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Antepartum Hemorrhage
Antepartum Hemorrhage
A 30 year old G2P1 with previous spontaneus vaginal delivery and appropriately grown fetus is admitted at term with fresh vaginal bleeding and abdominal pain. On examination she is distressed with pain, pale, her pulse is 100 bpm, blood pressure 110/80 mmHg, and she has a tender uterus contracting 3/10minutes. Although she had tried to clean herself as much as possible, while waiting for the ambulance to transfer her to the maternity unit, you notice that she has blood stains on her feet between her toes.
Problems?
Bleeding during pregnancy (active) Atterm pregnancy Pain, high pulse, uterine contraction
Antepartum bleeding
Vaginal bleeding in 20 weeks to at-term pregnancy.
Etiology of APH
Cervical Contact bleeding (ex: coitus, pap-smear, neoplasia, bimanual exam) inflammation (ex: infection) Cervical dilatation and effacement (ex: in parturition, incompetence cervix) Placenta abruptio previa Rupture of sinus marginalis vasa previa Others - abnormality of coagulating factors
Vaginal bleeding
Risk factor Test (NO bimanual )
Assessment Fetal / Maternal Moth & baby instabile Hemodinamiic ressucitation Moth & baby instabile Labor Expectant Consider blood loss, etiology and gestational weeks Moth & baby stabile Lab / fetal monitoring U/S vaginal exam
Hemodinamic ressucitation
Early and aggressive to protect fetus and maternal organ from hypoperfussion and prevent DIC Stabilitation of vital sign tanda vital Crystalloid infusion with large bore cath Haemoglobine serial and coagulation profile Oxigen
Perawatan Janin
Posisi lateral meningkatkan curah jantung sampai 30% Pertimbangkan amniosentesis untuk tes kematangan paru Pemantauan DJJ dan kontraksi (persalinan) Monitor berkala sedikitnya 4 jam untuk membuktikan adanya perdarahan janin, solusio, fetal maternal transfusion
Classification
Total - fetal death Partial fetus can tollerate up to 30-50% of plasental separation
Abruptio placentae
Risk factors
hypertension: gestational or before Trauma abdomen Drug abuse (cocain and sedative) Previous abruption hystory Uterus stretching gemelli, polyhidramnion Smoking, more >1 pack/day
Clinical features
Risk factors exist Hemodinamic status not always related to amount of bleeding (concelead type) Can cause fetal dystress uterus - pain, irritable, contraction or tetanic With ultrasound can be differentiated from previa in the form of retroplasentair hemorrhage
SOLUSIO
Janin hidup janin mati koagulopati persalinan (hati-hati DIC) Nilai maturitas
Classification
total partial marginal
Risk factors
History of plasenta previa History of SC or uterus operation multiparity (5% in grand multipara)
Clinical features
Bleeding, without pain ( unless during parturition) Hemodinamic status related to amount of bleeding Can be tolerated by fetus, unless mother in unstable condition uterus not pain, not irritable, no contration Can cause malpresentation Ultrasound can define the diagnosis
PLASENTA PREVIA
Nilai maturitas
Matur
Immatur
persalinan dengan s.c (hati-hati akreta) dapat dicoba pervaginam jika marginal
Komplikasi
ex-sanguinasi setelah amniotomi
Diagnosis
Apt test - Kleihauer test dari darah vagina bradikardia janin (terminal) berawal takikardia atau sinusoidal
Prognosis
Mortalitas janin sebesar 50-70%
Simpulan
Nilai keadaan ibu dan stabilitas Nilai apakah janin dalam keadaan baik Resusitasi yang tepat Nilai penyebab dari perdarahan hindari periksa dalam Tatalaksana ekspektatif jika sesuai Terminasi kehamilan jika ada indikasi ibu atau janin
Summary
Etiology and risk factors Diagnosis Management - Assessment of maternal and fetal - Ressuciation - No vaginal exam before ascertain about placenta location