Antepartum Hemorrhage Family Medicine Specialist CME University of Health Sciences.
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Transcript of Antepartum Hemorrhage Family Medicine Specialist CME University of Health Sciences.
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Antepartum Hemorrhage
Family Medicine Specialist CMEUniversity of Health Sciences
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Objectives
For antepartum hemorrhage:• Describe and define the two major causes of
bleeding in pregnancy • Discuss the history and clinical examination
for a patient presenting with bleeding in pregnancy
• Describe the management and care of a pregnant patient with bleeding
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Clinical Case
20 year-old G3P1A1 female presents to the district hospital with vaginal bleeding. She is pregnant but is unsure of her dates as she got pregnant while breastfeeding. You can palpate a fetus in a breech position and the fetal heart rate is heard.
What is the differential diagnosis?What questions are you going to ask her?What is your management plan for her?
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Antepartum Hemorrhage
Definition
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Antepartum Hemorrhage
Definition:
Vaginal bleeding from 22 weeks to term or delivery.
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Incidence and Etiology
• Incidence: – Occurs in 2% - 5% of all pregnancies
• Etiology:– Placental abruption (40%)– Placenta previa (20%)– Unclassified (35%)– Lower genital tract (5%)
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Definition
Placental Abruption• Premature separation of
the placenta from the uterine wall
Placenta Previa• Implantation of the
placenta in the lower segment of the uterus either close to or over the internal cervical os
• Total/complete previa – entirely covers the os
• Partial previa – partially covers the os
• Marginal previa – placenta lying close to the os
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Placenta Previa Classification
Complete Previa Partial Previa Marginal Previa
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Risk FactorsPlacental Abruption• Idiopathic• Maternal hypertension• Prior abruption• Abdominal trauma –
MVA/Assault/Falls• Substance Abuse - Maternal
smoking/Alcohol/Cocaine• Multiparity• Advanced maternal age• Uterine malformation• Rapid uterine decompression -
PROM
Placenta Previa
• Prior cesarean section or uterine surgery
• Multiple gestation• Advanced maternal age• Multiparity• Smoking• Prior placenta previa
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HistoryPlacental Abruption
• Abdominal pain • Backache• Prior hypertension• Trauma• Fall• Assault
Placenta Previa
• Prior uterine surgery or cesarean section
• Painless bleeding
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ExaminationPlacental Abruption• Vital signs – Shock out of
proportion to blood loss• Uterus – tender, increased
tone, irritable, contractions • Normal fetal presentation• Abnormal or absent fetal
heart rate
Placenta Previa• Vital signs – Shock
corresponds to blood loss• Uterus – soft, not tender,
no irritability or contractions
• Abnormal fetal presentation or high presenting part
• Normal fetal heart rate
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Diagnosis
Placental Abruption• Ultrasound – Abdominal
may be diagnostic but a negative ultrasound does not rule out abruption
Placenta Previa• Ultrasound – Definitive
diagnosis • Better with transvaginal
ultrasound but can be made with abdominal ultrasound
• 75% of women will have a bleed in the early third trimester
• Must be at a hospital that can perform cesarean section
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Clinical Management
• Call for HELP• ABC’s -Airway/Breathing/Circulation• Talk to the patient – explanation & plan• Monitor vital signs• Elevate legs/roll to side to avoid aspiration• Obtain History and do Examination
– NO CERVICAL EXAM UNTIL PREVIA RULED OUT• Pelvic ultrasound to locate placenta• Ausculate for fetal heart rate
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Clinical Management - 2• Laboratory
– CBC– Type and Screen/Crossmatch for blood– PT/PTT
• Provide oxygen to mother• 2 Large bore IV’s 16/18 with Normal Saline or
Ringer’s Lactate (1 L in 20 minutes)• Reassess maternal & fetal status• Transfer to facility where a cesarean section can
per performed when patient stable
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Clinical Management – 3Unstable Patient
• Primary objective:– Fluid replacement– Delivery
• Simultaneously:– Oxygen to mother & O2 saturation– Active fluid resuscitation in 1 H - 2 larger bore IV’s
rapidly infuse 2 L Normal saline/Ringer’s Lactate – Assessment of maternal vital signs/urine output– Continuously monitor fetal well-being
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Clinical Management – 4Unstable Patient
• Arrange for delivery– Transfer if required– Possible Cesarean section
• Placenta previa (partial or complete)• Abruption with unstable maternal or fetal status
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Clinical Management – 5Stable Patient
• Maternal & fetal surveillance for 12 – 24 hours• If abruption secondary to abdominal trauma –
monitor for minimum of 4 hours after trauma• Attention to maternal hemodynamic status –
at risk for subsequent bleed• If preterm, expectant management• Transfer to higher risk facility if indicated
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Bedside Clot test - Coagulopathy
• 2 mLs of venous blood in plain glass tube• Hold tube in closed fist to keep it warm• After 4 minutes, tip the tube slowly to see if
clot is forming. Tip every minute until the blood clots and tube can be turned upside down
• Failure of a clot after 7 minutes or a soft clot suggests coagulopathy
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Clinical Case
20 year-old G3P1A1 female presents to the district hospital with vaginal bleeding. She is pregnant but is unsure of her dates as she got pregnant while breastfeeding. You can palpate a fetus in a breech position and the fetal heart rate is heard.
What is the differential diagnosis?What questions are you going to ask her?What is your management plan for her?
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Conclusion
• Antepartum hemorrhage most often due to:– Placental abruption– Placenta previa
• Primary difference is presence or absence of abdominal pain
• Rapid diagnosis and appropriate treatment required to prevent maternal and neonatal mortality
• May need to transfer patient for appropriate care for mom and baby