Mutungi Session Objectives At the end of this session, the students will be able to: • Define late pregnancy bleeding (LPB) • List the differential diagnosis of LPB • Describe the prognosis and principles of management of LPB • Discuss in detail the main causes of LPB namelyplacental site bleeding; o Placenta praevia o Abruptio placentae Definition and incidence Definition: • Late pregnancy bleeding (LPB) or antepartum haemmorhage (APH) refers to any vaginal bleeding that occurs in the third trimester of pregnancy (at or after 28 weeks of gestation) Incidence: • 3-10% Differential diagnosis 1. Placental site bleeding a. Placenta praevia b. Abruptio placentae 2. Local causes a. Infections b. Neoplasms i. Benign e.g. polyps ii. Malignant e.g. carcinoma of the cervix c. Vulval varicosities d. Heavy ‘show’ 3. Ruptured uterus Prognosis APH: • Is an obstetrical emergency • Can very easily lead to maternal mortality • Is associated with high perinatal mortality • Easily progresses into a state of collapse (shock) PRINCIPLES OF MANAGEMENT • Objective in management of LPB must therefore be to prevent the possibility of the adverse outcomes mentioned above • Hence, the first step is to fix an intravenous line & draw blood for group and cross match (GXM) before shock sets in. • Then, and only then, should other aspects of management be considered! Patient Assessment • Assessment of the patient’s condition • General condition

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Vital signs History General examination Abdominal examination State of the fetus Speculum examination

Supportive Treatment Supportive treatment if & when required 1. Treatment of shock a. Raise foot of the bed b. Plasma expanders e.g. Dextran c. Blood transfusion d. Oxygen 2. Treatment of anemia a. Transfusion b. Hematinics Make a prognostic diagnosis of APH • Mild, moderate or severe • Placenta praevia, placenta abruption or other Make a decision on the projected management plan • Conservative • Immediate intervention PLACENTA PRAEVIA Definition & Clinical significance Definition • The placenta is wholly or partially placed in the lower uterine segment (LUS) Clinical significance • The mother is likely to bleed as a result of premature placental separation Mechanisms of placenta separation • The shearing effect on the placenta is as a result of the formation of the LUS or the taking up (effacement) of cervix due to uterine contractions Types of placenta praevia • Minor if it can allow vaginal delivery • Major if it cannot allow vaginal delivery Definitive diagnosis: Made by ultrasound examination or at examination under anesthesia (EUA); 4 types of placenta praevia are recognized: • • Type I – Placenta reaches the LUS but does not encroach on the internal cervical os Type II – Placenta encroaches on the internal os but does not cover it: o Type II anterior if the placenta is anterior o Type II posterior if the placenta is posterior

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Type III – the placenta covers the internal os but not completely Type IV- the placenta covers the internal os completely, even if it was to reach full dilatation

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Clinical significance of typing • Types I & II anterior: Are non-obstructive & vaginal birth can be allowed if not bleeding • Type II posterior: Directly impedes descent along the sacral curve • Types III & IV: Obstruct the cervical os and delivery by cesarean section is mandatory in order to avoid bleeding Pathogenesis Several theories: 1. Rapid embryo development – reaches the uterine cavity before the endometrium is receptive 2. Previous endometrial damage, or poor vascularization o Multiple uterine scars o Previous D&C o Fibroids 3. Multiple pregnancy – the large placenta encroaches on to the LUS 4. Rising maternal age Clinical features 1. Painless vaginal bleeding, often before 36 weeks a. First haemorrhage often less severe – termed as ‘warning haemorrhages’ b. Blood is often fresh & bright red c. Pain is not a feature d. The general condition of the patient is commensurate with the amount of blood loss 2. Abdominal examination: a. Non-tender

If at or near term, delivery is always indicated; mode of delivery depends on amount of bleeding and ‘type’ of the placenta If hemorrhage is life threatening at any gestation, emergency cesarean delivery is indicated If not at or near term and hemorrhage is not life threatening, conservative management is preferred

