ANTIPARTUM HAEMORRHAGE OR OBSTETREC HAEMORRHAGE

 Definition – “APH is defined as the hemorrhage from the genital tract after 28 week of pregnancy but before birth of the baby”

Course:-

APH

Placental bleeding Extra placental Un explained

70% (5%)         or

             Indeterminate (25%)

Placenta previa Abruption placenta Cervical polyp

        Cervical carcinomas

            Varicose Vein

(1) Placenta Previa:- Implantation of placenta on the lower uterine segment either completely or partially”

Etiology:- This is not definitely known some factors are

Responsible – (i) Dropping down theory

   (ii) Defective deciduas

  (iii) Big surface of placenta

Pre disposing factors:-

Multiparty

Advanced age over 35 year

History of C.S

Increase placental size

Any abnormality in placenta

Smoking

Degrees:- four degree are par presently recognizes

(i) Type 1 ( low lying):-

Major part is attached to upper segment

Lower margin encroaches on lower segment but not up to internal

(ii) Type II (Marginal):-

Placenta reaches margins of internal os but doesn’t covert

(iii) Type III (In complete/partial control):-

Clinical features:-

(i) Vaginal bleeding:- 

Sudden, Painless, causeless & recurrent

Subsequent bleeding are heavier than first

Gen. conditions is anemic & blood loss

(ii) Abdominal Exam reveals:-

Size of uterus & period of gestation

Uterus feels relaxed, soft & elastic without any tenderness.

Mal presentation

Free of twins pregnancy

Head is floating

FHS Present

(iii) Vulval Inspection:- 

Bleeding is bright red

Vaginal exam

Complications:-

(1) Maternal:-

During pregnancy:- Ante partum hemorrhage

Mal presentation

Pre mature labour

During Labour:-

Early suture of membrane

PPH         Post partum hemorrhage

Card prolapsed

Retained placenta surgical needs

Slow dilation of cervix

Puerperium:-

Sepsis

Embolism

Sub involution

(2) Fetal:-

Low Birth weight

Birth injuries

Congenital malformation

IUD

Prevention:-

Antenatal case to improve health status & anemia

Antenatal diagnosis for low lying placenta at 20 weeks & sonography at 34 weeks

Family planning

Birth Limitation

Management:-

Bed rest

Assess blood loss

IV fluid infusion

Blood transfusion

Assess fundal ht & FHS

Make provision for emergency

(1) Patient not in labour before the end of 38 weeks 

(A) Expectant Treatment Objective- To advise foetal maturity To treat maternal anomies Procedure:- Bed rest in High risk pregnancy goes to toilet under supervision To have adequate food. Iron folic acid (1 day- cap) Diazepam  5 ml at bed time Placental sonography is done on cessation of bleeding (Vaginal speculum exam is done) 2 day after cessation of bleeding	(B) Active Treatment Indication:- If bleeding is severe of continue Termination of expectant treat at the end of 38w Examination under anesthesia in OT is done (1) Induction of labour AROM+ Oxytocin (2) Caesarean section is done Under blood transfusing  Indication- P.P degree IV, III, II (If foetus is dead) Any degree P.P with other high risk (Mal presentation)
USG show placenta at upper segment She goes home followed by clinic case- readmission after 38 weeks	USG show P.P She stay in the hospital under expectant treat till 38 weeks when active treatment is done If bleeding sew cases (with blood transfusion) If bleeding server  Active treatment

(2) Patient not in labour after 38 weeks of pregnancy:-

Placental sonography

Examination Under anesthesia Severe degree PP

In Mild degree         C.S

Active treatment

Induction of labour/C.S

(3) Patient in labour:-

Low rupture of membranes Caesarean section in

For mild degree P.P Severe degree P.P

Caesarean Section for P.P

Quick laparotomy is done by mild line – low transverse incision

Pain on the lower segment are tied by two ligatures incision is made b/w ligatures

Placenta coming on the way of incision either baby’s presentation is searched going around the margin

Placenta is incised card is clamped quickly

Prompt delivery of foetus is done Inj. Methargin 2 mg IV & 10 U oxytocin is 500 ml glucose drip.

