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ANTEPARTUM HAEMORRHAGE
ANTEPARTUM HAEMORRHAGE
• It is defined as bleeding from or into the
  genital tract after the 28th week of pregnancy.
CAUSES

•   Placental bleeding (70%)                   unexplained (25%)        extraplacental (5%)




Placenta praevia (35%)   abruptio placenta (35%)                   Local cervicovaginal lesions
                                                                        - cervical polyp
                                                                        - carcinoma cervix
                                                                        - varicose vein
                                                                        - local trauma
Placenta Praevia
Placenta praevia
• When the placenta is
  implanted partially or
  completely over the
  lower uterine segment
  it is called placenta
  praevia.
INCIDENCE
•   0.5% among hospital deliveries
•   80%-multiparous
•   Increased beyond the age of 35
•   Multiple pregnancy
ETIOLOGY
• Dropping down theory-due to poor decidual
  reaction in the upper uterine segment
  fertilized ovum drops down & gets implanted
  in the lower segment.
• Persistence of chorionic activity in the decidua
  capsularis.
• Defective decidua results in spreading of the
  chorionic villi
• Big surface area of the placenta as in twins
Predisposing factors
PATHOLOGICAL ANATOMY
• Placenta
  – Large and thin
  – Degeneration with infarction and calcification
• Umbilical cord
  – Battledore (margin)
  – Velamentous (membranes)
• Lower uterine segment
  – Due to increased vascularity LUS becomes soft
    and friable
Calcified placenta
Types or degrees
• Type-1(low lying)-major
  part is attached to the
  upper segment and only
  the lower margin
  encroaches onto the
  lower segment but not
  up to the os.
Type-II(Marginal)
• Placenta reaches the
  margin of the internal
  os but does not cover it.
Type III(incomplete or partial central)
• Placenta covers the
  internal os
  partially(covers the
  internal os when closed
  but does not entirely do
  so when fully dilated)
Type IV (central or total)
• Placenta completely
  covers the internal os
  even after it is fully
  dilated.
CAUSE OF BLEEDING
     Placental growth slows down in later months

