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Seminar On Aph
Seminar On Aph
Karuna kumari
Date : 24.10.2011
Duration : 2hours
Abruptio placenta
-incidence of antepartum
hemorrhage
- Complications of placenta
praevia and abruptio placenta
- Nursing diagnosis for APH
placenta
Antepartum hemorrhage
BEHAVIOURAL OBJECTIVES
General objective: by the end of the session, students will be able to gain in depth
knowledge about antepartum hemorrhage and its management.
Specific objectives :
INTRODUCTION
DEFINITION
Antepartum hemorrhage is defined as bleeding from or into the genital tract after
28th week of pregnancy but before birth of the baby.
- Dutta
- Encyclopedia
INCIDENCE
ETIOLOGY
ABRUPTIO PLACENTA
INTRODUCTION
The heart rate of the fetus can be associated with the severity
DEFINITION
The term abruption means to tear apart and term accidental implies
separation as a result of trauma but does not occur spontaneously.
INCIDENCE
ETIOLOGY
( unknown).
Risk factors:-
a) High birth order pregnancies is gravida 5 and above – three times more
common than in first birth
b) Advancing age of the mother
c) Poor socio economic condition
d) Malnutrition
e) Smoking and alcohol abuse (drinking more than 14 alcohol drinks/week in
pregnancy)
f) A tendency of recurrence in subsequent pregnancies is ten fold
g) Diabetes
h) Uterine fibroids
i) Poly hydraminos
j) Chorio amnionitis/vasculitis
k) Blood cloting disorders
CLASSIFICATION:
2. Concealed : -
In this type, some part of the blood collects inside ( concealed) and a
part is expelled ( revealed) usually one variety predominates over the other. This
type is quite common
II. DEGREES
Grade 1 : These show external bleeding only or mild tetany but no evidence of
maternal shock.
Grade 2 : There is uterine tetany usually with uterine tenderness possible with
external bleeding, fetal distress or death but with no evidence of shock
CLINICAL TYPES
Predisposing factors
Trauma
Pregnancy
Hypertension
Use of drugs like cocaine
Smoking
decreased fibrinogen
increased fibrin
Couvelaire uterus
Features : dark pot wine colour, patchy or diffuse, sub peritoneal petechial
hemorrhage , free blood in peritoneum and broad ligament.
Changes in Other Organs:
CLINICAL FEATURES:
INVESTIGATIONS:
DIFFERENTIAL DIAGNOSIS:
Placenta praevia
Rupture uterus
Rectus Sheath hematoma
Apendicular or interstinal perforation
Twisted ovarian tumor
Volvulus
Acute hydramnios
Tonic uterine contractions
PROGNOSIS:
The prognosis of mother & baby depends on the clinical types (revealed,
concealed, mixed), degree of placental separation, the interval between separation
of placenta and delivery of baby and efficacy of treatment. Bleeding in placental
obruption is almost always maternal. Fetal bleeding is only observed with
traumatic variety of placental abruption.
COMPLICATIONS:
1. Maternal
a. In revealed type-maternal risk is proportionate to visible blood loss.
Maternal death is rare.
b. In concealed type –
- Hemorrhage leads to intra peritoneal or braod ligament hematoma
- Shock due to release of thromboplastin in maternal circulation
- Blood coagulation disorders for example disseminated intravascular
coagulopathy
- Oliguria and anuria due to hypovolemia
- Post partum hemorrhage due to atony of uterus
- Puerperal sepsis
- Ischemic pituitary necrosis
- Sheehan‟s syndrome
2. Fetal
Prematurity
Anoxia
Fetal death in revealed ( 25-30%) and in concealed type (50-100%)
MANAGEMENT
Treatment at home
In the hospital
1. In revealed type:
Assess the case for amount of blood loss, maturity of fetus whether the client is
in labour or not
Preliminaries
1. Blood is sent for haemoglobin, coagulation profile, ABO and Rh typing and
also test for detection of protein
2. Ringer lactate drip is started with a wide bored cannula and arrangement for
blood transfusion is to be made
3. Close m9onitoring of fetal and maternal condition
Definitive Treatment:
A. Preacautions:
1. Rapid management is critical
2. Fetal death occurs in upto 30% within 2hr.
3. Don‟t delay the management for ultrasound conformation.
a. Ultrasound is unreliable for diagnosis.
b. Placental abruption is clinical diagnosis.
B. Indications:
1. Brisk bleeding.
2. Unstable vital signs.
3. Fetal distress
4. Grade II and III placental abruption.
C. Immediate interventions:
1. Oxygen
2. Trendelenberg position
3. Obtain immediate intravenous access.
a. Two large bore IV (16-18 gauze)
b. Initiate isotonic crystalloid bolus – normal saline, ringer lactate.
