Antepartum Hemorrhage (APH) & PPH

Antepartum Hemorrhage (APH)

• Any bleeding ≥ 28 weeks of pregnancy before placental separation.

Causes & Differential Diagnosis of APH

Vasa previa

• Unprotected vessels may rupture

• After ARM: Fetal distress + bleed.
• Less blood loss + marked fetal distress

• Leads to fetal blood loss → life-threatening

 

Types	A/w	Notes
1	Velamentous cord	ㅤ
2	Placenta Succinturiata	• Umbilical cord attached only to bigger lobe • Smaller lobe if left behind → cause PPH

Apt Test

• Alkali denaturation test → detects HbF.

• Principle:
• HbF resistant,
• HbA denatured by NaOH.

• Result:
• Fetal blood → pink
• Maternal blood → yellow-brown

Management

• Before bleeding → Elective C-section.

• If bleeding → Emergency C-section (risk of fetal exsanguination).

Classifications of Placenta Previa

Classification

Clinical Approach

• P/S, P/V Examination:
• Contraindicated in placenta previa
• Permitted in abruptio placentae

Importance of USG in Placenta Previa

• Confirm diagnosis.

• Detect malpresentation.

• Rule out placenta accreta spectrum (PAS).

Notes on Placenta Previa

• M/c malpresentation: Transverse lie > breech presentation.

• A/w: Placenta accreta spectrum is possible.

• Stallworthy sign:
• Seen in posterior variety of placenta previa.
• HR ↓↓ when head pushed downwards

• Older type 2 posterior placenta was called dangerous variety placenta previa.

Management of Low Lying Placenta in Level 2 Scan

Management & Complications of APH

Management of a Case of Bleeding ≥ 28 weeks
(Diagnosis not known)

1st step:

• Maternal resuscitation
• Manage airway, breathing, circulation monitoring & management.

Immediate C-section if:

• Vitals unstable.

• Fetal distress (+).

• DIC.

Further Evaluation if

1. vitals stable/

2. FHS: Normal /

3. no DIC:
• Screening test.
• TAS
• TVS (IOC)
• Placenta previa confirmed (+).

Management of Placenta Previa

• Placenta previa comes with bleeding → VITALS STABLE

EXPECTANT MANAGEMENT

• Continue pregnancy with
• McAfee & Johnson Regime:
• Admit the patient.
• Arrange blood.
• Give Inj corticosteroid (For fetal lung maturity).
• Tocolytics:
• Give if contractions +
• gestational age <34 weeks
• C/I ≥34 weeks
• MgSO4:
• Give for neuroprotection (Gestational age <32 weeks).
• Also used as tocolytic
• Anti-D: Administer in Rh negative patients.
• Mnemonic: MCaFee
• Mgso4
• Corticosterioid
• Tocolytics

ACTIVE MANAGEMNET

• Immediate termination of pregnancy C- section
• Even if FHR is absent

Management of Abruptio Placenta

ARM:

• To be done in all patients of abruptio

• Helps diagnose, decreases blood loss, augments labour

• Even in Intrauterine death

NEVER GIVE TOCOLYTICS

34 WEEKS

Complications:

• DIC (d/t thromboplastin)

• Preterm labour (d/t thromboplastin)

• Retroplacental clot.

• Couvelaire uterus:
• Seen in concealed hemorrhage
• Hysterectomy is not done

Disseminated Intravascular Coagulopathy (DIC)

• M/c cause: Abruptio placenta.

• Other causes:
• Intrauterine death of fetus,
• amniotic fluid embolism,
• septic shock,
• acute fatty liver of pregnancy.

• Management: 
• Fresh Frozen Plasma (FFP)/Cryoprecipitate.

PCPNDT act:

• Radiologist (During antenatal checks) can look for congenital anomalies of the fetus

• But do not look for sex.

Postpartum Hemorrhage (PPH)

Definition:

• ≥500 ml blood loss after vaginal delivery.

• ≥1000 ml blood loss after caesarean section.

• ACOG: ≥1 litre blood loss after any type of delivery.

• WHO Update added 1 more definition
• ≥300 ml blood loss + Any of following changes
• HR > 100 / min
• SBP < 100 mmHg
• DBP < 60 mmHg
• Shock index > 1

Most Common (m/c) Causes:

Management of PPH

WHO Update for Prevention of PPH

• Use only one of 3 drugs for prevention (NOT TREATMENT)
• Oxytocin
• DOC
• 10 IU IM/IV infusion
• Carbitocin (heat stable)
• 100 Ug IM/IV
• Tab Misoprostol
• 600 Ug Oral

1st step: Maternal resuscitation

• Airway, breathing, circulation monitoring & investigations:
• Blood grouping
• Bleeding Time (BT)
• Clotting Time (CT)

• P/A examination + P/A uterine massage
• Assess uterine tone:
• Decreased -> Atonic PPH
• Normal -> Traumatic PPH
• P/V exam:
• Rule out presence of membrane/placental tissue.

PPH Drugs

• Drugs not used in PPH:
• Dinoprostone (PGE2): for induction of labour (IOL)
• Carbitocin: used in AMTSL

Uterotonics in management of PPH:

• Oxytocin IV infusion (20 IU in 500ml NS)
• If fails, methergine 0.2 mg IM (repeated 2-4 hours)
• If fails, Carboprost 250 mcg IM:
• Repeat every 15-90 mins
• Max: 8 times/2 mg

• Add on: Misoprostol:
• WHO: 800 mcg PO or S/L
• ACOG: 600-1000 mcg oral, S/L or P/R

Once diagnosis confirmed:

• Bimanual massage + uterotonic drugs
• + Tranexamic acid (1g in 100 ml NS over 10-20 mins)

• If bleeding not controlled in 30 mins,
• Mechanical compression.
• Bakri balloon catheter (max capacity: 500ml)

If bleeding continues,

• If Stable
• Uterine Artery Embolisation
• If Not available
• B-Lynch sutures (most common)
• Hayman suture
• Cho square suture
• Gunshella suture

• If Unstable
• Shift to OT
• Proceed to stepwise devascularization
• Order of ligation
1. Uterine artery ligation.
2. Ovarian artery ligation.
3. Ant division of Internal Iliac

In case of PPH during CS

• Uterotonics f/b

• B Lynch sutures (No Balloon tamponade)
• as abdomen is already open

If bleeding persists, check vitals.

• Check vitals:
• If stable:
• Ligate anterior division of internal iliac artery.
• If unstable:
• Subtotal hysterectomy
• uterus removed, cervix spared

If bleeding persists

• Pelvic pressure packs applied:
• Umbrella pack
• Parachute pack