Lower segment progressively dilates

Inelastic placenta sheared off the wall of lower segment

Opening up of uteroplacental vessels


                       Bleeding
SPONTANEOUS CONTROL OF
          BLEEDING
 Thrombosis of the open sinuses.
 Mechanical pressure by the presenting part.
 Placental infarction.
CLINICAL FEATURES
 Symptoms
   Vaginal bleeding(sudden
    onset,painless,causeless,recurrent)
 Signs(general condition & anemia are
 proportionate to the visible blood loss)
   Abdominal examination
     Size of the uterus proportionate to the period of gestation.
     Uterus feels relaxed, soft and elastic without localized area
      of tenderness.
     Persistence of malpresentation (breech,transverse,unstable
      lie)
     Head is floating
     FHS present
Signs contd:
 Vulval inspection
   To examine whether the still bleeding is there or not
   Character of the blood-bright red or dark colored &
    the amount of blood loss
   Bleeding is bright red as bleeding occurs from the
    separated uteroplacental sinuses close to cervical
    opening & escaped out immediately.
 Vaginal examination should be done as it can
 provoke further separation of placenta with
 torrential hemorrhage.
Confirmation of diagnosis
• USG-TAS,TVS,color Doppler flow study.
• MRI
• CLINICAL
  – Internal examination (double set-up examination)
  – Direct visualization during LSC’s
  – Examination of placenta following vaginal delivery
Differential diagnosis
• Abruptio placenta
• Vasa praevia(unsupported umbilical vessels in
  velamentous placenta)
• Local cervical lesions
COMPLICATIONS
• Maternal
• During pregnancy
  – APH with shock
  – Malpresentation
  – Premature labor either spontaneous or induced
COMPLICATIONS
• During labor
   –   Early rupture of membranes
   –   Cord prolapse
   –   Intrapartum haemorrhage
   –   Increased operative interferance
   –   Postpartum haemorrhage
        • Imperfect retraction of the lower uterine segment on which the
          placenta is implanted.
        • Large surface area of placenta with atonic uterus due to
          preexisting anemia
        • Trauma to cervix and lower segment because of extreme softness
          and vascularity.
        • Retained placenta(increased surface area,morbid adhesion)
PUERPERIUM
• Sepsis is increased due to
  – Increased operative interference
  – Placental site near to vagina
  – Anemia & devitalized state of the patient
  Subinvolution
  embolism
fetal
• Low birth weight
• Asphyxia
   – Early separation of placenta
   – Compression of the placenta
   – Compression of cord
• Intrauterine death
   – Severe degree of separation of placenta
   – Maternal hypovolaemia
   – shock
• Birth injuries-increased intraoperative interference
• Congenital malformation
prognosis
• Reduction of maternal deaths in placenta
  praevia due to
  – Early diagnosis
  – Omission of internal examination
  – Free availability of blood transfusion facilities.
  – Potent antibiotics
  – Wider use of caesarean section with expert
    anesthetist
  – Skill & judgment with which the cases are
    managed
fetal
• Fetal mortality ranges from10-25%.
• Reduction of deaths is principally due to
  judicious extension of expectant treatment
  thereby reducing loss from prematurity, liberal
  use of LSC’s which greatly lessens the loss
  from anoxia and improvement in the NICU.
MANAGEMENT
• Prevention
  – Adequate antenatal care to improve the health
    status of the women & correction of anemia.
  – Antenatal diagnosis of low-lying placenta at 20
    weeks with routine ultrasound.
  – Significance of warning hemorrhage
  – Family planning & limitation of births
Nursing diagnosis
• Risk for Impaired Fetal Gas Exchange r/t Disruption of Placental
  Implantation
• Fluid Volume Deficit r/t Active Blood Loss Secondary to Disrupted
  Placental Implantation
• Active Blood Loss (Hemorrhage) r/t Disrupted Placental
  Implantation
• Fear r/t Threat to Maternal and Fetal Survival Secondary to
  Excessive Blood Loss
• Activity Intolerance r/t Enforced Bed Rest During Pregnancy
  Secondary to Potential for Hemorrhage
• Altered Diversional Activity r/t Inability to Engage in Usual Activities
  Secondary to Enforced Bed Rest and Inactivity During Pregnancy
•
Nursing interventions
• If continuation of the pregnancy is deemed safe for patient
  and fetus administer magnesium sulfate as ordered for
  premature labor
• Obtain blood samples for complete blood count and blood
  type and cross matching
• Institute complete bed rest
• If the patient and placenta previa is experiencing active
  bleeding, continuously monitor her blood pressure, pulse
  rate, respiration, central venous pressure, intake and output,
  and amount of vaginal bleeding as well as the fetal heart rate
  and rhythm
• Assist with application of intermittent or continuous
  electronic fetal monitoring as indicated by maternal and fetal
  status.
Nursing interventions
• Have oxygen readily available for use should fetal
  distress occur, as indicated by bradycardia, tachycardia,
  late or available decelerations, pathologic sinusoidal
  pattern, unstable baseline, or loss of variability.
• If the patient is Rh-negative and not sensitized,
  administer Rh (D) immune globulin (RhoGAM) after
  every bleeding episode.
• Administer prescribed IV fluids and blood products.
• Provide information about labor progress and the
  condition of the fetus.
• Prepare the patient and her family for a possible
  caesarian delivery and the birth of a preterm neonate,
  and provide thorough instructions for postpartum care.
Nursing interventions
• If the fetus less than 36 weeks gestation expect to administer an
  initial dose of betamethasone: explain that additional doses may be
  given again in 24 hours and possibly for the next 2 weeks to help
  mature the neonates lungs.
• Explain that the fetus survival depends on gestational age and
  amount of maternal blood loss. Request consultation with a
  neontologist or pediatrician to discuss a treatment plan with the
  patient and her family.
• Assure the patient that frequent monitoring and prompt
  management greatly reduce the risk of neonatal death.
• Encourage the patient and her family to verbalize their feelings
  helps them to develop effective coping strategies, and refer them
  for counseling, if necessary.
• Anticipate the need for a referral for home care if the patient
  bleeding ceases and she’s to return home in bed rest.
Abruptio placenta
DEFINITION
• Bleeding occurs due to premature separation of
  placenta.
• Varieties
  – Revealed: Following separation of placenta, blood
    insinuates downwards between membranes and
    decidua.
  – Concealed: Blood collects behind separated placenta
    or collected in between the membranes and decidua.
  – Mixed: some part of the collects inside(concealed) & a
    part is expelled out(revealed).
Incidence & significance
• Overall incidence is about 1 in 150 deliveries
ETIOLOGY
   High birth order pregnancies.
   Advancing age of the mother
   Poor-socio-economic condition.
   Malnutrition
   Smoking
   Preeclampsia
   Trauma
      External cephalic version,RTA,amniocentesis
 Sudden uterine decompression
    Delivery of 1st baby of twins,sudden escape of liquor amnii in
     hydramnios,premature rupture of membranes
 Short cord
 Supine hypotension syndrome
 Sick placenta
 Folic acid deficiency
 Torsion of the uterus
 Cocaine abuse
 thrombophilias
PATHOGENESIS
             Hemorrhage into the decidua basalis