Nursing Management:-

Assessment:-

Proper Assessment of bleeding is done

Necessary History taken

Vital signs and foetal status is recorded

Blood is taken for cross matching clothing studies and electrolytes

Nsg. Diagnosis:-

Excessive blood loss R/T Haemorrhage

Fluid volume deficit

Anxiety R/T  maternal & foetal condition

Knowledge deficit R/T treatment

Rick for infection R/T Hemorrhage & anemia

Interventional:-

IV infusion and necessary pre operative & post operative case

Accurate Assessment of Maternal & focal well being

Administration of antibiotics as per direction

Education about perineal hygiene and importance of bed rest

Abnormal Endometrium

Delayed Ovulation 

(B) Abruption Placenta (Accidental Haemorrhage):-

Definition:- “Bleeding Occurs due to premature separation of a normally Implanted placenta lying on the upper uterine segment”

It is series event accending for significant maternal and foetal morbidity and mortality

Types: - It is the based on the degree of placental separation (Classification Page’s class)

Grade O:- Less than 10% of the total placental surface area is detached

Grade-1:- 10% to 20% of the total placental surface area is detached

Grade 2:- 20 to 20% of the total placental surface area is detached there is uterine tenderness with or without external bleeding

Grade 3:- Greater than 50 % of the placental surface Areas is detached

Uterine tetany is severe the mother is in shock and fetus is dead

Clinically these types:-

(1) Revealed:- Blood comes out of cervical canal & visible externally

(2) Concealed:- Blood collects behind separated placenta not visible expelled  out side

(3) Mixed:- Some part of blood is collected inside & some expelled out side

Etiology:- The exact cause is unknown

It may be due to an workless or abnormality in arterioles and few precipitating factors are

Hypertension in pregnancy 

Thrombophilos

Trauma

Sick placenta

Sudden uterine decompression

Folic acid deficiency

Short card

Torsion of the uterus

Supine hypotension syndrome

Pre eclampsia

Pre disposing/ risk factor:-

Multigravida

Advance age of mother

Poor socio-economic status

Malnutrition

Smoking

Clinical Features:-

Revealed:- Painful Vaginal Bleeding (dark color)

Tender Uterus

Uterine out-put normal

FHS Present

Shock is absent

Abdominal discomfort

Concealed (Mixed):-

Acute pain abdomen

Slight vaginal bleeding of (dark color)

Shock

Severe pallor

Tender & rigid uterus

No Urine out put

FHS absent

Fetal parts not felt

Features of Pre-eclampsia May present

Investigation:-

USG

Blood HB

Urine for protein

Placontography

Prevention:- 

Elimination of known factors producing placental separation

Early detection & effective therapy pre-eclampsia, hypertension disorder

Avoid traumas & sudden decompression of uterus

Routine adm. Of folic acid

Crassest anemia

Start IV infusion

Nsg Management:-

Assessment:- History is recorded and amount if any visible blood loss is estimated

Nsg Diagnosis:- 

Fluid volume deficit R/T excessive blood loss

Pain R/T bleeding

Anxiety R/t Uncertainly of pregnancy out come 

Knowledge deficit R/T treatment

Intervention:-

In case of moderate separation the immediate aim of care is to reduce shock and to replace blood if the fetus is alive, immediate C.S may be indicated.

Severe separation of placenta is an accurate emergency the mother will be severely shocked invited C.S done as soon as the women’s condition is established

The women should be offered comfort & encouragement

Management:- AP

Gen. & Abdominal Exam

Fetal Status

Assess blood loss

Resuscitation

Revealed Concealed

Pt. in labour             Pt not in labour No response oliguris

AROM     37w <37W C.S AROM

Oxytocin       AROM Bleeding stop