ANTEPARTUM HAEMORRHAGE

DEFINITION

It is defined as bleeding from or into the genital tract after the 28^th week of pregnancy but before the birth of the baby.

TYPES/ CAUSES

 

Placental bleeding (75%)                             unexplained (25%)                       extra placental (5%)

-Placenta Praevia                                                                                 Local cervico-vaginal lesions    

-Abruption placenta                                                                              -Cervical polyp

                                                                                                              -Carcinoma cervix

                                                                                                              -Varicose vein

                                                                                                              -Local trauma

PLACENTA PRAEVIA

It is an obstetric complication in which the placenta is implanted partially or completely over the lower uterine segment. It can occur in the later part of the first trimester, but usually during the second or third. It affects approximately 0.5% of all labours.

Etiology

The exact cause for placenta Praevia is unknown, following are the postulated theories

·       Dropping down theory

The fertilized ovum drops down and is implanted in the lower segment. Poor deciduas reaction in the upper uterine segment may be the cause.

·       Persistence of chorionic activity

In the deciduas capsularis and its subsequent development into capsular placenta which comes in contact with deciduas vera of the lower segment can explain the formation of lesser degrees of placenta Praevia.

·       Defective deciduas

It causes spreading of the chorionic villi over a wide area in the uterine wall encroaching on to the lower segment.

·       Multiple pregnancy

The placenta bed of the twin placenta is prone to low implantation of at least a part of the placenta.

Risk Factor

§     Prior placenta praevia (4-8%)

§     First subsequent pregnancy following a cesarean delivery

§     Multiparity (5% in grand multiparous patients)

§     Advanced maternal age

§     Multiple gestations

§     Prior induced abortion

§     Smoking

Types Or Degrees Of Placenta Praevia

Placenta praevia is classified according to the placement of the placenta

¨     Type I or low lying:

The placenta encroaches the lower segment of the uterus but does not infringe on the cervical os.

¨     Type II or marginal:

The placenta touches, but does not cover, the internal os.

¨     Type III or partial:

The placenta partially covers the top of the cervix or internal os.

¨     Type IV or complete:

The placenta completely covers the internal os.

Clinical features

 Physical features

     Profuse hemorrhage

     Hypotension

     Tachycardia

     Soft and nontender uterus

     Normal fetal heart tones (usually)

Vaginal and rectal examination

o   Do not perform these examinations because they may provoke uncontrollable bleeding.

o   Perform examinations in the operating room under double set-up conditions (ie, ready for emergent cesarean delivery).

Diagnosis

Ø  Ultrasonography

It is the procedure to confirm the localization of placenta (placentography)

ü  Trans abdominal

ü  Trans vaginal

ü  Trans perineal

ü  Colour Doppler flow study

Ø  Clinical confirmation

ü  Vaginal/ double set up examination

ü  Direct visualization of placenta during caesarean section

ü  Examination of placenta following vaginal delivery

Complications

Maternal

v During pregnancy

R Severe bleeding

R Malpresentation

R Premature labour

v During labour

R Early rupture of membranes

R Cord prolapsed

R Slow dilatation of cervix

R Intrapartum bleeding

R PPH

R Retained placenta

v Puerperium

R Sepsis

R Subinvolution

R Embolism

Fetal

R Low birth weight

R Asphyxia

R Intrauterine death

R Birth injury

R Congenital malformation

MANAGEMENT

Ø  Adequate antenatal care

Ø  Significance of haemorrhage should not be ignored

Ø  Family planning and limitation of birth will reduce the risk of placenta praevia

Ø  Do not perform vaginal and rectal examination or giving enema

Ø  Monitor FHR and prepare client for ultrasonography

Ø  Facilitate double set up examination by the obstetrician

à Prepare for caesarean section before vaginal examination

à Vaginal examination is done in operating room

à Type and cross match for possible blood transfusion

Ø  Manage bleeding episode

à Keep NPO

à Monitor vital signs and FHS

à Complete bed rest

à Maintain IV infusion

à Maintain perineal pad for estimate blood loss

à Prepare for caesarean delivery

à Maintain sterile technique

Ø  Support mother and family

Ø  Provide information about nature of problem

Ø  Prepare women for vaginal birth if pregnancy is near term the cervix is favourable and marginal placental site is identified.

MANAGEMENT IN HOSPITAL

                                             All APH patients are to be admitted

·       General & abdominal examination

·       Clinical assessment of blood loss

·       HB%, ABO% Rh group, hematocrit

·       USG

·       IV infusion or cannula  

 

·        No active bleeding                                                 Bleeding continous

·        Pregnancy less than 37 weeks                                       Pregnancy more than 37wks

·       Patient stable                                                          Patient in labour

·       FHS- good                                                              FHS- absent

·       CTG – reaction fetus                                              Gross fetal malformation

37 weeks

                                                                                Steroid therapy if        

                                                                                pregnancy less than 34wks

 

CS

Double set up examination

Internal examination in OT                                                        without internal examination

 

Satisfactory progress without bleeding                       Bleeding continues

        Vaginal Delivery                                                 Caesarean Section

NURSING PROCESS

Assessment – Assess for

1.     Painless unexplained vaginal bleeding after the 20^th week

2.     Intermittent gushes of blood

3.     Placental placement revealed by ultrasonography

4.     Maternal apprehension caused by the bleeding episode

Nursing diagnosis

1.     Hemodynamic alteration

2.     Risk for fetal injury

3.     Risk for infection

4.     Ineffective away clearance

5.     Anxiety

6.     Anticipatory grieving

7.     Family process disturbance

8.     Risk for altered family parenting

9.     Health seeking behavior

Planning

1.     Monitor for bleeding episode

2.     Monitor maternal and fetal wellbeing

3.     Provide opportunity for support and counseling

4.     Provide education for self care

5.     Blood investigation