ANTEPARTUM HEMORHAGE

DEFINITION: Bleeding from or within the genital tract after the age of fetal viability till fetal delivery (end of the second stage of labor).

AETIOLOGY:

1- Placenta previa [Maternal placental site bleeding]

2- Accidental Hemorrhage = Abruptio placentae [Maternal placental site bleeding]

3-Vasa previa [Fetal hemorrhage]

4-Rupture of the uterus during pregnancy & Spontaneous rupture during delivery

5-Excessive show

6-Local gynecological causes.

VASA PREVIA

Definition: Fetal hemorrhage due to ruptured fetal blood vessel traversing the membranes.

Etiology: Presence of fetal blood vessel in the membranes as in :

-Bipartite placenta

-Placenta succenturiata

-Velamentous insertion of the U.C

Diagnosis:

-Before ROM fetal blood vessel is felt as a worm like structure.

-Bleeding vasa previa is characterized by:

1-Occurs only after ROM

2-Bleeding is from fetal blood.

3-Mild in amount.

4-Associated with severe fetal distress.

How to differentiate fetal from maternal blood?

	FETAL BLOOD	MATERNAL BLOOD
Hemoglobin :-Precent -Type	16-18 gm % Hb F	12-14 gm % Hb A
RBC : -Structure -Destruction with weak alkalis [Kleinhauer test] -Blood group	Nucleated Resistant Different from maternal sample	Anuclear Vulnerable Same as maternal blood sample

Management:

-Due to the severe fetal distress present in this condition delivery of the fetus should be carried out immediately followed by neonatal blood transfusion.

	Cervical dilatation assessment
Cervix fully dilated and no contraindication for forceps or ventouse application		Cervix not fully dilated
Forceps or ventouse delivery		Caesarean section

PLACENTA PREVIA		PLACETAL ABRUPTION
Total or partial insertion of the placenta on the lower uterine segment	Definition	APH due to premature separation of a normally situated placenta
1/200 More in Multipara	Incidence	1/200
1-Late appearance of the trophoblast 2-Late disappearance of the Zona Pellucida 3-Large placenta 4-Abnormal placental shapes.	Etiology	1-Toxemias of pregnancy [70% of cases] 2-Trauma to the abdomen 3-Traction by short cord 4-Tension decrease in the uterus e.g ROM in polyhydramnious 5-Torsion of the uterus 6-Implantation on an abnormal decidua e.g over a septum or myoma 7-Bleeding tendency
Type I : Lateralis: In LUS but not reaching the margin of the Internal os when the cervix is closed & Fully dilated. Type II: Marginalis : reaching the margin of the internal os when the cervix is closed & Fully dilated. Type III: Centralis incomplete: partially covering the internal os when the cervix is closed & Fully dilated. Type IV: Centralis complete : completely covering the internal os when the cervix is closed & Fully dilated.	Types and clinical classification	A)According to vaginal bleeding: 1-Revealed Accidental Hemorrhage [40%]: All bleeding is vaginal no blood retained retroplacentally. 2-Concealed Accidental Hemorrhage [20%]: All bleeding is retained retroplacentally & no vaginal bleeding.Why? 3-Mixed Accidental Hemorrhage [40%]: Bleeding partly concealed and partly revealed. B)According to severity:
U/S classification: -Low lying placenta: In the LUS > 5 cm from the internal os. -Marginalis : < 5 cm from the internal os -Centralis: partially or completely covering the internal os.			Mild	Moderate	Severe
		Bleeding	Mild R no evidence of Concealed.	Mod R or evidence of Concealed	Severe R or evidence of Concealed
		Maternal GC	Good	Affected	Shocked
		Fetus	Good	Distressed	Dead
		IF DIC present = Severe with DIC.

				COMPLICATIONS I-Maternal
	A) Maternal During pregnancy
1-Bleedig : Antepartum and intrapartum Û 2-Rh isoimmunization of Rh –ve mother Û When severe Û3- Shock Û 4-ARF , 5-Sheehan syndrome.
6-Malpresentaion and nonegagement					6-DIC
					7-Couvlaire uterus: Dissection of the myometrium by blood.
			B) Maternal during labor
1-Intrapartum hemorrhage 2-PROM Û ± 3- Cord prolapse 4-Soft tissue obstruction to delivery. 5-Postpartum hemorrhage [Atonic, Retained placenta, ±Traumatic] 6-Air embolism 7-Amniotic fluid embolism.					1-Intrapartum hemorrhage 2-Postpartum hemorrhage [Atonic, DIC] 3-Amniotic fluid embolism,
		C)Maternal during puerperium
Puerperal Sepsis, Subinvolution of the uterus, 2ry PPH
				II-Fetal
Abortion, IUGR, IUFD, Prematurity					IUFD, Prematurity.

