Antepartum Hemorrhage
Antepartum Hemorrhage
Antepartum Hemorrhage
Placenta previa
Abruptio placenta
Kottayam Kottayam
Introduction:
ANTEPARTUM HEMORRHAGE:
Causes:
PLACENTA PREVIA:
Definition:
Incidence:
A clinical grading is
i. Because of the curved birth canal, major thickness of the placenta overlies
the sacral promontory, thereby diminishing the antero-posterior diameter of
the inlet and prevents engagement of the presenting part. This hinders
effective compression of the separated placenta to stop bleeding.
ii. Placenta is more likely to be compressed if vaginal delivery is allowed.
Etiology:
Dropping down theory: the fertilized ovum drops down and is implanted in
the lower segment of the uterus. This may be due to poor decidual reaction
in the upper uterine segment and delayed disappearance of zona pellucida.
Persistence of chorionic activity: decidua capsularis develop into capsular
placenta and comes in contact with decidua vera.
Predisposing factors:
a. Advancing maternal age increases the risk of placenta previa. At the extremes,
it is 1 in 1500 for women 19 years of age or younger, and it is 1 in 100 for
women older than 35 years of age.
b. Multiparity is associated with previa. In a study of 314 women who were para 5
or greater.
c. Ananth and associates (2003a) found that the rate of placenta previa was 40
percent higher in multifetal gestations compared with that of singletons.
d. History of any previous caesarean section or any other scar in the uterus. Miller
and associates (1996) cited a threefold increase of previa in women with prior
caesarean delivery in over 150,000 deliveries
Pathological anatomy:
placenta- placenta may be large and thin. There is often a tongue shaped
extension from the main placental mass. Extensive areas with degeneration and
calcification may be evident. Placenta will be morbidly adherent.
Umbilical cord: the insertion of the cord may be on the margin or near the internal
os. Vasa previa (fetal vessels running across the internal os) may rupture along
with rupture of membranes.
Lower uterine segment: due to increased vascularity, lower uterine segment and
the cervix becomes soft and friable.
Causes of bleeding: as the placental growth slows down in later months and the
lower segment progressively dilates, the inelastic placenta is sheared off the wall
of the lower segment. This leads to opening up of utero placental vessels and lead
to an episode of bleeding. The blood is almost always maternal, although fetal
blood may escape from the villi especially when the placenta is separated during
the trauma.
Clinical features:
Symptoms:
Signs :
The uterus feels relaxed, soft, and elastic without any localized areas
of tenderness.
Persistence of malpresentation like breech and increased frequency of
twin pregnancy.
Slowing of the foetal heart rate on pressing down the fetal head down
into the pelvis which soon recovers as the pressure is released is
suggestive of the presence of low lying placenta especially of posterior
type. (stall worthy sign).
Vulval inspection: Whether the bleeding is still there or not, character of the
blood (bright red or dark colored), amount of blood loss- to be assessed from
blood stained clothing. In placenta previa, the blood is bright red as the
bleeding occurs from the separated utero- placental sinuses close to the
cervical opening and escapes out immediately.
Clinical presentation:
The most common symptom is the painless vaginal bleeding in the third
trimester of pregnancy. According to Crenshaw et.al., approximately one-third
of patients with placenta previa have their first bleeding episode before 30
weeks, a third from 30-35 weeks, and a third after 36 or more weeks. The
earlier in pregnancy the bleeding occurs, the worse is the outcome of
pregnancy.
Fetal distress is unusual if there is no severe hemorrhage.
Clinical diagnosis:
Transabdominal scan:
Placental migration:
USG at 17 wks of gestation reveals placenta covering the internal os in
about 10% of cases. Repeat USG at 37 weeks show no placenta in the lower
uterine segment in more than 90% of cases.
Since the report by King (1973), the apparent peripatetic nature of the
placenta has been well established. Sanderson and Milton (1991) found that 12
percent of placentas were "low lying" in 4300 women at 18 to 20 weeks. Of those
not covering the internal os, previa did not persist and hemorrhage was not
encountered. Conversely, of those covering the os at mid pregnancy, about 40
percent persisted as a previa. Thus, placentas that lie close to the internal os, but
not over it, during the second trimester, or even early in the third trimester, are
unlikely to persist as previas by term.
Transvaginal scan: Transducer is inserted into the vagina without touching the
cervix. This is safe and avoids the discomfort of a full bladder. It also gives
accurate results.
Colour Doppler flow study: Prominent venous flow in the hyper echoic areas near
the cervix is consistent with the diagnosis of placenta previa.
Clinical confirmation:
Double set-up examination- this is a type of vaginal examination.
Indications are:
Palpation of placenta in the lower segment not only confirms the diagnosis
but also identifies the degree.
Differential diagnosis:
Abruptio placenta.
Vasa previa- bleeding will be fetal with detection of fetal blood cells in the
blood.
Complications:
MATERNAL:
During pregnancy:
Preterm labour.
During labour:
FETAL:
Congenital malformations.
Prognosis:
Management:
Prevention:
At home:
3. Quick but gentle abdominal examination to note the fundal height and
auscultate FHS to assess the well being of the fetus.
Transfer to hospital:
Transported by flying squad service, with an intravenous dextrose saline
drip on flow.
Admission to hospital:
All the cases of APH must be considered as placenta previa and admitted to
hospital.
Treatment:
Immediate attention:
A. Expectant treatment:
The policy had been advocated by Macafee and Johnson (1945), in an
attempt to improve the fetal salvage without increasing undue maternal
hazards. The aim is to continue pregnancy for fetal maturity without
compromising the maternal health.