                    Decidual hematoma


                  Rupture of the basal plate

Communication of the haematoma with intervillous space



 Lack of contraction of the uterus and compression of the torn
         bleeding points as it is distended by conceptus
pathogenesis
• Blood so accumulated will find the direction in
  following ways:
  – Complete accumulation behind the placenta.
  – Blood may dissect down wards in between the
    membranes & the uterine wall & ultimately
    escapes out through the cervix or may be kept
    concealed by the pressure of the fetal head on the
    lower uterine segment.
  – Blood may gain access to amniotic cavity after
    rupturing through the membranes.
Couvelaire uterus
• Severe form of concealed abruptioplacenta.
• Massive intravasation of blood into the
  uterine musculature upto the serous coat.
• Condition can be diagnosed only by
  laparotomy.
Naked eye features
• Uterus is dark port wine colour which may be
  patchy or diffuse.
• Occurs intially on cornua before spreading to
  other areas more specially over the placental
  site
Changes in other organs
• Fibrin knots in hepatic sinusoids
• Kidneys –acute cortical necrosis or acute
  tubular necrosis.(intra-renal vasospasm
  because of massive haemorrhage)
• Shock proteinuria (renal anoxia)
Blood coagulopathy
• Excess consumption of plasma fibrinogen due
  to DIC & retroplacental bleeding.
• Hypofibrinogenemia
• Elevated fibrin degradation products
• D-dimer
Clinical classification
• Grade0:clinical feature may be absent. Diagnosis made
  after inspection of placenta following delivery.
• Grade1:
   – External bleeding is slight.
   – Uterus-irritable,tenderness may or may not be present,
     shock is absent,FHS is good
• Grade2:
   – External bleeding mild to moderate, uterine tenderness is
     always present, shock is absent, fetal distress or even fetal
     death occurs.
• Grade3:
   – Bleeding is moderate to severe or may be concealed,
     uterine tenderness is marked, shock is pronounced,fetal
     death,coagulation defect,anuria
investigations
• Hb%(low value proportionate to the blood
  loss).
• Coagulation profile
  – Clotting time increased(>6mt)
  – Fibrinogen level low(>150mg/dl)
  – Platelet count count low
  – Partial thromboplastin time increased
  – FDP and D-dimer increased
• Urine for protein
Differential diagnosis
• Revealed type
  – Placenta praevia
• Mixed or concealed type
  –   Rupture uterus
  –   Rectus sheath haematoma
  –   Appendicular or intestinal perforation
  –   Twisted ovarian tumor
  –   Volvulus
  –   Acute hydramnios
  –   Tonic uterine contraction
Prognosis
• Depends on the clinical type, degree of
  placental separation, interval between the
  placental separation and delivery of the baby
  & efficacy of treatment.
MATERNAL
• In revealed type: Maternal risk is proportionate
  to the visible blood loss and maternal death.
• In concealed type: The prognosis is very
  uncertain.
• Fetal:
• In revealed type the fetal death is to the extent of
  25-30%
• In concealed type however the fetal death
  appreciably high ranging from 50-100%.The
  deaths are due to prematurity and anoxia due to
  placental separation.
Management
• Prevention and early detection and effective therapy
  of preeclampsia and other hypertensive disorders of
  pregnancy.
• Needle puncture during amniocentesis should be
  under ultrasound guidance.
• Avoidance of trauma-forceful external cephalic version.
• Avoid sudden decompression of uterus, in acute or
  chronic hydramnios.
• To avoid supine hypotension the patient is advised to
  lie in left lateral position in the later months of
  pregnancy.

