dr. Arman Sanun, SpOG Depart.

of Obstetrics - Gynecology Padjadjaran University / Hasan Sadikin Hospital BANDUNG

OBSTETRICAL HEMORRHAGE

Bleeding before 20 weeks of pregnancy

Antepartum hemorrhage
Post partum hemorrhage

Cause of vaginal bleeding at the third trimester

Rupture of vaginal varicose Laceration of vagina or cervix Placenta previa

Abruptio placentae

ANTEPARTUM HEMORRHAGE

Placenta Previa

Abruptio placentae

Normal implantation of the placenta

Fundal Corpus

Implantation at the lower segment

Front Behind

PLACENTA PREVIA :

DEFINITION :
Placenta is located over or very near the internal os Prae : Front Vias : Route

FOUR DEGREES OF THIS ABNORMALITY 1. Total placenta previa

The internal cervical os is covered completely 2. Partial placenta previa

The internal cervical os is partially covered

FOUR DEGREES OF THIS ABNORMALITY

3. Marginal placenta previa
The edge of placenta is at the margin of the internal os

2. Low lying placenta

The placenta is implanted in the lower uterine segment such that the placental edge actually does not reach the internal os but is in close proxymity to it

VASA PREVIA :

The fetal vessels course through membranes and present at the cervical os
Uncommon cause of antepartum hemorrhage, associated with a high rate or fetal death

THE DEGREE OF PLACENTA PREVIA

Depend on large measure on the cervical dilatation at the time of examination Eg. Low lying placenta at 2 cm dilatation may become a partial placenta previa at 8 cm dilatation because the dilating cervix has uncovered placenta

Total placenta previa

BLEEDING >>> !!!

Marginal placenta previa

Placenta

cervix

CHANGING THE DEGREE OF P.P

Marginal

Amnion (+) Lateral Dilatation >

Dilatation

Bleeding Retracted

Amnion

Lower segmen

Lower segmen

Cervix
Bleeding

Partial placenta previa

> 1/2 O BLEEDING >>>

< 1/2 O

BLEEDING >

PREDISPOSING FACTOR :

Multipara, with interval <

Fibroids Habitual abortion

CLINICAL FINDINGS :

Hemorrhage :

Frequent Usually does not appear until near the end of the second trimester or after

Painless

Spontaneously
Initial bleeding is rarely profuse as to prove fatal

Lacunae

Maternal vessels

HAFT ZOTE

Fetal vessels

CLINICAL FINDINGS :

Oblique or lie position

Presenting part - high

DIAGNOSIS :

Speculum
Fornix palpation Double set up examination at the operating room USG

WARNING :

Digital palpation to try to ascertain changing relations between the edge of the placenta and the internal os as the cervix dilates can incite severe hemorrhage
Examination of the cervix is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean section

MANAGEMENT :

Active : Termination Vaginally CS Expectative : Depend on maturity (< 37 weeks ; < 2500 gr) Bleeding Maternal condition

VAGINAL DELIVERY :

Amniotomy tamponade
Braxton Hicks version Cunam Willet

TAMPONADE BY PRESENTING PART

Placenta
Amnion Cervix

In tact

Head press the placenta

Amnion (+)

Head Breech

CUNAM-WILLETT

PLACENTAL ABRUPTION :

DEFINITION :
The separation of the placenta from its site of normal implantation before the delivery of the fetus after 22 weeks of pregnancy

SINONYM :

Accidental hemorrhage Abruptio placentae

Solutio placentae
Ablatio placentae

Premature separation of the normally

implanted placenta

PATHOLOGY
Hemorrhage into the decidua basalis Decidua then splits, leaving a thin layer adherent to the myometrium Decidual hematoma

Separation, compression and the ultimate destruction of the placenta adjacent to it

TYPE :

Concealed hemorrhage separated completelly freq 20% fatal External hemorrhage incomplete freq 80%

CONCEALED HEMORRHAGE

EXTERNAL HEMORRHAGE

COMBINED

ETIOLOGY :

Hipertension Trauma Multiparity Folic acid deficiency Hidramnion ; gemelly Umbilical cord - short

CLINICAL DIAGNOSIS :

Hemorrhage with pain

Fetal - Not palpable

Heart beat - not detected

Uterine hypertonus

Anemi shock
Amnion bulging

COMPLICATION :

Early : - Hemorrhage - Shock

Late : - Consumtive coagulopathy - Hypofibronogenemia - Utero placental apoplexy (couvelaire uterus) - Renal failure

MANAGEMENT :

Depend on status of the mother & fetus:

Transfusion

Electrolyte solution
Corticosteroids Fibrinogen

OBSTETRIC MANAGEMENT :

Amniotomi Oxytocin infusion Cesarean section : Fetus alive Cervix not dilated 2 hours after oxytocin infusion uterine contraction (-) Histerektomi