ANTEPARTUM HAEMORRHAGE
APH is
bleeding from the genital tract in pregnancy after 24 weeks of gestation and before
onset of labor.
Obstetric
haemorrhage is one of the major causes of maternal death.
The
Haemorrhage is divided in to 3 parts:
1: minor haemorrhage is when the blood loss is estimated
less than 50ml.
2: major haemorrhage is when the blood loss is estimated
50ml-1000ml with no signs of clinical shock.
3: massive haemorrhage is when the blood loss is estimated
more than 1000ml and also signs of clinical shock.
What are
the clinical shock?
1: tachycardia is when the heart rate is above than
100 beats per minute.
Normal heart
rate is 60-100 beats per minute.
2: pale, cool because of peripheral
vasoconstriction.
3: delayed capillary refill time >2seconds.
4: tachypnea is when the respiratory rate is more
than 20 breath per minute.
Normal
respiratory rate 12-20 breathing per minute.
5: hypotension is when blood pressure is less than
normal.
Normal blood
pressure 120/80mmhg.
6: oliguria is defined abnormally low urine
output.
Normal urine
output is measured by 0.5-1.5ml/kg/hour.
7: altered mental status is when the person is in confusion
or drowsiness.
8: metabolic acidosis is when the body acid – base balance
disturbed and there is too much acid or too little bicarbonate.
The role of
clinical assessment in women presenting witth APH is First to establish whether
urgent intervention is required to manage maternal or fetal compromise.
The process
of traige include:
A. history
taking to assess pain
B. An
assessment of the extent of vaginal bleeding.
C. The
cardiovascular condition of the mother.
D. An
assessment of fetal wellbeing.
If there is
no maternal compromise a full history should be taken.
Causes of
antepartum haemorrhage:
The most
common causes of APH are placenta abruptio and placenta praevia.
Other causes can be:
1: uterine rupture
2: cervical
erosions
3: genital
tract tumours
4: Trauma
5: local
infection
6:
Varicosities
7: vasa praevia
Placenta
abruptio
Placenta abruptio is premature separation of partially
or completed from the implanted placenta from the uterine wall before time of
birth.
Clinical
features
1. abdominal pain of sudden onset
constant and severe
2. the uterus is Tender and may become
hard later
3. Vaginal bleeding it is usually dark
bleeding.
4. Back pain
5. The possibility amount of blood
hidden shock in the patients will be inconsistent with external loss.
6. Fetal distress since placenta
detaching from the uterine wall and blood supply of the baby is being effected
fetal distress may be observe. If
placenta completely detaches the wall therefore absolutly no receiving blood
supply the fetus will be dead
7. Fetal lies normal and head is
engaged.
8. Ultrasound: placenta location will be
normal.
Most of the
time it can not be identified in ultrasound so it is a clinical diagnose.
Causes and
risk factors:
A: maternal
hypertension (chronic or pregnancy induced hypertension)
B: trauma of
the abdomen
C: smoking
D: previous
history of placenta abruptio
E: advanced
maternal age
F: Multiple
pregnancies (twins or more)
G:
polyhydramnios
H: premature
rupture of membranes
I:
intrauterine infection
J: low body
mass index
K: Fetal
growth restriction
Diagnose
1: fetal
monitoring
3: physical
examination
Prevention
While it can
not b eprevented always but can reduce the risk:
1: Managing
blood pressure
2: Avoiding
smoking
3: Prenatal
care checkups
Treatment
A: Mild
cases can be treated as monitoring closely
B: Severe
cases always required immediate delivery mostly by caesarean section.
C: If there
is blood loss blood transfusion
Placenta
praevia
placenta
praevia is a pregnancy related condition
where the placenta detaches or covers the low segment of cervix partially or
complete.
Types of
placenta praevia
1: complete
is when placenta covers all the cervix
2: Partially
is when the placenta covers partially or some of the cervix
3: Marginal
is when placenta reaches the edge of the cervix
4: Low lying
is when the placenta is near the cervix.
Clinical
features
1. The
condition will seem painless.
2. No
tenderness also no abdominal pain.
3. Fresh vaginal
bleeding.
4. Because
of bleeding shock will consistent with external loss.
5. Fetal
lies abnormal and head will be high.
6. While
bleeding is from placenta the fetal heart will be normal.
7.
Ultrasound placenta location will be low.
The risk
factors of placenta praevia.
1. Previous
placenta Praevia
2. Previous caesarean section or uterine
surgery
4. Multiple
pregnancies.
5. Advanced
maternal age greater than 40
6. Smoking
7. Uterine fibroid
Diagnose
Transvaginal
ultrasound is the primary method and safe method.
Transabdominal
untrasound
Avoid while
examining placenta praevia.
Vaginal
examination (finge)
Management
Management
depends on the how severe the situation is and gestational age:
1: expectant
management if it is preterm bed rest
2: if heavy
bleeding the patient will be hospitalized
3:
corticosteroid for fetal lung maturity
4: elective
caesarean section if placenta covers the cervix and no bleeding
5: emergency
caesarean section if there is heavy bleeding.
Vasa
praevia
Vasa praevia
this occurs when fetal blood vessels run
in membranes below of presenting fetal part
throught the placenta membranes.
Rupture of
membrane ➡ rupture of fetal blood vessels in
membrane➡ ruptured vasa praevia ➡
severe fetal distress.
Uterine
rupture
Uterine
Rupture is obstetric emergency which the uterine muscular tears usually during
child birth and can cause massive haemorrhage and fetal distress.
It is
recommended that woman be advised to report all vaginal bleeding to their
antenatal care provider.
conculusion
ANTEPARTUM HAEMORRHAGE is a condition of
obstetric complications associated with high maternal and perinatal morbidity
and mortality.
Early
antenatal care are advised to all pregnancy woman to avoid the risk and asses
the situation.
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