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  • 2. ANTEPARTUM HAEMORRHAGE • It is defined as bleeding from or into the genital tract after the 28th week of pregnancy.
  • 3. CAUSES • Placental bleeding (70%) unexplained (25%) extraplacental (5%) Placenta praevia (35%) abruptio placenta (35%) Local cervicovaginal lesions - cervical polyp - carcinoma cervix - varicose vein - local trauma
  • 5. Placenta praevia • When the placenta is implanted partially or completely over the lower uterine segment it is called placenta praevia.
  • 6. INCIDENCE • 0.5% among hospital deliveries • 80%-multiparous • Increased beyond the age of 35 • Multiple pregnancy
  • 7. ETIOLOGY • Dropping down theory-due to poor decidual reaction in the upper uterine segment fertilized ovum drops down & gets implanted in the lower segment. • Persistence of chorionic activity in the decidua capsularis. • Defective decidua results in spreading of the chorionic villi • Big surface area of the placenta as in twins
  • 9. PATHOLOGICAL ANATOMY • Placenta – Large and thin – Degeneration with infarction and calcification • Umbilical cord – Battledore (margin) – Velamentous (membranes) • Lower uterine segment – Due to increased vascularity LUS becomes soft and friable
  • 11. Types or degrees • Type-1(low lying)-major part is attached to the upper segment and only the lower margin encroaches onto the lower segment but not up to the os.
  • 12. Type-II(Marginal) • Placenta reaches the margin of the internal os but does not cover it.
  • 13. Type III(incomplete or partial central) • Placenta covers the internal os partially(covers the internal os when closed but does not entirely do so when fully dilated)
  • 14. Type IV (central or total) • Placenta completely covers the internal os even after it is fully dilated.
  • 15. CAUSE OF BLEEDING Placental growth slows down in later months Lower segment progressively dilates Inelastic placenta sheared off the wall of lower segment Opening up of uteroplacental vessels Bleeding
  • 16. SPONTANEOUS CONTROL OF BLEEDING  Thrombosis of the open sinuses.  Mechanical pressure by the presenting part.  Placental infarction.
  • 17. CLINICAL FEATURES  Symptoms  Vaginal bleeding(sudden onset,painless,causeless,recurrent)  Signs(general condition & anemia are proportionate to the visible blood loss)  Abdominal examination  Size of the uterus proportionate to the period of gestation.  Uterus feels relaxed, soft and elastic without localized area of tenderness.  Persistence of malpresentation (breech,transverse,unstable lie)  Head is floating  FHS present
  • 18. Signs contd:  Vulval inspection  To examine whether the still bleeding is there or not  Character of the blood-bright red or dark colored & the amount of blood loss  Bleeding is bright red as bleeding occurs from the separated uteroplacental sinuses close to cervical opening & escaped out immediately.  Vaginal examination should be done as it can provoke further separation of placenta with torrential hemorrhage.
  • 19. Confirmation of diagnosis • USG-TAS,TVS,color Doppler flow study. • MRI • CLINICAL – Internal examination (double set-up examination) – Direct visualization during LSC’s – Examination of placenta following vaginal delivery
  • 20. Differential diagnosis • Abruptio placenta • Vasa praevia(unsupported umbilical vessels in velamentous placenta) • Local cervical lesions
  • 21. COMPLICATIONS • Maternal • During pregnancy – APH with shock – Malpresentation – Premature labor either spontaneous or induced
  • 22. COMPLICATIONS • During labor – Early rupture of membranes – Cord prolapse – Intrapartum haemorrhage – Increased operative interferance – Postpartum haemorrhage • Imperfect retraction of the lower uterine segment on which the placenta is implanted. • Large surface area of placenta with atonic uterus due to preexisting anemia • Trauma to cervix and lower segment because of extreme softness and vascularity. • Retained placenta(increased surface area,morbid adhesion)
  • 23. PUERPERIUM • Sepsis is increased due to – Increased operative interference – Placental site near to vagina – Anemia & devitalized state of the patient Subinvolution embolism
