Management of APH (Antepartum haemorrhage) Abruptio Placentae and Placenta previa (PP)

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

Placenta previa (PP)

Management of APH (Antepartum haemorrhage) Abruptio Placentae and Placenta previa (PP)


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—
  • } 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

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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
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