CLINICAL PICTURE

I-HISTORY AND SYMPTOMS

	Placenta previa	Revealed Acc	Concealed Acc	Mixed Acc.
Type of patient & history of AE	Multiparous, usually with history suggestive of large placenta e.g. DM, Erythroblastosis fetalis..etc	Usually history suggestive of hypertension or PET also there may be history of trauma, bleeding tendency.ets
Complication	Collapse due to severe bleeding from genital tract	From genital tract	Within GT	From & within GT
Vaginal bleeding	Usually recurrent fresh bright red blood , not elicited by a cause unless after P/V or sexual intercourse.	Present	Absent	Present usually dark red blood.
Pain	No pain { Unless labor pains}	No Pain	Severe acute abdominal pain	Severe acute abdominal pain

II-EXAMINATION AND SIGNS

	Placenta previa	Revealed Ace	Concealed Acc	Mixed Acc.
General Examination -Signs Etiological factor	e.g. Signs of D.M	e.g. hypertension & Proteinuria, evidence of trauma, bleeding tendency ..etc
-Signs of Complication	Shock due to severe bleeding from genital tract and proportionate to amount of bleeding	Shock due to severe bleeding from genital tract and proportionate to amount of bleeding	Hypovolemic Shock with no apparent bleeding from genital tract	Shock due to severe bleeding from genital tract and not proportionate to amount of bleeding
		In All Cases: The Blood pressure may be decapitated inspite of the severe shock state due to preexisting hypertension, also the pulse may be within normal not reflecting the severe shock state due to associated neurogenic shock. So in Accidental hemorrhage we should relay on other signs of shock especially CVP, UOP to assess degree of hypovolemia.
Abdominal examination	· F.L is equal to amenorrhea · Uterine examination may reveal MALPRESENTATION & / or boggy LUS · FHS are normal or show evidence of fetal distress	· FL equal amenorrhea · Uterine examination reveals no abnormality · FHS show distress or death of the fetus.	· FL more than amenorrhea · Uterus is tense tender and tonic to the degree that fetal parts may not felt and fetal heart sounds may not be heard.
P.V Examination	Absolutely CONTRAINDICATED may lead to fatal hemorrhage from placenta previa.

INVESTIGATIONS

	PLACENTA PREVIA	ACIDENTAL HEMORRHAGE
1-TO DIAGNOSE CAUSE OF APH	ULTRASOUND identifies placental site accurately	ULTRASOUND views a normally situated placenta, may view separation.
2-TO IDENTIFY COMPLICATIONS	HB%, Hematocrit value, Kidney functions	......&Coagulation profile
3-TO DIAGNOSE AETIOLOGICAL FACTOR	e.g Blood Sugar	e.g Proteins in urine
4-ROUTINE INVESTIGATIONS

Old tests to Localize the placenta are now obsolete e.g X-ray, thermography, ..etc.

TREATMENT

Conservation of Pregnancy

1- Fetus is premature

and 2- No Fetal Distress

and   3- The patient is not in labor

and   4- No complication:  

-No or Mild bleeding in cases of placenta previa

Mild Accidental Hemorrhage [Criteria?]

Termination of Pregnancy

1- Fetus is mature, OR

2-If the fetus becomes distressed OR                 3- If the patient is in labor, OR

4- Complication Present or Anticipated OR

-Placenta Previa with moderate or severe bleeding

-Moderate or Severe Accidental Hemorrhage [Criteria?]

CONSERVATION OF PREGNANCY

1-Hospitalization and Rest

2-Diet should be supplemented with iron.

3-Sedation

4-Follow up of maternal condition:

-Symptoms: e.g. amount of vaginal bleeding/day

-Signs: e.g. Vital Data/6 hours,

-Investigation e.g. HB% & CBC day after day

Re U/S /2 weeks for placental migration

5-Follow up fetal condition:

-Symptoms: F.K Chart

-Sign: Fetal Growth & FHS

-Inv.: Non-Stress Test, Biophysical Profile.

6-Control of etiological factor: e.g. control of D.M (Placenta Previa), Control of trauma (Acc.Hge)

7-Treatment of complications [That do not indicate termination]: e.g. iron therapy, AntiD for Rh -ve mothers.

TERMINATION OF PREGNANCY

A-Time of termination

Along with termination the following management should be carried out:

1-Correction of shock [Lines of treatment, Monitoring of shocked patient.]

2-In cases of accidental hemorrhage due to PET, Management of PET by MgSO4 should be started.

B-Method of termination

I-Placenta Previa:

Indications of C.S : 1-All cases with marked bleeding.

2-All Types of placenta previa apart from Low lying and marginalis anterior..

Induction of labor & vaginal delivery is carried out for patients fulfilling the following criteria:

1-No or mild vaginal bleeding.+

2-Low lying or marginalis anterior placenta previa.+

3-Fetal presentation Cephalic-Vertex.+

4-Cervix is favorable for induction.

Since P/V may initiate bleeding, [but must be done to verify 3 & 4], it is done only when -all other criteria for VD are proved and

-Done with the following requirements:

In the operating room - Blood at hand - Anesthesia present and ready - Double set up for VD & CS - Doctor and nurse scrubbed and ready for CS - Another doctor and nurse scrubbed and ready for VD.

II-Accidental Hemorrhage:

Induction of labor & vaginal delivery is carried out {as usual} In addition to:

Strict monitoring for both mother and fetus.

Indications for CS

1-Severe bleeding (How to know?)

2-Tonic uterus with fetal life +ve inspite of the assessment of amount of bleeding since sudden fetal death in these cases is 40%

3-Progressive increase in fundal level (thus it is marked with a skin marker pen on admission.

4-Some advise C.S for cases with evidence of concealed hge & fetal delivery is not expected to occur withinn 6 hours since most complications of Acc. Hge are directly proportional to abruption - delivery interval.

5-Associated obstetric indication e.g fetal distress during VD, Previous CS, abdominal circlage...etc.

C-Postpartum Care

{As Usual}