4. Blood transfusion atleast one litre minimum in concealed type to prevent
complications.
5. Call for immediate obstetric and neonatal support.
6. Delivery within 20 min if there is fetal distress.
7. Caesarean section unless iminant vaginal delivary by induction. If the
cervix is unfavourable early caesarean section is performed. If the
progress of labour is delayed (6-8 hr). Late caesarean section is
performed especially in case of couvelerie uterus.
8. Anti D game globulin if maternal blood is Rh negative.
D. Monitoring:
1. Orthostatic blood pressure and pulse
2. Monitor intake & output.
3. Maintain urine output over 30 cc/hr.
4. Monitor HB or hematocrit q 1-2hr
- Maintain HB more than 10 g/dl or heamatocrit more than 30%.
- In fusion of packed RBC as needed.
5. Monitor Coagulation studies
- Transfusion of fresh frozen plasma as needed
- Platelet transfusion as needed
NURSING MANAGEMENT:
Nursing Diagnosis:
Nursing Interventions:
- Monitor maternal vital signs
- Monitor fetal heart rate
- Monitor uterine contractions and vaginal bleeding
- Vaginal delivary depends on degree and timing of separation of placenta in
labour
- Caeserean delivery indicated for moderate to severe placental separation.
- Evaluate maternal laboratory values
- Replace fluid and electrolyte and if required transfuse blood
- Provide emotional support assess the client condition and determine the
extent of bleeding frequently
- Check fundal height every 30 min. As if the level of fundal height increases
suspects abruptio placenta.
- Count the no. Of pads that the client uses, weighing them as necessary to
measure amount of blood loss.
- Maintain IO chart
- Encourage woman to verbalise her feelings
- Keep all equipments ready for caesarean delivery.
- Council the client and help her by developing effective coping stratergies.
PLACENTA PRAEVIA
INTRODUCTION
In the last trimester of pregnancy the isthmus of the uterus unfolds and
forms the lower segment. In a normal pregnancy the placenta does not overlie it, so
there is no bleeding. If the placenta does overlie the lower segment, as is the case
with placenta praevia, it may shear off and a small section may bleed.
DEFINITION:
INCIDENCE:
ETIOLOGY:
The surface area of the placenta as big as in case of multiple pregnancy. Then
placenta encroach into lower uterine segment
Defect in decidua
The major part of the placenta is attached to the upper segment and only the
lower margin encroaches onto the lower segment but not upto the os
2. Type II ( Marginal )
The placenta reaches the margin of the internal os but does not cover it
The placenta completely covers the internal os even after it is fully dilated
For clinical purpose the types of placenta praevia graded into two
types . that are
1. Mild degree
As per above classification the type I and II anterior comes under first category
2. Major degree
Type II posterior, type III and type IV are considered as major degree
PATHOPHYSIOLOGY
The inelastic placenta is shared off the wall of lower uterine segment
Inevitable bleeding
PATHOLOGICAL ANATOMY
Placenta:
The placenta may be large or thin. There is often tongue shaped extension
from the main placenta mass. Extensive areas of degeneration with infarction,
calcification may be evident. The placenta may be morbidly attached due to
poor decidual reaction
Umbilical cord:
The cord may be attached to the margin or into membranes. The insertion of
the cord may be closed to the internal os gives rise to vasa praevia . which may
rupture along with rupture of membranes
Due to increased vascularity the lower uterine segment and the cervix
become soft and more friable
CLINICAL FEATURES
Symptoms
- Vaginal bleeding
- Sudden onset
- Painless bleeding
- Recurrent
- Unrelated activity
Signs
DIAGNOSIS
History collection
Abdominal examination : The presenting part felt like soft boggy through
the brim in case of major degree
Vulval inspection : Is done to note the colour and amount of bleeding
Vaginal examination must be not be done
Placentography usually performed to detect localisation of placenta and the
relationship between margin of placenta in relation to the internal os
Colour Doppler flow study to note the venous flow in the hyperechoic areas
Magnetic resonance image to see the quality of placental image excellence
Double set up of examination ( vaginal examination) is done to by keeping
everything ready for caesarean section in operation theatre
Differential diagnosis
- Abruption placenta
- Vasa praevia
- Local cervical lesion
- Circumvallate placenta
COMPLICATIONS
1. Maternal
a. During pregnancy
- Antepartum hemorrhage
- Malpresentation
- Premature labour
b. During labour
- Early rupture of membranes
- Cord prolapsed
- Slow dilatation
- Intrapartum hemorrhage
- Increased operative deliveries
- Post partum hemorrhage
- Retained placenta
c. Puerperium
- 15th day of puerperium may be incidence of sepsis
2. Fetal
- Low birth weight baby
- Asphyxia
- Intrauterine death
- Birth injuries
- Congenital malformation
PROGNOSIS
At home
Immediate attention
Expectant treatment
Definitive treatment
Definitive treatment should be instituted soosn after hospitalization or following
expected treatment resolves into:
Generally low placenta becomes alright on its own. But incase, you want to
have a natural childbirth or a home birth, it is best to ensure that the problem
has been resolved. Here are some ways through which can help yourself. Low
placenta finds its cure by three techniques.
