ANTEPARTUM HEMORRHAGE MANAGEMENT

BMC /OG Guideline.

ANTEPARTUM HEMORRHAGE.


Definition:
Bleeding from genital tract of a pregnant mother from 28weeks until delivery.
This must be distinguished from show of labor and genital bleeding from urethra or anus:-

CAUSES:
      Main causes:
Placenta praevia----( Inevitable hemorrhage
Abrutio placenta---( Accidental hemorrhage

Others:     
Vasa praevia
Local lesion of the cervix or vagina
Uterine rupture.






IMPORTANT INFORMATIONS FROM THE HISTORY

 Mother should be asked:
   Whether bleeding follow intercourse, fall, trauma or domestic violence.
Whether the blood loss associate with abdominal pain or uterine contraction.
Whether was pure blood or mixed with amniotic fluid.
Hx of placenta praevia or abrutio placenta.


Risk factors for APH

ABRUTIO PLACENTA
PLACENTA PRAEVIA
VASA PRAEVIA
UTERINE RUPTURE.
Previous abruption
Previous previa
Valamentous cord insertion.
Previous Classical uterine incision.
Hypertension
Multparity

Multiple gestationMultparity
Trauma
Advanced maternal age
Injudicious use of oxytocin.Short umbilical cord
Multiple gestations.SPROM
Tobacco
Polyhydraminous
CLINICAL CHARACTERISTICS.


CLINICAL FINDINGPLACENTA PRAEVIAABRUTIO PLACENTAOnsetMay be gradual progressiveOften abrupt, unexpectedHow evidentAlways externalExternal or concealedFHRUsually presentMay be presentPresentationOften malpresentationMay be normalClinical signs of pre-eclampsia.Incidence is littleIncidenceBackacheAbsentPresentColour of bloodBright redDark reds







Uterine characteristic.

Clinical findingsPlacenta praeviaAbrutio placenta.PainPainless unless labourIntense and steady.TendernessAbscentPresentToneSoft and relaxedFirm and relaxedShapeNormalEnlarged and change shape

            

GENERAL MANAGEMENT.

Call for help. Urgent mobilize staff available.

Patient hx and quick assessment.

If in shock- Give 2 litres I/V fluids (R/L OR N/S) via 2 large bore cannula in the first hour, then re asses signs of shock ¼ hrly.
If not in shock infuse fluid accordingly.
X-match at least 4 unit of blood and order H.B.
Avoid digital cervical exam until Utra-Sound done to rule out placenta previa.
If there is DIC give FFP and Platelet.
Timing and route of delivery.
Hysterectomy should be performed if bleeding from non contracting uterus cannot be controlled.
SPECIFIC MANEGEMENT OF APH.
PLACENTA PRAEVIA
ABRUTIO PLACENTA
VASA PRAEVIANever appropriate to allow vagina delivery.Insert Foley catheter and monitor input and output at least 30 to 60mls/hr.
Never appropriate to allow vaginal delivery.Do emergency C/S if bleeding or DIC Uncontrolled, pregnancy at term, mother and fetus unstable

Analgesia by senior.
Do emergency C/S as soon as DX is madeDo Elective if pregnancy is term and fetus stable.Do be side clotting test.(Normal within 7 min) to exclude DIC repeat after 1hr.Conservative Management if bleeding controlled, fetus is alive and premature.

Monitor vital s
Signs, BP, P.R.
Bed rest at hospital.Be aware of visible loss which is only 1/3 of total amount.

Ensure blood is available.Vaginal delivery if the cervix is favourable and no contraindication to SVD.Correct Anaemia Ferrous Sulphate 200mg TDS and folic acid until 6weeks post delivery.

Do artificial rupture of membranes(ARM)Give betamethasone 12mg OD for 48hrs or Dexamethasone 6mg OD or 24hrs before 4 weeks.Prime augment labour with oxytocin 5IU in 500mls of 5% dextrose or R/L.Do elective C/S at 38weeks.iGrand multipara 1.25IU in 500mls of 5% Dextrose or R/L.Monitor labour using Partogram.Inform Pediatrician.Give Betamethasone 12g if appropriate.
After delivery estimate blood loss including the retro placenta clot.
-Continue with oxytocin 20IU in 500mls 5% Dextrose for 6hrs.
Give haematenics for 6 weeks.
Emergency C/S.
.Fetus is alive.
There is heavy vaginal bleeding threatening the mother life(with normal clotting profiles
There is other obstetric indication for C/S

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