Management of APH (Antepartum haemorrhage) and ManagementPlacenta previa (PP)

• Management
• } b.  Standard management of symptomatic patients with PP
  • ◦ hospitalization with hemodynamic stabilization and continuous maternal and fetal monitoring.
  • ◦ Laboratory studies should be ordered
  • ◦ Steroids should be given to promote lung maturity for gestations between 24 and 34 weeks.
  • ◦ Rho(D) immunoglobulin should be administered to Rh-neg-ative mothers.
• } is then based on
• } gestational age,
• } severity of the bleeding, and
• } fetal condition and presentation.
• } d.  Management of complications, such as
  • } placenta accreta or one of its variants

Management of Placenta previa (PP)

• } In patients with PP and a previous history of cesarean section, cesarean hysterectomy-may be required.
• } in cases where uterine preservation is highly desired and no bladder invasion has occurred,
• } bleeding has been successfully controlled with selective arterial embolization or
• } packing of the lower uterine segment, with subsequent removal of the pack through the vagina in 24 hours.
• } 2. Term Gestation, Maternal and Fetal Hemodynamic Stability.
  • } At this point, management depends on placental location.
  • } a. Complete Previa.
    • } Patients with complete previa at term require cesarean section.
  • } b. Partial, Marginal Previa.
    • } These patients may deliver vaginally;
    • } a double setup in the operating room is recommended.
    • } The patient should be prepared and draped for cesarean section.
    • } An anesthesiologist and the operating room team should be present.
    • } If at any point maternal or fetal stability is compromised, urgent cesarean section is indicated.
• } 3.  Term Gestation,
  • } Maternal and Fetal Hemodynamic Instability.
  • } The first priority is to stabilize the mother with
  • } fluid resuscitation and
  • } administration of blood products, if necessary.
  • } a.  Delivery is indicated with
    • } evidence of nonreassuring fetal heart rate tracing,
    • } life-threatening maternal hemorrhage,
    • } or any bleeding after 34 weeks with known fetal lung maturity.
  • } b.  Delivery should then occur via cs.
    • } If the mother is hemody-namically stable and fetal loss has occurred or the fetus is less than 24 weeks,
    • } then vaginal delivery can be considered.
• } 4.  Preterm Gestation, Maternal and Fetal Hemodynamic Stability
  • } a.  Labor Absent.
    • } Patients at 24 to 37 weeks’ gestation with PP who are hemo-dynamically stable can be
    • } managed expectantly until fetal lung maturity has occurred.
    • } Hospitalization until stabilized
    • } Bed rest with
    • } periodic assessment of maternal hematocrit
    • } Blood transfusions to keep hematocrit above 30% in patients with a
    • } low-grade continuous bleed
    • } steroids for fetal lung maturity
    • } Fetal testing, and serial ultrasounds
    • } Tocolysis is used for
    • } the administration of antenatal steroids in an otherwise stable patient.
    • } After initial hospital management,
    • } care as an outpatient
    • } if the bleeding has stopped for more than 1 week,
    • } no other complications exist,
    • } and the following criteria are met:
    • } ■  The patient can maintain bed rest at home.
    • } The patient has a responsible adult present at all times who can assist
    • } in an emergency situation.
    • } The patient lives near the hospital with
    • } available transportation to the
    • } hospital and is adherent to medical care.
    • } once a patient has been hospitalized
    • } for three separate episodes of bleeding,
    • } she remains in the hospital until delivery
  • } b.  Labor Present.
    • } Twenty percent of patients with PP show evidence of uterine contractions.
    • } If the patient and fetus are stable,
    • } tocolysis may be considered
    • } with magnesium sulfate.
    • } Preterm Gestation,
    • } Maternal and Fetal Hemodynamic Instability.
    • } maternal stabilization with
    • } resuscitative measures is the priority.
    • } Once stable,
    • } the patient should be delivered by urgent cesarean section.
    • } This is a very rare condition in which
    • } the umbilical vessels in the membranes are passing oppo­site the internal cervical in case of velamentous insertion of the cord.
    • } Rupture of these vessels will lead to
    • } bleeding of fetal origin which is very dangerous

RUPTURE VASA PRAEVIA

• } It should be suspected when
• } fetal distress is marked with mild vaginal bleeding and good general condition of the mother
• } . Examination of the blood will show fetal RBCs.
• } Treatment is by immediate caesarean section
• } It is one form of ante partum haemorrhage in which the bleeding occurs due to the premature separation of normally situated placentae .
• } It occurs in three forms—
  • 1.Concealed type
  • 2.Revealed type
  • 3.Mixed type

Abruptio Placentae

• } History of trauma
• } High birth order of pregnancies
• } Low socio economic status
• } Advancing age of mother
• } Sudden decompression
• } Pregnancy induced hypertension
• } External version

Etiology

• } GRADE 0—
  • } No clinical features
• } Grade 1—
  • } Slight external bleeding and tenderness
  • } Fetal distress may occur
• } Grade 2—
  • } External bleeding mild to moderate
  • } Shock absent

Grading of ABP

• } Grade 3—
  • } Bleeding moderate to severe May be concealed
  • } Marked uterine tenderness
  • } Fetal death is a rule
  • } Shock present
  • } Depending upon the degree of separation, speed at which separation occurs and amount of blood concealed inside the uterine cavity , the features of ABP can be studied comparatively under following headings
  • } Symptoms
  • } General condition
  • } Pallor
  • } Toxemia

CLINICAL FEATURES

• } Hight of utrus
• } Uterine feel
• } Fetal parts
• } FHS
• } Coagulation profile

Management

• Management Comparison of PP and AP
• } Feature of Bleeding
  • ◦ Painless
  • ◦ Causeless
  • ◦ Recurrent
• } Character of bleeding
  • ◦ Bright red
• } General condition & anemia
  • ◦ Proportionate to visible blood loss
  • ◦ Painfull bleeding with h/o trauma
  • ◦ Bright red
  • ◦ Out of proportion to visible blood loss
• } Abdominal examination
  • ◦ Height of the uterus is proportional to gestational age
• } Feel
• ◦ Uterus feelsvsoft and relaxed
  • } Malpresentation
  • ◦ It is common in pp
  • ◦ Painful bleeding with h/o trauma
  • ◦ May be disproportionate rarely enlarge
  • ◦ Tender and hard
  • ◦ unrelated
• } F.H.S.
  • ◦ Usualy present
• } Placenta in lower segment
• } Engagement
  • ◦ High floating
  • ◦ Absent/feeble
  • ◦ Upper segment
  • ◦ Tender and hard
  • ◦ Normal engagement