Antepartum hemorrhage

#The Causes of APH :

Placental causes : ( placenta previa, placental abruption, vasa previa )
Local causes : ( vaginal trauma , vaginal infection , cervical carcinoma ,
cervical ectropion , cervicitis ).

Placental previa :
# incidence of placenta previa 5 : 1000
# other predisposing factor to placenta previa : Assisted conception ,
uterine structure anomalies.
#U/S confirm diagnosis.
#P.V is contra indicated because it can participate bleeding
#associated with fresh vaginal bleeding.

#a case of minor placenta previa : admitted for observation until 24 hour

without bleeding .
#can dillivered vaginaly if placenta < 2 cm away from internal os.

Placental abruption :
# incidence of placental abruption : .4- 2% and increase when use of
histological examination of placenta .
# In most cases( 2/3 ), the separation reaches the edge of the placenta,
tracks down to the cervix and is revealed as vaginal bleeding. The
remaining cases are concealed( 1/3), and present as uterine pain and
potentially maternal shock or fetal distress without obvious bleeding.

# other predisposing factor to placenta abroptio : hypertension , anti

coagulant therapy .
#U/S isn’t a reiable diagnostic tool.
#associated with dark vaginal bleeding.
# signs & symptoms of placental abruption : (tachycardia, pale , anxity
of mother , painful firm abdomen, decrease fetal movement, tender
uterous and hard in palpation it called "couvelair uterous " due to large
blood volum in myotonium : it described as woody hard uterous )

#conservative management of mild cases including :

1. Close monitoring of fetal well being.

2. Using U/S for fetal growth and amniotic fluid volum.
 3. Umbilical artery by Doppler.
4. CTG.

#for sever cases

1. Admitted in 48 hour.
2. Give steroid if Gestational age < 34 week . to enhance
maturity of lung.
3. Give anti D if ( Rh- )

#case with placenta abruption and baby died : vaginal delivary with
artificial rupture of membrane.

#complication of placenta abruption to mother : DIC , renal failure . to

fetus : perinatal death , FGR,

Vasa previa :

#Vasa praevia is present when fetal vessels traverse the fetal membranes
over the internal cervical os. These vessels may be from either a
velamentous insertion of the umbilical cord or may be joining an
accessory (succenturiate) placental lobe to the main disk of the placenta.

#The diagnosis is usually suspected when either spontaneous or artificial

rupture of the membranes is accompanied by painless fresh vaginal
bleeding

#By CTG : abnormal tachy cardia , deep deceleration.

#risk factors :

1. Placenta previa.
2. Velamentous placental incersion.
3. Multiple pregnancy.

morbid adherent of placenta

In women who have had a previous caesearean section, there is a risk that
the placenta implants into, and thus invades, into the previous scar. This
is called a ‘morbidly adherent placenta’ and there are three types:
1. Placenta accrete : Placenta is abnormally adherent to the uterine wall.

2. Placenta increta : Placenta is abnormally invading into the uterine

wall.

3. Placenta percreta : Placenta is invading through the uterine wall.

#The risk of a morbidly adherent placenta increases with

increasing numbers of previous Caesarean sections.

Postpartum hemorrhage
# types: Minor PPH : loss of 500-1000 ml
Major PPH : loss of more than 1000 ml

#fetal risk factors od PPH :

1. Large baby.
2. Multiple pregnancy.
3. Polyhydrominous.
4. Shoulder dystosia.

#usual causes od 2nd PPH :

1. Retained product.(most common)
2. Uterine infection : endometritis.
3. Hormonal contraception.
4. Bleeding disorders.
5. Rarely carcinoma.

# associated feature of 2nd PPH :

1. Crampy abdominal pain.
2. Uterous is larger than appropriate.
3. Passage of bits of placental tissue
4. Sypmtoms and signs of infection.

#causes of PPH :
 Tone : is the most
common cause of PPH and can cause torrential loss of blood
immediately following delivery. It can be predicted, and therefore
steps taken to prevent it, by the use of oxytocic infusions and active
management of the third stage of labour.
 Tissue : retained placenta
  Trauma : laceration and tear of genital system.
 Thrombin : This can occur in women with an underlying disorder
such as Von Willebrand’s disease, or platelet disorders. It more
commonly arises in women who have developed a consumptive
coagulopathy as a result of another obstetric complication, such as
a massive placental abruption, an unidentifi ed dead fetus, amniotic
fluid embolus or massive haemorrhage.

#Massive PPH will require correction of clotting factors using fresh

frozen plasma, platelets and cryoprecipitate.
#catherization is needed because that empty bladder enhance uterine
contraction.

# management of 2nd PPH ; in heavy bleeding :

1. I.V infusion.
2. Crossmatching of blood.
3. Syntocinon.
4. Ex. Under anesthesia and evacuation of uterous.
5. Antibiotic if placental tissue is found.
6. In minimal bleeding : use U/S to exclude retained product.

#Management PPH
Massage
Give oxytocine : to encourage contraction
Vaginal examination : to ( remove clotting , assess genital tract
trauma, if there is a tear , need prompt compression , repaire )
Bimanual compression.
Laparotomy : for bilateral uterine artery ligation , and if bleeding
continuous do iliac artery ligation.
If bleeding not stopped : hysterectomy as last resort.