Antepartum Hemorrhage

A 30 year old G2P1 with previous spontaneus vaginal delivery and appropriately grown fetus is admitted at term with fresh vaginal bleeding and abdominal pain. On examination she is distressed with pain, pale, her pulse is 100 bpm, blood pressure 110/80 mmHg, and she has a tender uterus contracting 3/10minutes. Although she had tried to clean herself as much as possible, while waiting for the ambulance to transfer her to the maternity unit, you notice that she has blood stains on her feet between her toes.

Problems?
Bleeding during pregnancy (active) Atterm pregnancy Pain, high pulse, uterine contraction

Antepartum bleeding
Vaginal bleeding in 20 weeks to at-term pregnancy.

How often it occurs?

2%-5% of all pregnancy Cause: - abruptio placenta 40% - 1% - placenta previa 20% - % - unclassified 35% - Genital tract lesion 5% - Lain-lain

Etiology of APH
Cervical Contact bleeding (ex: coitus, pap-smear, neoplasia, bimanual exam) inflammation (ex: infection) Cervical dilatation and effacement (ex: in parturition, incompetence cervix) Placenta abruptio previa Rupture of sinus marginalis vasa previa Others - abnormality of coagulating factors

How to define the diagnosis?

Do history taking carefully Perform physical examination NEVER DO BIMANUAL EXAM

How to define the diagnosis?

Ultrasound Good to define placenta previa Less useful for abruptio placenta (active case) Monitor the fetus (CTG) to assess baby wellbeing and uterine contraction Speculum exam Preferably, after ultrasound exam Do not perform bimanual exam

How to define the diagnosis?

Blood test, blood type, Rh, Coombs Coagulation profile PTT, fibrinogen or clotting time 2 - 4 unit cross matched PRC Tes Kleihauer-Betke differentiate vaginal or maternal blood Lung maturity test if pregnancy <35 wks

Vaginal bleeding
Risk factor Test (NO bimanual )
Assessment Fetal / Maternal Moth & baby instabile Hemodinamiic ressucitation Moth & baby instabile Labor Expectant Consider blood loss, etiology and gestational weeks Moth & baby stabile Lab / fetal monitoring U/S vaginal exam

FIRST THINGS TO DO- ABC s

Inform the patient Observe mother and fetus

Infusion, large bore cath

Crystalloid infusion Blood and Coagulation profile

Blood type and cross match

Ask for help

Hemodinamic ressucitation
Early and aggressive to protect fetus and maternal organ from hypoperfussion and prevent DIC Stabilitation of vital sign tanda vital Crystalloid infusion with large bore cath Haemoglobine serial and coagulation profile Oxigen

Perawatan Janin
Posisi lateral meningkatkan curah jantung sampai 30% Pertimbangkan amniosentesis untuk tes kematangan paru Pemantauan DJJ dan kontraksi (persalinan) Monitor berkala sedikitnya 4 jam untuk membuktikan adanya perdarahan janin, solusio, fetal maternal transfusion

ABRUPTIO PLACENTA- Definition

Separation of placenta from its bed before the parturition

Classification
Total - fetal death Partial fetus can tollerate up to 30-50% of plasental separation

Abruptio placentae

Risk factors
hypertension: gestational or before Trauma abdomen Drug abuse (cocain and sedative) Previous abruption hystory Uterus stretching gemelli, polyhidramnion Smoking, more >1 pack/day

Clinical features
Risk factors exist Hemodinamic status not always related to amount of bleeding (concelead type) Can cause fetal dystress uterus - pain, irritable, contraction or tetanic With ultrasound can be differentiated from previa in the form of retroplasentair hemorrhage

SOLUSIO
Janin hidup janin mati koagulopati persalinan (hati-hati DIC) Nilai maturitas

Matur Persalinan pervaginam or s.c

Immatur Steroid plus expektatif Transfusi? Rujuk?

Plasenta Previa Placenta insertion cover the ostium or low lying

Classification
total partial marginal

- cause bleeding during contraction

Risk factors
History of plasenta previa History of SC or uterus operation multiparity (5% in grand multipara)

Old gravida Multipel gravida Smoking

Clinical features
Bleeding, without pain ( unless during parturition) Hemodinamic status related to amount of bleeding Can be tolerated by fetus, unless mother in unstable condition uterus not pain, not irritable, no contration Can cause malpresentation Ultrasound can define the diagnosis

PLASENTA PREVIA
Nilai maturitas

Matur

Immatur

persalinan dengan s.c (hati-hati akreta) dapat dicoba pervaginam jika marginal

Steroids plus expektatif Transfusi? Rujuk?

Vasa Previa - Definisi

Pembuluh darah pada selaput ketuban berjalan melewati servix Insersi vellamentosa atau lobus suksenturiata

Komplikasi
ex-sanguinasi setelah amniotomi

Diagnosis
Apt test - Kleihauer test dari darah vagina bradikardia janin (terminal) berawal takikardia atau sinusoidal

Prognosis
Mortalitas janin sebesar 50-70%

Simpulan
Nilai keadaan ibu dan stabilitas Nilai apakah janin dalam keadaan baik Resusitasi yang tepat Nilai penyebab dari perdarahan hindari periksa dalam Tatalaksana ekspektatif jika sesuai Terminasi kehamilan jika ada indikasi ibu atau janin

Jauhkan jari anda yang berdarah dari serviks!

Summary
Etiology and risk factors Diagnosis Management - Assessment of maternal and fetal - Ressuciation - No vaginal exam before ascertain about placenta location