  • 24. fetal • Low birth weight • Asphyxia – Early separation of placenta – Compression of the placenta – Compression of cord • Intrauterine death – Severe degree of separation of placenta – Maternal hypovolaemia – shock • Birth injuries-increased intraoperative interference • Congenital malformation
  • 25. prognosis • Reduction of maternal deaths in placenta praevia due to – Early diagnosis – Omission of internal examination – Free availability of blood transfusion facilities. – Potent antibiotics – Wider use of caesarean section with expert anesthetist – Skill & judgment with which the cases are managed
  • 26. fetal • Fetal mortality ranges from10-25%. • Reduction of deaths is principally due to judicious extension of expectant treatment thereby reducing loss from prematurity, liberal use of LSC’s which greatly lessens the loss from anoxia and improvement in the NICU.
  • 27. MANAGEMENT • Prevention – Adequate antenatal care to improve the health status of the women & correction of anemia. – Antenatal diagnosis of low-lying placenta at 20 weeks with routine ultrasound. – Significance of warning hemorrhage – Family planning & limitation of births
  • 28. Nursing diagnosis • Risk for Impaired Fetal Gas Exchange r/t Disruption of Placental Implantation • Fluid Volume Deficit r/t Active Blood Loss Secondary to Disrupted Placental Implantation • Active Blood Loss (Hemorrhage) r/t Disrupted Placental Implantation • Fear r/t Threat to Maternal and Fetal Survival Secondary to Excessive Blood Loss • Activity Intolerance r/t Enforced Bed Rest During Pregnancy Secondary to Potential for Hemorrhage • Altered Diversional Activity r/t Inability to Engage in Usual Activities Secondary to Enforced Bed Rest and Inactivity During Pregnancy •
  • 29. Nursing interventions • If continuation of the pregnancy is deemed safe for patient and fetus administer magnesium sulfate as ordered for premature labor • Obtain blood samples for complete blood count and blood type and cross matching • Institute complete bed rest • If the patient and placenta previa is experiencing active bleeding, continuously monitor her blood pressure, pulse rate, respiration, central venous pressure, intake and output, and amount of vaginal bleeding as well as the fetal heart rate and rhythm • Assist with application of intermittent or continuous electronic fetal monitoring as indicated by maternal and fetal status.
  • 30. Nursing interventions • Have oxygen readily available for use should fetal distress occur, as indicated by bradycardia, tachycardia, late or available decelerations, pathologic sinusoidal pattern, unstable baseline, or loss of variability. • If the patient is Rh-negative and not sensitized, administer Rh (D) immune globulin (RhoGAM) after every bleeding episode. • Administer prescribed IV fluids and blood products. • Provide information about labor progress and the condition of the fetus. • Prepare the patient and her family for a possible caesarian delivery and the birth of a preterm neonate, and provide thorough instructions for postpartum care.
  • 31. Nursing interventions • If the fetus less than 36 weeks gestation expect to administer an initial dose of betamethasone: explain that additional doses may be given again in 24 hours and possibly for the next 2 weeks to help mature the neonates lungs. • Explain that the fetus survival depends on gestational age and amount of maternal blood loss. Request consultation with a neontologist or pediatrician to discuss a treatment plan with the patient and her family. • Assure the patient that frequent monitoring and prompt management greatly reduce the risk of neonatal death. • Encourage the patient and her family to verbalize their feelings helps them to develop effective coping strategies, and refer them for counseling, if necessary. • Anticipate the need for a referral for home care if the patient bleeding ceases and she’s to return home in bed rest.
  • 33. DEFINITION • Bleeding occurs due to premature separation of placenta. • Varieties – Revealed: Following separation of placenta, blood insinuates downwards between membranes and decidua. – Concealed: Blood collects behind separated placenta or collected in between the membranes and decidua. – Mixed: some part of the collects inside(concealed) & a part is expelled out(revealed).
