baby
MANAGEMENT IMMEDIATE ATTENTION Blood samples are taken A large bore IV cannula is sited Infusion of NS Gentle abdominal palpation Inspection of vulva EXPECTANT MANAGEMENT - Macaffee and Johnson regime Bed rest Periodic inspection Supplementary hematinics A gentle speculum examination Rh immunoglobulin Termination done at 37 weeks Steroid therapy - Inj betamethasone is given to hasten the lung maturity of the fetus
CONT. EXPECTANT MANAGEMENT - Macaffee and Johnson regime Bed rest Periodic inspection Supplementary hematinics A gentle speculum examination Rh immunoglobulin Termination done at 37 weeks Steroid therapy Inj. betamethasone is given to hasten the lung maturity of the fetus
ACTIVE MANAGEMENT INDICATIONS Bleeding occurs at or after 37 weeks of pregnancy Patient is in labour Patient is exsaguinated state on admission Bleeding is continuing and of moderate degree Baby is dead or known to be congenitally malformed DEFINITIVE MANAGEMENT CESAREAN DELIVERY Placental edge is within 2cm from the internal os VAGINAL DELIVERY Placental edge is clearly 2-3cm away from the internal os
COMPLICATION MATERNAL DURING PREGNANCY APH Malpresentation Premature labor
Complications during labour MATERNAL Early rupture of the membrane Cord prolapse Slow dilation Intrapartum haemorrhage Increased incidence of operative interference PPH FETAL Asphyxia Birth injury Low birth weight (m/c) IUD Congenital malformations
Abruptio placenta
DEFINITION DEFINITION Abruptio placenta is defined as haemorrhage occurring in pregnancy due to the separation of a normally situated placenta. It is also called accidental haemorrhage or premature separation of placenta.
INCIDENCE It is 1 : 200 It is less than previa Accounts for 5 % maternal mortality and 20% perinatal mortality
Types of abruption 1. Revealed In this type the blood seeps between the decidua and the membranes to present at the vagina 2. Concealed In this the blood gets collected behind the placenta and forms the retro placental clot Sometimes it may be due to collection between the decidua and membranes but it cant present at vagina because the presenting part is firmly pressed over the cervix 3. Mixed 4. In this type it is partly revealed and partly retroplacenta

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ANTEPARTUM HAEMORRHAGE.pptx

  • 2. Third-trimester bleeding, ranging from spotting to massive hemorrhage, occurs in 2% to 6% of all pregnancies. The differential diagnosis includes: Bloody show from labor Abruptio placentae (AP) Placenta previa (PP) Vasa previa (VP) Cervicitis, postcoital bleeding, trauma, uterine rupture, and carcinoma.
  • 5. DEFINITION When the placenta is implanted partially or completely over the lower uterine segment(over and adjacent to the internal os)it is called placenta previa.
  • 6. INCIDENCE O.5 1% among hospital deliveries 80% cases found in multiparous women Increase incidence beyond 35yrs Increase incidence with high birth order and multiple pregnancy 1 in 300- 400 pregnancy .
  • 7. MECHANISM OF BLEEDING Progressive stretching of the lower uterine segment normally occurs during the 3rd trimester and labour, but the inelastic placenta cannot stretch with it. This leads to inevitable separation of a part of the placenta with unavoidable bleeding. The closer to term, the greater is the amount of bleeding.
  • 8. ETIOLOGY THEORIES POSTULATED Dropping down theory Persistence of chorionic activity Defective decidua Big surface area of the placenta
  • 9. HIGH RISK FACTORS Multiparity Increased maternal age Previous cesarean section or any other scar in the uterus ( fibroids myomectectomy ) Placental size and abnormality ( twin) Smoking( due to defective decidual vascularisation) Prior curettage
  • 10. BROWNE`S CLASSIFICATION 1. TYPE I Low lying Major part of the placenta is attached to the upper segment Only the lower margin encroaches to the lower segment But not up to the os 2. TYPE II Marginal Placenta reaches the margin of the internal os But does not cover it 3. TYPE III Incomplete or partial central Placenta covers the internal os partially 4. TYPE IV Central or total Placenta covers the internal os even after it is fully dilated Type 1 and type 2 are minor degree. Type 3 and 4 are major degree.
  • 13. CLINICAL FEATURES & SYMPTOMS VAGINAL BLEEDING The classical presentation is painless antepartum haemorrhage. Causeless Recurrent SIGNS General condition and anemia are proportionate to the visible blood loss ABDOMINAL EXAMINATION The size of the uterus proportionate to the period of gestation The uterus feels relaxed, soft and elastic without any localised area of tenderness Persistence of malpresentation ( breech) Head is floating Fetal heart sound heard usually Stallworthys sign VAGINAL EXAMINATION SHOULD NOT BE DONE IN SUSPECTED
  • 14. CONFIRMATION OF DIAGNOSIS LOCALISATION OF PLACENTA SONOGRAPHY TAS TVS Color Doppler flow study MAGNETIC RESONANCE IMAGING CLINICAL By internal examination(double set up examination) Direct visualization during caesarean section Examination of the placenta following vaginal delivery
  • 15. MANAGEMENT There are two types of management for placenta previa based on certain criteria They are : Expectant management Active management The most important guiding principle is when the mothers life is at risk dont think about saving the baby
  • 16. MANAGEMENT IMMEDIATE ATTENTION Blood samples are taken A large bore IV cannula is sited Infusion of NS Gentle abdominal palpation Inspection of vulva EXPECTANT MANAGEMENT - Macaffee and Johnson regime Bed rest Periodic inspection Supplementary hematinics A gentle speculum examination Rh immunoglobulin Termination done at 37 weeks Steroid therapy - Inj betamethasone is given to hasten the lung maturity of the fetus
  • 17. CONT. EXPECTANT MANAGEMENT - Macaffee and Johnson regime Bed rest Periodic inspection Supplementary hematinics A gentle speculum examination Rh immunoglobulin Termination done at 37 weeks Steroid therapy Inj. betamethasone is given to hasten the lung maturity of the fetus
  • 18. ACTIVE MANAGEMENT INDICATIONS Bleeding occurs at or after 37 weeks of pregnancy Patient is in labour Patient is exsaguinated state on admission Bleeding is continuing and of moderate degree Baby is dead or known to be congenitally malformed DEFINITIVE MANAGEMENT CESAREAN DELIVERY Placental edge is within 2cm from the internal os VAGINAL DELIVERY Placental edge is clearly 2-3cm away from the internal os
  • 19. COMPLICATION MATERNAL DURING PREGNANCY APH Malpresentation Premature labor
  • 20. Complications during labour MATERNAL Early rupture of the membrane Cord prolapse Slow dilation Intrapartum haemorrhage Increased incidence of operative interference PPH FETAL Asphyxia Birth injury Low birth weight (m/c) IUD Congenital malformations
  • 22. DEFINITION DEFINITION Abruptio placenta is defined as haemorrhage occurring in pregnancy due to the separation of a normally situated placenta. It is also called accidental haemorrhage or premature separation of placenta.
  • 23. INCIDENCE It is 1 : 200 It is less than previa Accounts for 5 % maternal mortality and 20% perinatal mortality
  • 24. Types of abruption 1. Revealed In this type the blood seeps between the decidua and the membranes to present at the vagina 2. Concealed In this the blood gets collected behind the placenta and forms the retro placental clot Sometimes it may be due to collection between the decidua and membranes but it cant present at vagina because the presenting part is firmly pressed over the cervix 3. Mixed 4. In this type it is partly revealed and partly retroplacenta