Topic Antepartum haemorrhage

Subject

Duration of presentation 45 minutes

Venue

Type of group

Student’s prerequisite knowledge Students have brief knowledge about Antepartum haemorrage .

General objectives:
After this class the knowledge of students about Antepartum haemorrhage will increase.

Specific objectives:
The objectives of this class include:

 Definition of APH
 Causes of APH
 Definition of placenta praevia
 Causes , clinical features, diagnosis of placenta praevia
 Treatment
 Definition of abruption placenta
 Causes, clinical features, diagnosis of abruption placenta
 Treatment
 Lesson Plan
On
Antepartum haemorrhage
Sr. Time Specific Content Teaching- Evaluation
no. (min) objectives learning
activities & AV
aids
1 ½ To introduce the ANTEPARTUM HAEMORRHAGE Lecture cum What is
topic discussion with antepartum
It is defined as the bleeding from or into the genital tract after
the help of PPT haemorrhage?
the 28th week of pregnancy but before the birth of the baby
(thus the 1st & 2nd stage of labour are included)
2 1 To define the CAUSES OF APH Lecture method What is cause of
causes of APH. • Placental praevia with PPT APH?
• Placenta abruption
• Vasa Praevia
• Incidental and indeterminate causes = 50-60% APH
• Non Placental causes – local genital tract trauma
3 2 To tell the PLACENTA PRAEVIA Lecture method What is placenta
placenta praevia Placenta previa is a condition that may occur during with PPT praevia?
pregnancy when the placenta implants in the lower part of
the uterus and obstructs the cervical opening to the vagina
(birth canal).
4 2 To tell about INCIDENCE Lecture method What are
incidence  The incidence of placenta previa is approximately 1 with PPT incidence ?
out of 200 births.
 Increases with each pregnancy, and it is estimated
that the incidence in women who have had 6 or more
previous deliveries may be as high as 1 in 20 births.
 Doubled in multiple pregnancy (such as twins and
 triplets).
5 2 To explain CAUSES Lecture method What are causes
causes of PP  Endometrium factors: with PPT of PP?
 a scarred endometrium (lining of the uterus)
 Curretage for several times
 an abnormal uterus
 Placental factors
 Large
 abnormal formation of the placenta.
 Development retardation of fertilized egg
6 1 To tell risk RISK FACTORS Lecture method What are the
factors of PP  Multiparity (previous deliveries), with PPT risk factors ?
 Multiple pregnancy,
 Previous myomectomy (removal of uterine fibroids
through an incision in the uterus), and
 A previous C-section (if the scar is low and close to the
vaginal cervix region).
7 2 min. To tell grading of GRADING Lecture method What are
placenta praevia • Grade 1 ( 1st Degree) with PPT grading of
Part of placenta lies in the lower segment but does not reach placenta
os praevia?
• Grade 2 ( 2nd Degree)
The lower margin of the placenta reaches the internal os but
does not cover it
• Grade 3 ( 3rd Degree)
The placenta covers the os
• Grade 4 ( 4th Degree)
The placenta lies centrally over the os
8 7 min To explain about CLINICAL FINDINGS Lecture method What are clinical
clinical findings Symptoms with PPT finding ?
 Spotting during the first and second trimesters
  Sudden, painless, and profuse vaginal bleeding
in pregnancy during the third trimester (usually
after 28 weeks)
 Uterine cramping may occur with onset of
bleeding
 Bleeding may not occur until after labor starts
in some cases
Signs
 The uterus is usually soft and relaxed.
 The infant position is oblique or transverse in
about 15% of cases.
 Fetal distress is not usually present unless
vaginal blood loss has been heavy enough to
induce maternal shock, placenta abruptio, or a
cord accident occurs.
 No digital examination
 On vulval examination – only inspection is to
be done .
 Vaginal examination must not be done.
DIAGNOSIS
 Painless & recurrent vaginal bleeding in the 2nd half of
pregnancy should be taken as placenta praevia unless
confirmed by diagnosis.
 Trans-vaginal sonography is safe in presence of
Placenta praevia & more accurate than trans-
abdominal in locating placenta.
 MRI- non invasive method without any risk of ionising
radiation. Quality of placental imaging is excellent.
 Today, ultrasound has the ability to measure the
distance between the edge of the placenta and the
cervix. This allows us to clearly describe the exact
 position of the placenta.
 A placenta that is > 2cm away from the cervix can
attempt vaginal birth.
 Placental migration occurs during the second and third
trimesters, but is less likely to occur if the placenta is
posterior or there has been a previous LSCS.
9 3 min. To tell about PREVENTION OF PLACENTA PRAEVIA Lecture method What are
prevention of To minimize the risk there should be- with PPT prevention of
placenta praevia  Adequate antenatal care placenta praevia ?
 Antenatal diagnosis of low lying placenta at 20 wks.
 Significance of WARNING HAEMORRHAGE should not
be ignored.
10 6 min. To explain TREATMENT Lecture method What are the
treatment of The course of treatment depends on with PPT treatment of
placenta praevia  the amount of abnormal uterine bleeding, placenta praevia ?
 whether the fetus is developed enough to survive
outside the uterus,
 the amount of placenta over the cervix,
 the position of the fetus,
 the parity (number of previous births) for the mother,
and
 the presence or absence of labor.
 Early in pregnancy, transfusions may be given to
replace maternal blood loss.
 Medications may be given to prevent premature