  • 34. Incidence & significance • Overall incidence is about 1 in 150 deliveries
  • 35. ETIOLOGY  High birth order pregnancies.  Advancing age of the mother  Poor-socio-economic condition.  Malnutrition  Smoking  Preeclampsia  Trauma  External cephalic version,RTA,amniocentesis  Sudden uterine decompression  Delivery of 1st baby of twins,sudden escape of liquor amnii in hydramnios,premature rupture of membranes  Short cord  Supine hypotension syndrome  Sick placenta  Folic acid deficiency  Torsion of the uterus  Cocaine abuse  thrombophilias
  • 36. PATHOGENESIS Hemorrhage into the decidua basalis Decidual hematoma Rupture of the basal plate Communication of the haematoma with intervillous space Lack of contraction of the uterus and compression of the torn bleeding points as it is distended by conceptus
  • 37. pathogenesis • Blood so accumulated will find the direction in following ways: – Complete accumulation behind the placenta. – Blood may dissect down wards in between the membranes & the uterine wall & ultimately escapes out through the cervix or may be kept concealed by the pressure of the fetal head on the lower uterine segment. – Blood may gain access to amniotic cavity after rupturing through the membranes.
  • 38. Couvelaire uterus • Severe form of concealed abruptioplacenta. • Massive intravasation of blood into the uterine musculature upto the serous coat. • Condition can be diagnosed only by laparotomy.
  • 39. Naked eye features • Uterus is dark port wine colour which may be patchy or diffuse. • Occurs intially on cornua before spreading to other areas more specially over the placental site
  • 40. Changes in other organs • Fibrin knots in hepatic sinusoids • Kidneys –acute cortical necrosis or acute tubular necrosis.(intra-renal vasospasm because of massive haemorrhage) • Shock proteinuria (renal anoxia)
  • 41. Blood coagulopathy • Excess consumption of plasma fibrinogen due to DIC & retroplacental bleeding. • Hypofibrinogenemia • Elevated fibrin degradation products • D-dimer
  • 42. Clinical classification • Grade0:clinical feature may be absent. Diagnosis made after inspection of placenta following delivery. • Grade1: – External bleeding is slight. – Uterus-irritable,tenderness may or may not be present, shock is absent,FHS is good • Grade2: – External bleeding mild to moderate, uterine tenderness is always present, shock is absent, fetal distress or even fetal death occurs. • Grade3: – Bleeding is moderate to severe or may be concealed, uterine tenderness is marked, shock is pronounced,fetal death,coagulation defect,anuria
  • 43. investigations • Hb%(low value proportionate to the blood loss). • Coagulation profile – Clotting time increased(>6mt) – Fibrinogen level low(>150mg/dl) – Platelet count count low – Partial thromboplastin time increased – FDP and D-dimer increased • Urine for protein
  • 44. Differential diagnosis • Revealed type – Placenta praevia • Mixed or concealed type – Rupture uterus – Rectus sheath haematoma – Appendicular or intestinal perforation – Twisted ovarian tumor – Volvulus – Acute hydramnios – Tonic uterine contraction
  • 45. Prognosis • Depends on the clinical type, degree of placental separation, interval between the placental separation and delivery of the baby & efficacy of treatment.
  • 46. MATERNAL • In revealed type: Maternal risk is proportionate to the visible blood loss and maternal death. • In concealed type: The prognosis is very uncertain. • Fetal: • In revealed type the fetal death is to the extent of 25-30% • In concealed type however the fetal death appreciably high ranging from 50-100%.The deaths are due to prematurity and anoxia due to placental separation.
  • 47. Management • Prevention and early detection and effective therapy of preeclampsia and other hypertensive disorders of pregnancy. • Needle puncture during amniocentesis should be under ultrasound guidance. • Avoidance of trauma-forceful external cephalic version. • Avoid sudden decompression of uterus, in acute or chronic hydramnios. • To avoid supine hypotension the patient is advised to lie in left lateral position in the later months of pregnancy.