Antepartum haemorrhage ( APH ) :

Objective : to understand APH ( definition , causes ,

management of each cause and the effect of each on fetal and
maternal condition.
APH : is vaginal bleeding after 20 weeks of gestational age,
CAUSES:
Placenta previa,
placenta abruption,
vasa previa
- cervical or vaginal laceration
Congenital bleeding disorder
Cervical or vaginal lesion ( cancer )
Show of labor
Unknown ( by exclude the above )
placenta previa: is placenta inserted wholly or in part into the
lower segment of uterus.
Clinically classified into :
Major: when the placenta lies over the internal os.
Minor or partial :the leading edge of placenta is in the lower
uterine segment but not covering the cervix os.
Types of placenta previa:
Complete (total ) pp
Partial pp
Marginal pp
Low - lying pp ( within 2-3 cm os)
Risk factors of pp : multipara , multiple pregnancy , previous
scaring of uterus ( myomectomy , C/S) , previous curettage .
maternal smoking
Clinical suspicion of placenta previa : ( clinical presentation)
Painless vaginal bleeding ( bleeding is bright red) after 20 weeks ,
abnormal lie , high presenting part , uterine contraction may or may
not present.
Definite diagnosis relies on ultrasonography :routine U/S
scanning at 20 weeks of gestation should include placental
position.
Physical :
Profuse hemorrhage (in severe cases) , hypotension ,
tachycardia.
Soft & not tender uterus
Normal fetal heart tones
Vaginal examination do not perform because may provoke
uncontrollable bleeding ( perform examination in the operating
room under double set –up conditions.
Diagnosis :
TVS improve the accuracy of placental localization & are safe ,
so the suspected diagnosis of placenta previa at 20 weeks of
gestation by abdominal U/S should confirmed by TVS.
MRI: antenatal sonographic imaging can be complemented by
MRI in equivocal cases to distinguish those women at special
risk of placenta accrete.
Management :
Expectant treatment : suitable ( no active bleeding . fetal
wellbeing assured by U/S )
Bed rest,
correct anemia ( HB ≥ 10 gm . PCV ≥ 30 )
fetal surveillance with U/S every 3 weeks
tocolytics :Mgso4 if patient with uterine contractions
corticosteroids to improve fetal lung maturity
Rh immunoglobin given to Rh negative women
Preterm delivery may have to be done in :
dead baby , recurrence attack of bleeding which is continuing ,
congenitally malformed fetus .
Active line of management :
Resuscitation : 2 IV line ( 2 large bore cannula ) prepare 4-6
unit of blood , start crystalloid until blood prepare or give O
negative blood, catheterization ( to measure urine output )
Vital sign monitor (PR & BP every 15 min) continuous fetal
heart monitor , quantitative monitoring of Vaginal blood loss
Send for CBC, PT, PTT, RFT , serum electrolyte
Unstable hemodynamic or underlying diseases ( cardiac ,
pulmonary ) then place swan Ganz catheter ( CVP)
Delivery indicated ( life threatening maternal bleeding ,
unstable FHR )by C/S with general anesthesia .
Mode of delivery in PP :
Based on clinical judgement supplemented by sonographic
information , if placenta edge < 2 cm from internal os in the
third trimester then C/S.
Time of delivery :
Elective delivery by C/S in asymptomatic women is not
recommended before 38 weeks of gestation for pp , or before
36-37 weeks of gestation for suspected placenta accrete .
Placenta accrete :
Abnormal attachment of the placenta to the uterine wall (
deciduas ) such that the chorionic villi invade abnormally into
the myometrium , it associated with placenta previa in 5-10 %
of the case .incidence of it increased with the number of prior
C/S .
Management of placenta accrete :
Uterine conservation 1- placenta removal & over sewing
uterine defect 2- localized resection & uterine repair
3- leaving placenta send for radiation
4-Caesseran hysterectomy
Vasa previa :
Vaginal bleeding associated with membrane rupture lead to
fetal compromise , delivery should not delay .
