Download - Case Study 29-APH
Case study 29Case study 29
ANTEPARTUME HAEMORRHAGE
Zarul naim Mohd Tamizi
APH
• Definition: vaginal bleeding from 24 weeks to delivery of baby.• Common causes:
Placenta praevia Placenta abruptio Local causes (cervicitis, cervical ca, cervical ectropian, vagina
trauma,vagina infection) Unexplained APH
Placenta Praevia
• Placenta which has implanted partially or wholly in the lower uterine segmentGrade 1 – Just enters lower segment(3-5cm from OS)
Grade 2 – Enters LUS but does not reach os (<3cm from OS) Grade 3 – Partially covers os but not completely Grade 4 – Completely covers os
• Risk factors:Uterine scar (Caesarian, myomectomy, curretage)MultiparityMultiple gestationsUterine structure anomalyAssisted conception
Placenta Abruptio
• The premature separation of the placenta-before delivery of the fetus.
• Occur in 1% of pregnancy
• Types:Revealed - Pain + Vaginal bleeding-80%Concealed - pain/shock + no vaginal bleeding-20%
Risk factors:
PolyhydramniosTrauma to abdomenSmokingCrack cocaine usageThrombophilia Anticoagulant therapy
Previous abruptioHypertensionPre-eclampsiaIUGRMultiple gestation
Placenta Praevia Placenta Abruptio
Features of bleeding Painless, recurrent, always revealed
Painful, revealed, concealed or mixed
General condition Proportional to blood loss Out of proportion in concealed type
Abdomen Soft, relaxed, malpresentation is common,
Tense, tender & woody, head maybe enganged
Fetal heart sound Usually present Usually absent particularly in concealed type
U/S Low lying placenta Normal lying placenta, retroplacenta clot
Diagnosis U/S Clinically
CASE
• 30 year old woman, Para 1+0• Previous spontaneous vaginal delivery and appropriately
grown fetus• Admitted at term with fresh vaginal bleeding and abd pain• On examination: in pain, pale, pulse is 100bpm, BP is
110/80mmHg and tender uterus which is contracting 3 minutely
• Blood stains on her feet between her toes
Q1: what is the most likely diagnosis and why is this the case?
Placenta abruptio(revealed) because of antepartum bleeding associated with abdominal pain and tenderness of the uterus.
Symptoms: Vaginal Bleeding ( Revealed) 80% Abdominal /Back Pain (Severe) 70% Fetal Distress 60% Contractions (Hypertonic) 35% Preterm Labour 25% Fetal Death in utero 15%
Q2: what are the risk to the mother
and fetus?
• Mother: Hypovolaemic shock Acute renal failure DIC PPH – uterine
atony(Couvelaire uterus)
Maternal mortality Operative delivery Recurrence
Fetus: Hypoxia - Fetal distress Anaemia Growth Retardation - if
treated conservatively and survives
CNS Abnormalities Intra Uterine Death
Q3: how should you assess and manage this situation?
• Call for help• Resuscitation
– Admit labour room– Estimated amount of blood loss
• Mild : 2 pads soaked / < 200ml• Severe : > 2 pads soaked / > 200 ml
– Mild : 1 IV line & GXM 2 units blood– Severe : 3 IV lines & GXM 4 units blood– Use branula size 16 and below and transfuse immediately
• Blood InvestigationsFBC (low Hb, low platelet), BUSE + Creat (Acute renal failure),
Coagulation profile (PT,APTT,INR), GXM
• U/S scan (Retroplacental clot, exclude placenta praevia, check fetal viability etc)
Hx and P/E
• Hx: vaginal bleeding, painful or not, abdominal pain, risk factors (previous abruptio,trauma)
• P/E: vital sign (BP,pulse,temperature), colour (pale),sign of
anemia Abdomen(tense,tender and woody, uterus larger than date VE – avoid before exluded placenta praevia
Investigations
• For fetal: CTG
• For maternal: FBC Coagulation screen GXM 4 units Catheterization (monitor urine output) Urea and creatinine (renal failure)
• In this patient because she is already at term, delivery is indicated
1. Vaginal delivery – cervix favourable or foetal death - ARM + oxytocin augmentation
2. LSCS – usually indicated for foetal distress - use prophylactic oxytocin infusion routinely in
these cases
• Before LSCS or Vaginal delivery, always correct Hypovolaemia DIVC Ensure urine output >30ml/hr Other causes
Q4:One hour later : Maternal condition unchanged from admission. borderline tachycardia, BP satisfactory, uterus contract
3:10 min and remains tender.
CTG: appropriate beat to beat variability, no decelerations.
Coagulation screens:
Hb - 8.4 g/dl, platelets - 105x109 /l, fibrinogen - 2.2 g/l,APTT - 48 s, PT - 14 s, Fibrin degradation product - 2.1 mg/ml
Comment on these result and discuss further
managementResults Interpretation Impression
Hb 8.4g/dl(11-16g/dl)
Low Anaemia
Platelets 105x109 /l(150-400x109/l)
Low
Disseminated Intravascular
Coagulation(DIVC)
Fibrinogen 2.2 g/l(2-4 g/dl)
Borderline low
aPTT 48s(35-45s)
Prolonged
pT 14s(12-15s)
normal
Fibrin degradation products
2.1mg/ml(<1mg/ml)
Raised
DIC Secondary phenomenon following trigger of
generalised coagulation activity
Why?• Retroplacenta blood clot
– Consumptive coagulopathy– Hypofibrinogenemia
• Increase pressure within uterus (bp)• Release of thromboplastin from circulation
/retroplacenta clot
management
1. Involve support services (anaesthethist, blood bank, etc) early
2. Replace blood constituents and coagulation factors in addition to blood transfusion, start giving Cryoprecipitate (6 units) followed by FFP (2 units) and platelet concentrate (4 units)
3. Repeat tx if necessary and check coagulation profile 2 hourly.
4. Plan for delivery (treat the cause)
Q5: cervix is found to be 5 cm dilated and fully effaced with no placental palpable.
The fetal head is at the level of ischial spines and is in left
occipito-anterior position, should you perform
amniotomy?
Artificial rupture of membrane (ARM) Enhanced labor Using Hollister amniohook Stimulates release of endogenous prostaglandin Assessment based on Bishop’s score to determine
favourable cervix
What is amniotomy?
YES
• Term
• Favourable cervix
• No fetal distress
After ARM
Assess liquor : for blood stained or meconium stained
Monitor progress of labour, maternal and fetal condition
If prolonged labour, fetal distress, and uncontrolled haemorrhage -Emergency Caesarian section
Indication for LSCS• Bishop score <7• Fetal distress• Severe abruption with alive fetus• Other obstetric complication• No uterine contraction with oxytocin &
prostaglandin• Uncontrolled bleeding
• Q6: amniotomy is performed and she delivers a live male infant less than 1 hour later. The infant is healthy with Apgar score of 9 at 5 min. Placenta is rapidly delivered and has approximately 500ml of clot adherent to about 25% of its surface area. She recovers uneventfully.
• What is the risk of having a similar event in subsequent pregnancy?
Risk of recurrence :
5-15%% after one abruption25% after two abruption
Advice patient :• Get early and continuous prenatal care.
• Early recognition and proper management of conditions in the mother such as diabetes and high blood pressure
• If pregnant, don't engage in activity more vigorous than what you were accustomed to before pregnancy.
• Avoid risk factors when possible. Maintain a positive lifestyle free of smoking, alcohol and recreational drug use (e.g., cocaine use).
• Proper and adequate nutrition prior to becoming pregnant and during pregnancy
THANK YOU