labor, prolonging pregnancy to at least 36 weeks.
 Beyond 36 weeks, the benefits of additional infant
maturity have to be weighed against the potential for
major hemorrhage.
 Cesarean section is the method for delivery. It has
proven to be the most important factor in reducing
 maternal and infant death rates.
11 2 min. To define vasa VASA PRAEVIA Lecture method What is vasa
praevia  Rare event with PPT praevia ?
 Umbilical cord vessels are covered only by chorion and
amnion (membranes)
 Vessels are exposed and can rupture under pressure
or ARM
 Baby at risk of severe bleeding and death
 May feel like a cord pulsating on vaginal examination
 May be diagnosed on colour Doppler U/S.
12 4 min. To define ABRUPTIO PLACENTA Lecture method What is abruption
abruption • Separation of a normally implanted placenta – usually with PPT placenta ?
placenta by haemorrhage into the decidual basalis .
• The amount of bleeding depends on:
• the size of the bleeding vessels
• the amount of placental separation
• The more extensive the bleeding, the more likely it is
to strip the membranes from the uterine wall and pass
through the cervix and vagina.
13 3 min. To explain about CAUSES OF ABRUPTIO Lecture method What are causes
causes of AP • Unknown cause is the most common with PPT of AP ?
• Hypertensive disorders
• Previous APH
• Abdominal trauma
• Associations have been made with abnormal
trophoblastic invasion and or vessel formation
• Other predisposing factors - Rapid reduction in uterine
size, Cocaine use, smoking, poor nutrition, advancing
parity, multiple pregnancy.
14 3 min. To tell about types BLEEDING MAY BE Lecture method What are the type
of bleeding • Revealed with PPT of bleeding?
 • Concealed
• Mixed
15 2 min. To explain clinical CLINICAL CLASSIFICATION Lecture method What are clinical
classification of AP  Grade -0 with PPT classification?
clinical feature may be absent. The diagnosis is made after
inspection of placenta following delivery.
 Grade -1
external bleeding is slight.Uterus –irritable, tenderness may
or may not be present.Shock- absent, FHS- Good
 Grade -2
external bleeding is mild to moderate. Uterine tenderness is
always present.Shock –absent, fetal distress or fetal death
occurs.
 Grade -3
Bleeding is moderate to severe or may be concealed,
uterine tenderness is marked. Shock – pronounce. Fetal
death is ruled.
CLINICAL PRESENTATION
• Vaginal bleeding of varying amount
• Uterine tenderness
• Abnormal FHR pattern
• Uterine contractions (high frequency, low intensity)
(35%)
• Uterine Hypertonus
• Clinical presentation features are dependant on
degree of abruption and blood loss.
16 4 min. To tell about PREVENTION OF ABRUPTION Lecture method What are the
prevention of AP • Actively treat maternal hypertension with PPT prevention of AP
• Screen for domestic violence
• Screening & brief intervention for smoking and
substance abuse
  Seat belt worn under pregnant abdomen.
 Early identification of potential / actual domestic
violence situations assists with keeping women safe.
 Wherever possible offer women assistance to stop
smoking or drug programs as required.
COMPLICATIONS OF PRAEVIA & ABRUPTIO
Maternal
 Haemorrhagic shock
 Coagulopathy/DIC
 Uterine rupture
 Renal failure
 Maternal death
Fetal
 Fetal Hypoxia
 Anaemia
 Growth restriction
 CNS damage
 Fetal death
17 4 min. To explain MANAGEMENT Lecture method What are the
management of • Maternal welfare assessment – monitoring of vital with PPT treatment of AP?
AP signs, blood loss, urine output. Always think about a
concealed haemorrhage
• Insert two large bore cannulars – 14 or 16g
• Fluid replacement
• Cross match 4 units of packed cells
• Resuscitation and/or delivery
• In the presence of significant blood loss - oxygen
• Fetal welfare assessment
• electronic FHR monitoring
• U/S for placental position/ vasa praevia
• Steroid cover if preterm
 • Anti D if Rh -ve
• Make a diagnosis – Clinical - Ultrasound
• Maternal education and support
• Preparation for Preterm birth – transfer if required
18 2 min. To tell about DIFFERENCE B/W PP & AB Lecture method What are the
difference Placenta praevia with PPT difference
between placenta between placenta
praevia and  Painless apparently causeless and recurrent bleeding. praevia and
abruption  Bright red colour abruption
placenta  Bleeding is always revealed placenta?
 Height of uterus proportionate to gestational age
 Feel uterus soft and relaxed
 FHS usually present
 Placenta in lower segment
 Placenta is felt on the lower segment
Abruptio placentae
 Painful often attributed top re- eclampsia or trauma
 Dark colour
 Revealed , concealed or usually mixed.
 Enlarged in concealed type
 May be tense, tender and rigid
 Absent specially in
 concealed type
 Placenta in upper segment
 Placenta is not felt on lower segment. Blood clots
should not be confused with placenta
SUMMARY
Today we had discussed about the following

 Definition of APH
 Causes of APH
 Definition of placenta praevia
 Causes , clinical features, diagnosis of placenta praevia
 Treatment
 Definition of abruption placenta
 Causes, clinical features, diagnosis of abruption placenta
 Treatment

ASSIGNMENT:
Explain about difference between placenta praevia and abruption placenta?

REFERENCES:

 A V Raman “Textbook of maternity nursing” published by WOLTERS KLUWER, edition-2nd ,pg no.77-91.
 D. C. DUTTA’S “textbook of obstetrics” published by HIRALAL KONAR, edition -7th ,pg no.241-260.
 www.google.com
 www.wikipedia.com