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HAEMORRHAGE
LEARNING OBJECTIVES:
At the end of this tutorial the student will be
able to:
Define APH
Discuss the etiology and differential diagnosis of
APH
Describe the assessment and management of a
woman with APH
Abruptio placenta
NUMBER (%)
141 (19)
125 (16)
115 (15)
108 (14)
50 (7)
47 (6)
44 (6)
32 (4)
ETIOLOGY
Placental:
- Placenta praevia
- Placenta abruption
- Vasa praevia
Local cause:
- Cervical polyps
- Cervicitis, Vaginitis
- Cervical cancer.
FULL HISTORY
(Should be taken after the mother is stable.)
Fetal movement
-If it reduced and associated with spontaneous or iatrogenic rupture of the fetal membranes : ruptured
vasa praevia
Hx of ruptured membranes
Hx cervical smear (date/normal or abnormal)
-Previous cervical smear history possibility of Ca cervix. Symptomatic pregnant women usually present
with APH (mostly postcoital) or vaginal discharge.
EXAMINATION
EXAMINATION
Speculum :
-identify cervical dilatation or visualise a lower
genital tract cause.
INVESTIGATIONS
Blood test
- FBC
- Coagulation profile
- Cross-match blood
Ultrasound
Colour doppler
Kleihauer test
Fetal monitoring:
CTG monitoring
MANAGEMENT
Conservative Management
Admit ( according to RCOG is 28weeks)
Monitor BP & Pulse rate
Pad chart - to monitor progress of the
leaking liquor
Minimize the abdominal examination
COMPLICATIONS OF APH
Maternal complications
Fetal complications
Anaemia
Fetal hypoxia
Infection
Maternal shock
Fetal death
Consumptive coagulopathy
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Definition
Classification (GRADING/CLINICAL)
TYPE 1
The placenta
enroaches
into lower
segment
TYPE II
The placenta
reaches the
margin of
cervical os
Type III
The placenta
covers the os but
not at full
dilatation.
Type IV
The placenta
completely covers
the cervical os.
Cervix
Placenta
Uterus
CLINICAL CLASSIFICATION
Minor :
Type 1 (anterior/posterior)
Type 2 anterior
Major:
Type 2 posterior (dangerous type)
Type 3
Type 4
Deliver vaginally
Type 1 Posterior >
likelihood of fetal distress
Caesarean section
Type 2 posterior >
chance of fetal distress
Type 3 & 4
anterior cut
through placenta to
deliver. Hence need
to be fast and
efficient.
ETIOLOGY
Advancing maternal age
Multiparity
Prior cesarean section ,manual removal
of placenta and dilatation and
curettage(D&C)
Multiple gestation
Smoking
History of PP
ETIOLOGY
The incidence of placenta praevia is 0.5%, bleeding from a placenta
praevia is about 20% of all cases of antepartum hemorrhage.
Maternal
influence
Haemorrhage
Shock
Anemia
Fetal influence
Distress or death
IUGR
Premature
Neonatal death
Postpartum
History
Maternal:
1) FBC
2) BUSE/RP
3) GSH
Fetal
1)CTG
2)U/S
MANAGEMENT
MANAGEMENT
DEFINITIVE TREATMENT
Type I,II(ant)
Caesarean
section
Satisfactory
progress without
bleeding
Vaginal
delivery
Bleeding continues
Caesarean section