• The first and most prevalent method to treat low placenta is rest. Doctors all
over the world suggest complete bed rest to pregnant women suffering from
placenta previa. In case of bleeding one is advised to put two pillows under
one‟s legs, knees onwards. Doctors also suggest women to restrict their
movements to the minimum, getting up only to eat and visit the toilet. Often
eating well and resting allows the baby to grow as the months proceed and the
baby itself pushes the placenta away from the cervix while fixing its head.
• Acupuncture is another method, quite prevalent in china, to help cure
placenta previa. The acupuncture practitioners have key puncture points where
they insert needles to help the placenta move away from the opening of the
uterus. Du 20 is one such point, located at the top of the head, known to cure
this problem.
• Traditional Chinese medicines also have a cure for placenta previa.
However, the herbs used are generally not disclosed by the practitioners. They
although pay visits at your home also to help those how can not get up from
their bed or travel. Nettles are one herb known to help during excessive
bleeding or spotting during pregnancy. It is a rich source of Vit-K.
• Vaginal examinations are not done on women suffering from low placenta
during pregnancy.
• In case of low placenta problem, avoid intercourse completely during the
course of your pregnancy.
• Exerting exercise or movement should be completely avoided.
• Any kind of bleeding to spotting should not be overlooked and should be
brought to the doctor‟s notice immediately.
NURSING MANAGEMENT:
Nursing Diagnosis:
Expected outcomes for the woman experiencing palcenta praevia may include the
following. The woman will;
PREVENTION
Primordial prevention
Primary prevention
Prevention, early detection and effective therapy of pre eclampsia and other
hypertensive disorders during pregnancy
Avoidance of trauma specially forceful external cephalic version under
anesthesia
Avoid supine hypotesion syndrome the patient is adviced to lie in the left
lateral position in the later months of pregnancy
Needle puncture during amniocentesis should be under the ultrasound
guidance
Significance of “warning hemorrhage” should not be ignored or
underestimated
Antenatal diagnosis of low lying placenta at 20 weeks with routine
ultrasound needs repeat ultrasound examination at 34 weeks to conform the
diagnosis.
Secondary prevention
Hospitalization
Amniocentesis is preferable for artificial rupture of membranes
Avoid sudden decompression of of the uterus in acute or chronic hydramnios
Administer Intravenous fuids with a large bore needle
Avoid vaginal examination
Either induction of labour or caesarean section performed based on period of
gestation and severity of disease condition
Maintainence of normal fluid volume
Teriary prevention
Immediate Hospitalization
Resuscitation
Blood transfusion
Caesarean section irrespective of gestational age
Abdominal examination
Height of the uterus Proportionate height. May be
disproportionately
enlarged in concealed
type.
Fouzia sheikh,fcps.
2007 to august 2008 at Department of Gynaecology and Obstetrics unit II, Liaquat
RESULTS: The incidence of APH was 5.4%. maternal and perinatal morbidity
was very high with increased rates of caeserian section ( 57.1% ), postpartum
hemorrhage ( 19%),
need of blood transfusion ( 77.4% ), shock ( 6.66% ), peripartum hysterectomy (
1%), preterm delivery ( 79.16% ) and maternal and perinatal mortality ( 3% and
49.7% respectively ).
CONCLUSION:
SUMMARY:
So far we have discussed about antepartum hemorrhage and its etiology and
classification. Then placental abruption its definition, etiology, types, effects on
mother and fetus, clinical features, prevention and medical and nursing
management. Then we also dealt about placenta praevia its definition etiology,
varieties clinical features and its management.
CONCLTION:
Books :
Journals
Web site
1. http:// www.medicinet.com
2. http:// www.medplus.com
3. http:// www.wilkipedia.com
SEMINAR
ON
ANTEPARTUM
HEMORRHAGE