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Antepartum

Hemorrhage(APH)

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Antepartum Hemorrhage

Death from hemorrhage still remains a leadingcause of maternal mortality.

Hemorrhage was a direct cause of more than 18percent of 321 pregnancy!related maternaldeaths.

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ANTEPARTUM

HEMORRHAGE Per "agina #lood loss after 2$ wee%s&

gestation.

'omplicates close to $ of allpregnancies and is a *D+'A,**-*/'0

+s one of the leading causes ofantepartum hospitaliation maternalmor#idity and operati"e inter"ention.

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'44/ 'A56*6

Placenta Pre"ia

Placental A#ruption

5terine -upture 7asa Pre"ia

loody 6how

'oagulation Disorder

Hemorrhoids

7aginal ,esion9+n:ury

'er"ical ,esion9+n:ury

/eoplasia

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;ey point to -emem#er

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Placenta Pre"ia

Defned as a placenta implanted in the lowersegment o the ters! presenting ahead othe leading pole o the ets"

1. Total placenta previa.

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Placenta Pre"ia

leeding results fromsmall disruptions in

the placentalattachment duringnormal de"elopmentand thinning of the

lower uterinesegment

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Placenta Pre"ia

Incidencea#out 1 in 3

Perinatal morbidity and mortality are primarilyrelated to the complications o premat!rity"beca!se the hemorrhage is maternal.

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Placenta Pre"ia

Etiology>

Ad"ancing maternal age

M!ltiparity

M!ltietal gestations

Prior cesarean delivery

#mo$ing

Prior placenta pre"ia

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Placenta Pre"ia

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Placenta Pre"ia

Placenta pre"ia may #e associated withplacenta accretaplacenta incretaorpercreta.

'oagulopathy is rare with placenta pre"ia.

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Placenta Pre"ia

Diagnosis.

Placenta pre"ia or a#ruption should always #e suspectedin women with uterine #leeding during the latter half ofpregnancy.

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Placenta Pre"ia

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Placenta Pre"ia

anagement

Admit to hospital

%& '()I%(L *+(MI%(TI&%%& '()I%(L *+(MI%(TI&%

+7 access

Placental localiation

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Placenta Pre"iaanagement

Severe

bleeding

Caesarean

section

Moderate

bleeding Gestation

>34/52

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Placenta Pre"ia

anagement Deli"ery is #y 'aesarean section

4ccasionally 'aesarean hysterectomy necessary.

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Placental A#ruption

Dened as the premature separation ofthe normally implanted placenta.

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Placental A#ruption

e,ternal hemorrhage concealed hemorrhage

Total

Partial

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Placental A#ruption

hat are the ris% factors for placentala#ruptionE

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Placental A#ruption

+ncreased age and

parity Preeclampsia

'hronic hypertension

Preterm ruptured

mem#ranes

ultifetal gestation

Hydramnios

'igarette smo%ing

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Placental A#ruption

Pathology

Placental a#ruption is initiated #y hemorrhage into the decidua#asalis.

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Placental A#ruption

leeding with placental a#ruption isalmost always maternal.

6ignicant fetal #leeding is more li%elyto #e seen with traumatic a#ruption.

+n this circumstance fetal #leedingresults from a tear or fracture in theplacenta rather than from theplacental separation itself.

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Placental A#ruption

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Placental A#ruption

Shock

Consumptive Coagulopathy

Renal Failure

Fetal Death

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Placental A#ruption

Management:

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5terine -upture

-eported in .3!.8 of all deli"eringwomen #ut .3!1.I among women with ahistory of a uterine scar (from a '96 fore=ample)

13 of all uterine ruptures occur outsidethe hospital

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5terine -upture

'lassic presentation includes "aginal#leeding pain cessation ofcontractions a#sence9 deterioration of

fetal heart rate loss of station of thefetal head from the #irth canal easilypalpa#le fetal parts and profoundmaternal tachycardia and hypotension.

Patients with a prior uterine scar should#e ad"ised to come to the hospital fore"aluation of new onset contractionsa#dominal pain or "aginal #leeding.

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HA< A-*

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5terine -upture

*=cessi"e uterinestimulation

H= of pre"ious '96

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5terine -upture

anagement> *mergent laparotomy

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7asa Pre"ia

-arely reported condition in which thefetal "essels from the placenta crossthe entrance to the #irth canal.

+ncidence "aries #ut most resourcesnote occurrence in 1>3pregnancies.

Associated with a high fetal mortalityrate (?!C?) which can #e attri#utedto rapid fetal e=sanguination resultingfrom the "essels tearing during la#or

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7asa Pre"ia

1. i!lo#ed placenta

2. 7elamentous insertion of the um#ilical cord

3. 6uccenturiate (Accessory) lo#e

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7asa Pre"ia

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7asa Pre"ia

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7asa Pre"ia

-is% Jactors>

ilo#ed and succenturiate placentas

7elamentous insertion of the cord

,ow!lying placenta ultiple gestation

Pregnancies resulting from in "itro fertiliation

Palpa#le "essel on "aginal e=am

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7asa Pre"ia

anagement>

hen "asa pre"ia is detected prior to la#or

the #a#y has a much greater chance ofsur"i"ing.

+t can #e detected during pregnancy with

use of trans"aginal sonography.

hen "asa pre"ia is diagnosed prior to la#or

electi"e caesarian is the deli"ery method of

choice.

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;leihauer!et%e

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Apt test