Abruptio placentae : it refers to a condition when
antepartum hemorrhage occurs due to
Premature separation of normally implanted placenta,
complicate 0.5 – 1.5 % .
Types :
Concealed : blood is retained within uterine cavity & is not
visible externally .
Revealed : the blood collected due to placental separation
escape by dissecting under the membranes & seen clinically.
Mixed : first concealed then becomes revealed
Risk factors :
Maternal hypertension
Trauma
Premature rupture of membrane
Polyhydarmnios with rapid decompression
Short umbilical cord
Folate deficiency
Tobacco smoking & cocaine
thrombophilia such as factor V leiden mutation
Previous abruption ( recurrence 10 fold )
Signs & symptoms :
Vaginal bleeding 80 %
shock
Abdominal pain
Uterine contraction ( tetany)
Uterine tenderness & difficulty in palpating fetal parts
Uterine tone increased
Uterine height may or may not correspond to the period of
amenorrhea .
Fetal heart may be normal, abnormal or absent .
Couvelaire uterus : severe forms of placental separation with
widespread extravasation of blood into uterine musculature .
Management :
Resuscitation & immediate delivery of fetus is indicated in
severe cases
Vaginal delivery indicated when :
Limited placental abruption
FHR is reassuring with continuous fetal monitoring
Placental abruption with a dead fetus .
Dysmenorrhoea: painful menstruation, may be primary (
no identifiable cause) , secondary ( associated with pelvic
pathology). It is commonest problem 50% of women (10%
interfere with daily activity).
Primary dysmenorrheal: occurs during ovulatory cycles
& usually appears within 6-12 months of the menarche. The
etiology of it has been attributed to uterine contraction with
ischemia & production of prostoglandins.
hypercontractility( increase amplitude, frequency of
uterine contraction) lead to decrease endometrial blood
flow (ischemia) with colicky pain.
During menstruation , prostoglandins are realeased as a
consequence of endometrial cell lysis. So menstrual fluid
from women with this disorder have higher than normal
levels of PGs especially PGF2 & PGE2 which produce the
discomfort & other associated symptoms such as nausea,
vomiting, headache.
Sign & symptom:
Pain begins a few hours before or just after the onset of
menstruation & usually lasts 48-72 hours, cramp - like & is
usually strongest over the lower abdomen & may radiate to
the back or inner thighs .this pain associated with other
symptoms ( nausea, vomiting diarrhea, fatigue, lower
backache, headache) .
Pelvic examination findings are normal.
Treatment:
Life style change: low fat diet, exercise may improve
symptoms by improving pelvic blood flow.
Medical measures: NSAIDs( ibuprofen, mefenamic acid,
naproxen.
Hormonal contraceptive: oral COCP ,hormone releasing
IUCDs. High dose –continuous daily progestogens(
medroxy progesterone acetate or dydrogesterone). Resistant
cases may respond to tocolytic agents( sulbutamol,
nifedipine).
Nonpharmacologic: psychotherapy ,hypnotherapy,
transcutanous electrical stimulation, heat patches.
Surgical:presacral neurectomy & uterosacral ligment
section.
Secondary dysmenorrhea :it isnot limited to the menses &
can occur before as well as after the menses. It is less
related to the first day of flow , develops in older women (
30-40) & is usually associated with other symptoms such as
dyspareunia, inferitility, abnormal uterine bleeding.
Causes :
-endometriosis & adenomyosis : pain extends to
premenstrual or postmenstrual phase or may be continuous,
deep dyspareunia, premenstrual bleeding .
- PID : initially pain may be menstrual, but with each cycle
it extend to premenstrual phase, intermenstrual bleeding,
pelvic tenderness.
- fibroid
- IUCD
- pelvic congestion: dull, ill defined pelvic ache, worse
premenstrual , relieved by menses .
- cervical stenosis & haematometra .
Treatment :
Treat the underlying cause. The treatments used for primary
dysmenorrheal are often helpful .