Vital prerequisites:
Selection of cases:
Suitable cases for expectant management are: (1) Mother is in good health
status (Haemoglobin > 10 gm%; haematocrit > 30%). (2) Duration of
pregnancy is less than 37 weeks. (3) Active vaginal bleeding is absent (4)
Fetal well being is assured (USG).
B. Active interference:
The indications of active treatment are: (1) Bleeding occurs at or after 37
weeks of pregnancy. (2) Patient is in labour. (3) Patient is in exsanguinated state
on admission. (4) Bleeding is continuing and of moderate degree. (5) Baby is
dead or known to be congenitally deformed.
These are also the contraindications for putting the patients to expectant regime.
Depending upon the urgency of the situation, definitive treatment should be
instituted as soon as possible.
C. Definitive Treatment
Definitive treatment whether instituted soon following
hospitalisation or following expectant treatment resolves into:
I. Vaginal examination in operation theatre followed by: (a) Low
rupture of the membranes or (b) Caesarean section.
II. Caesarean section without internal examination.
Abruptio placenta:
The separation of the placenta from its site of implantation before delivery
has been variously called placental abruption, abruptio placentae, or accidental
hemorrhage. The term premature separation of the normally implanted placenta is
most descriptive because it differentiates the placenta that separates prematurely
but that is implanted some distance beyond the cervical internal os from one that
is implanted over the cervical internal os—that is, placenta previa.
The primary cause of placental abruption is unknown, but there are several
associated conditions.
Short cord.
Sick placenta.
Thrombophilas.
Varities:
1) Revealed: the blood insinuates between the membranes and the decidua.
Ultimately the blood comes out of cervix to become visible. This is the
commonest type.
2) Concealed: the blood collects behind the separated placenta or collected
between the membranes and the decidua. The collected blood is prevented
from coming out by the presenting part which presses on the lower segment.
This type is rare.
3) Mixed: some part of the blood is collected inside and some part is expelled
out. Usually one variety predominates over the other.
Recurrent Abruption
Complications:
Intravascular coagulopathy:
Renal Failure
Acute renal failure may be seen in severe forms of placental abruption. This
includes those in which treatment of hypovolemia is delayed or incomplete. Of 72
pregnant women with acute renal failure described by Drakeley and colleagues
(2002), 32 percent had placental abruption. Fortunately, reversible acute tubular
necrosis accounts for 75 percent of cases of renal failure (Turney and colleagues,
1989). According to Lindheimer and associates (2000), acute cortical necrosis in
pregnancy is usually caused by abruptio placentae.
Seriously impaired renal perfusion is the consequence of massive
hemorrhage. Because preeclampsia frequently coexists with placental abruption,
renal vasospasm is likely intensified (Hauth and Cunningham, 1999). Even when
placental abruption is complicated by severe intravascular coagulation, prompt
and vigorous treatment of hemorrhage with blood and crystalloid solution often
prevents clinically significant renal dysfunction.
Kidneys may show acute cortical necrosis or acute tubular necrosis. The
precise mechanism is not clear but may be due to intrarenal vasospasm as a
consequence of massive haemorrhage. Shock proteinuria is probably due to renal
anoxia which usually disappears two days after delivery, whereas, proteinuria due
to preeclampsia tends to last.
Couvelaire Uterus
Naked eye features: Uterus is dark port wine colour (patchy or diffuse) occurring
initially in cornua, more in placental site.
Microscopic appearance: the uterine muscles over the area are necrosed and there
is infiltration of blood and fluid in between the muscle layers. The serosa may
split on occasions to allow blood to enter the peritoneal cavity. The blood vessels
show acute degenerative changes with thrombosis.
CHANGES IN OTHER ORGANS: In the liver, apart from the changes found in
pre-eclampsia, presence of fibrin knots in the hepatic sinusoids is an important
finding.
Clinical manifestations
Symptoms:
Signs:
CLINICAL FEATURES
Hemorrhage
Shock
Postpartum hemorrhage.
Puerperal sepsis.
Prevention:
Aims are:
Guidelines:
Treatment:
In the hospital:
Revealed type: assessment for amount of blood loss, maturity of fetus, whether
the patient is in labour, or not.
Preliminaries-
Definitive treatment:
Principles:
Monitoring of CVP.
Caesarean section:
Late CS if, inn spite of amniotomy and oxytocin, the labour is delayed
for more than 6-8 hrs and instead the general condition deteriorates
with appearance of complicating factors or there is evidence of fetal
distress.
Assessment:
Criteria I II III IV
Intensive observation and monitoring- vital signs, fluid intake and output,
blood studies.
IV fluids.
CVP monitoring.
Patient selection
Hospitalisation
Prevention of labour
Nursing diagnoses:
Purpose of review: The purpose of this review is to present the current evidence
supporting the screening, diagnosis and management of placenta previa.
Summary: This review addresses screening for placenta previa. A simple and
pragmatic ultrasound classification of placenta previa and low-lying placenta is
proposed. Caesarean section is recommended for delivery in cases of placenta
previa.
2. Association of caesarean delivery for first birth with placenta praevia
and placental abruption in second pregnancy, Q Yang, SW Wen
BJOG: An International Journal of Obstetrics & Gynaecology
Volume 114, Issue 5, pages 609–613, May 2007
References:
1. Cunningham, mc donald, gant. William’s obstetrics. 20 th edition. (1997).
Appleton and lange. International edition. Pages: 746-60.
2. Gillbert ES, manual of high risk pregnancy and delivery, 4 th edition, Elsevier
publications, pages: 309-408.
4. Dutta DC, textbook of obstetrics. 6th edition, central publishers, pages: 420-
46.