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 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—
} 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
ManagementComparison 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
