dr. Udin Sabarudin, SpOG, MMdr. Udin Sabarudin, SpOG, MM

Depart. of Obstetrics - Gynecology Padjadjaran University / Hasan Sadikin

HospitalBANDUNG

OBSTETRICAL HEMORRHAGE

Bleeding before 20 weeks of pregnancy

Antepartum hemorrhage

Post partum hemorrhage

Cause of vaginal bleeding at the third trimester

Rupture of vaginal varicose

Laceration of vagina or cervix

Placenta previa

Abruptio placentae

ANTEPARTUM HEMORRHAGEANTEPARTUM HEMORRHAGE

Placenta Previa

Abruptio placentae

Normal implantation of the placenta

Normal implantation of the placenta

Fundal Corpus

Front Behind

Implantation at the lower segment

Implantation at the lower segment

PLACENTA PREVIA :

DEFINITION :

Placenta is located over or very near the internal os

Prae : FrontVias : Route

FOUR DEGREES OF THIS ABNORMALITY

1. Total placenta 1. Total placenta previaprevia

The internal cervical The internal cervical os is covered os is covered completelycompletely

2. Partial placenta 2. Partial placenta previaprevia

The internal cervical The internal cervical os is partially os is partially coveredcovered

A BA B

FOUR DEGREES OF THIS ABNORMALITY

3. Marginal placenta previa3. Marginal placenta previa

The edge of placenta is at The edge of placenta is at the margin of the the margin of the internal osinternal os

2. Low lying placenta2. Low lying placenta

The placenta is implanted The placenta is implanted in the lower uterine in the lower uterine segment such that the segment such that the placental edge actually placental edge actually does not reach the does not reach the internal os but is in internal os but is in close proxymity to itclose proxymity to it

A BA B

VASA PREVIA :

The fetal vessels course through membranes and present at the cervical os

Uncommon cause of antepartum hemorrhage, associated with a high rate or fetal death

THE DEGREE OF PLACENTA PREVIATHE DEGREE OF PLACENTA PREVIA

Depend on large measure on the cervical dilatation at the time of examination

Eg. Low lying placenta at 2 cm dilatation may become a partial placenta previa at 8 cm dilatation because the dilating cervix has uncovered placenta

BLEEDING >>> !!!

Total placenta previa

Marginal placenta previa

Placenta

cervix

CHANGING THE DEGREE OF P.PCHANGING THE DEGREE OF P.P

Marginal

Amnion (+)Amnion (+)

Lateral

Dilatation >

Amnion

Bleeding

Retracted

DilatationDilatation

Lower segmen

Cervix

Bleeding

Lower Lower segmensegmen

Partial placenta previa

BLEEDING >>>

BLEEDING >

> 1/2 O

< 1/2 O

PREDISPOSING FACTOR :PREDISPOSING FACTOR :

Multipara, with interval <

Fibroids

Habitual abortion

CLINICAL FINDINGS :CLINICAL FINDINGS :

Hemorrhage : Frequent

Usually does not appear until near the end of the second trimester or after

Painless Spontaneously Initial bleeding is rarely

profuse as to prove fatal

Lacunae

Maternal vessels

HAFT ZOTE

Fetal vessels

CLINICAL FINDINGS :CLINICAL FINDINGS :

Oblique or lie position

Presenting part - high

DIAGNOSIS :DIAGNOSIS :

Speculum

Fornix palpation

Double set up examination at the operating room

USG

WARNING :WARNING :

Digital palpation to try to ascertain changing relations between the edge of the placenta and the internal os as the cervix dilates can incite severe hemorrhage

Examination of the cervix is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean section

MANAGEMENT :MANAGEMENT :

Active : Termination

Vaginally CS

Expectative : Depend on maturity

(< 37 weeks ; < 2500 gr) Bleeding Maternal condition

VAGINAL DELIVERY :VAGINAL DELIVERY :

Amniotomy tamponade

Braxton Hicks version

Cunam Willet

TAMPONADE BY PRESENTING PART

Placenta

Cervix

In tact

Amnion

Amnion (+)

Head press the placenta

Head Head Breech Breech

CUNAM-WILLETT

PLACENTAL PLACENTAL ABRUPTION :ABRUPTION :

DEFINITION :DEFINITION :

The separation of the placenta

from its site of normal implantation

before the delivery of the fetus

after 22 weeks of pregnancy

SINONYM :SINONYM :

Accidental hemorrhage

Abruptio placentae

Solutio placentae

Ablatio placentae

Premature separation of the

normally implanted placenta

PATHOLOGYPATHOLOGY

Hemorrhage into the decidua basalis

Decidua then splits, leaving a thin layer adherent to the myometrium

Decidual hematoma

Separation, compression and the ultimate destruction of the placenta adjacent to it

TYPE :TYPE :

Concealed hemorrhage separated completelly freq 20% fatal

External hemorrhage incomplete freq 80%

CONCEALED HEMORRHAGE

EXTERNAL HEMORRHAGE

COMBINED

ETIOLOGY :ETIOLOGY :

Hipertension Trauma Multiparity Folic acid deficiency Hidramnion ; gemelly Umbilical cord - short

CLINICAL DIAGNOSIS :CLINICAL DIAGNOSIS :

Hemorrhage with pain

Fetal - Not palpable

Heart beat - not

detected

Uterine hypertonus

Anemi shock

Amnion bulging

COMPLICATION :COMPLICATION :

Early : - Hemorrhage- Shock

Late : - Consumtive coagulopathy

- Hypofibronogenemia- Utero placental

apoplexy (couvelaire uterus)

- Renal failure

MANAGEMENT :MANAGEMENT :

Depend on status of the mother & Depend on status of the mother &

fetus:fetus:

Transfusion

Electrolyte solution

Corticosteroids

Fibrinogen

OBSTETRIC MANAGEMENT :OBSTETRIC MANAGEMENT :

Amniotomi Oxytocin infusion Cesarean section :

Fetus alive Cervix not dilated 2 hours after oxytocin

infusion uterine contraction (-)