Conservative management Objective: To achieve fetal maturity without compromising on maternal safety 1. Bed rest 2. Sedatives to enhance bed rest 3. Group & X-match 2-3 units of blood & keep ready in case it is required 4. Lung maturing steroids in event delivery becomes necessary 5. Delivery is indicated: • If there is torrential hemorrhage at any time (by emergency cesarean section) • If significant bleeding after 34 weeks of gestation • Once at 37 weeks of gestation Mode of elective delivery at term • Caesarean delivery if placenta praevia is obviously major type by ultrasound EUA in a double set-up situation – outcome of which is: • Caesarean if placenta praevia is major type • Artificial rupture of membranes & labour induction if placenta praevia is minor type Complications As a result of poor ability of the LUS to retract: • Increased blood loss at caesarean section • Postpartum hemorrhage ABRUPTIO PLACENTA Definition Premature separation of a normally situated placenta. Types

b. Uterine size corresponds with the GA
c. d. e. Presenting part is high Malpresentation is common Oblique lie is especially common

3. Pelvic examination: a. No room for digital examination
4. b. Speculum examination is permissible The fetus is often in good condition

Differential diagnosis include: • Abruptio placenta • Local genital causes of bleeding Definitive diagnosis: • Placental localization (placentography) is key to the determination of the mode of delivery • Ultrasound – is very accurate • EUA with a double set-up Management Basic principles:

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Concealed abruptio placenta – bleeding is confined in the retroplacental space

Revealed abruptio placenta – blood trickles from the retroplacental space, through the placental margin Nb: Abruptio placenta is often recurrent in the subsequent pregnancies. Pathogenesis of abruptio placenta • Faults at implantation may result in an area of weakness • Decidual infarcts • Extravasation of blood into the myometriun – responsible for “woody hardness” of the uterus

Excessive extravasation with resultant myometrial damage leads to couvelaire uterus

Etiological factors • Trauma – external blow; fall; external cephalic version • Hypertensive disease in pregnancy • Nutritional deficiency, especially folic acid • Grandmultiparity • Previous abortion, preterm labour, intrauterine growth restriction or fetal malformation • Previous history of abruptio placenta

Once the diagnosis is established, the following should be done:

Resuscitative measures –shock, hypoxia, DIC, etc. Delivery should be effected: Fetus not alive – vaginal delivery preferred unless hemorrhage is life-threatening Determine coagulation status Monitor urine output

o o

Fetus alive – cesarean delivery preferable

Clinical features • Severity of symptoms depends on the amount of retroplacental bleeding

SUMMARY Feature Bleeding Placenta praevia Abruptio placenta • Dark Continuous Pain present Often associated with labor Tense Tender & painful Disproportionate to blood loss Often difficult to palpate Dead in 50% of instances Malpresentation uncommon

Only 50% present with the classic clinical features e.g. o Hemorrhage:  Dark blood because of retention Amount of bleeding not commensurate with degree of anaemia Abdominal findings: Pain – related to the degree of intravasation & to peritoneal irritation  Tense abdomen – ‘woody hard’  Fetal parts difficult to define  Uterine size > dates  Fetal heart tones difficult to auscultate (ultrasound may be necessary to confirm fetal viability) General condition:   Degree of anemia & shock not commensurate with the apparent blood loss


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Bright red Recurrent Painless Usually no labor Relaxed No tenderness Proportional to blood loss

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Shock/ anaemia Fetus

Parts easily palpated • Often alive Malpresentation common


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Differential diagnosis 1. Placenta praevia 2. Local conditions 3. Uterine rupture 4. Acute polyhydramnios Complications

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Coagulation disorders: Due to consumption of Platelets, clotting factors by the retroplacental clot Pituitary necrosis: Due to shock Renal failure: Due to shock & DIC Postpartum bleeding: Due to uterine damage, atony & coagulation failure Fetal complications – influenced by the degree of placenta separation & the degree of shock/anaemia; o Intrauterine hypoxia o Intrauterine fetal death o Preterm delivery


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