DEBREMARKOS UNIVERSTIY COLLEGE OF

MEDICINE AND HEALTH SCINCE

DEPARTEMENTE OF PUBLIC HEALTH

SEMINAR ON APH and PPH

By
1 Samuel wondie
2 Sewyalew Aysheshim
3. Nigste Amare

MODELATORE BY. Dr.AWOKE

 Presentaton out line part one

 Definiton of APH
Caus of APH
Risk factor
Clinical manifestaton
Classificaton
Investgaton
Complicaton
Management
 Objectve
At the end of presentaton we should know
.Definiton of APH
.Caus of APH
.Risk factor
.Clinical manifestaton
.complicaton
.Diagnosis and management of APH
•
 APH
- is the occurrence of vaginal bleeding (VB) after
28th wks of gestaton and before delivery of
the fetus.
• Causes can be obstetric and non obstetric
 Obstetric Caus

• Placenta previa
• Abrupto placenta
• Vasa previa
• Uterine rupture
None Obstetric caus

• Cervical cancer or dysplasia

• Cervicits
Cervical polyps
• Cervical eversion
• Vaginal laceraton/trauma
• Vaginits
 A.Placenta previa
• Definiton:-
- is implantaton of the placenta in the LUS, with the placenta either
overlying or reaching the cervix, usually in advance of the presentng
part.
Four types:-
1. Low lying placenta previa Type I
2. Marginal placenta previa Type II
3. Partal placenta previa Type III
4. Total placenta previa Type 4
Minor degree- low lying
-marginalis anterior
Major degree- marginalis posterior
- partalis
- totalis
• Clinical feature
– Bleeding character
• Painless
• Bright red
• Causeless
• Recurrent
– V/S proportonal to amount of blood loss
– Uterus is soft and relaxed
– Floatng head
• Risk factors:
– Previous caesarean secton
– High parity
– Advanced maternal age
– Smoking
– Multple gestaton
– prior placenta previa
 Investgaton

• CBC
• Ultrasound
• Organ functon test
 Management
• Principles :-
 Admit or Refer all patents to a hospital

 NEVER NEVER NEVER do PV- EXAM

 Take Resuscitative measures

 Plan further management

 complicatons
Maternal
 Blood loss & shock
 Adherent placenta
 Transfusion risks
 Longer hospital stay
 Surgical morbidity
 Post partum hemorrhage
 Recurrence rate — 4 to 8 percent
Fetal / Neonatal
1. ↑ed PNMR from prematurity
2. ↑ed risk of fetal anomalies ( 5x)
3. ↑ed IUGR (20% Vs 5%)
4. Birth trauma ( b/c of malpresentaton)
5. Neonatal anemia
 Aprupio placenta
• Definiton:-
- premature separaton of the normally
implanted placenta
- also called accidental hemorrhage/ placental
abrupton
Types
1. revealed / external
2. concealed
 Clinical manefestaton
vaginal bleeding or occult uterine bleeding,
abdominal pain, uterine contractons or
hypertonus,
uterine tenderness,
Non reassuring fetal heart rate patterns or fetal
death, and
disseminated intravascular coagulaton (DIC).
Approximately 80 percent of placental abruptons
occur before the onset of labor
• Three grades based on clinical and laboratory
findings:
• Grade 1:
 A mild abrupton characterized by
o slight vaginal bleeding and minimal uterine irritability.
o Maternal blood pressure and fibrinogen levels are
unaffected.
o the fetal heart rate pattern is normal.
o Account for 40 percent
Grade 2:
 Partal abrupton with :
o mild to moderate vaginal bleeding and
significant uterine irritability or contractons.
o Maternal blood pressure is maintained, but the pulse is
often elevated and postural blood volume deficits may be
present.
o The fibrinogen level may be decreased, and
o the fetal heart rate often shows signs of fetal compromise.
o Account for 45 percent of all placental abruptons.
Grade 3:
 A large or complete abrupton characterized by
o moderate to severe vaginal bleeding or
o occult uterine bleeding with painful,
tetanic uterine contractons.
o Maternal hypotension and coagulopathy are
frequently present along with fetal death.
o Account for 15 percent of placental abruptons
 Risk factors:-
 Prior abrupton
 Advanced age and parity
 Preeclampsia
 Chronic hypertension
 Trauma
 Race and ethnicity
 PROM - cause or result
 Multfetal pregnancy
 Cigarette smoking
 Thrombophilias
 Cocaine use
 Myoma
 diagnosis
• primarily clinical, with supportve evidence
from sonographic, laboratory, and pathologic
studies.
• Although vaginal bleeding is the hallmark sign
of placental abrupton, 10 to 20 percent of
affected women may have an occult/
concealed/hidden hemorrhage
 Management
 Principles :-
 Admit or Refer all patents to a hospital.

 Never do PV- EXAM

 Take Resuscitatve measures

 Plan further management depend on GA & severity

 Complicatons
 Premature delivery.

 Fetal distress and death

 Hemorrhagic shock.

 Acute renal failure

 Uterine atony (Couvelaire uterus).
 PPH
 Vasa previa
• Vasa previa refers to velamentous inserton of
umblical cord and involved vessels may overlie
the cervix.
• Rupture of these vessels can occur with or
without rupture of the membranes and result
in fetal exsanguinaton
 Presentaton out line part two
• Definiton of PPH
• Caus of PPH
• Risk factor
• Clinical manefestatons
• Diagnosis
• Management
• Complicatons
 OBJECTIVES
• At the end of this presentaton we should to
know
• Definiton of PPH
• Clinical features of PPH
• Risk factors
• Diagnosis
• Managemenents
• Complicatons
 Definiton
• PPH is best defined and diagnosed clinically as
excessive bleeding that makes the patent
symptomatc (eg, lightheadedness, vertgo,
syncope) and/or results in signs of
hypovolemia (eg, hypotension, tachycardia, or
oliguria)
• The most common definiton of PPH is
estmated blood loss ≥ 500 mL after vaginal
birth or ≥ 1000 mL after cesarean delivery.
• Primary PPH ---PPH that occur within the first
day or 24 hr after delivery
• Secondary PPH----PPH that occurs after the
first day tll 6th week
1. Early ---- that occur in the first three weeks
2. Late -----that occur in the second
 Caused for PPH
• Atonic uterus
• Retained placenta
• Tears of cervix, vagina or perineum
• Retained placental fragments
• Ruptured uterus
• Inverted uterus
 Riskfactors
• Retained placenta.
• Failure to progress during the second stage of labor.
• Placenta accreta .
• Laceratons.
• Instrumental delivery .
• Large for gestatonal age newborn .
• Hypertensive disorders .
• Inducton of labor.
• Augmentaton of labor with oxytocin
• The major etologies of and risk factors for
PPH are described as 4 Ts
– Tone (Uterine tone)
– Tissue (Retained tssue--placenta)
– Trauma (Laceratons and uterine rupture)
– Thrombin (Bleeding disorders)
 Atony
• The most common cause of PPH is uterine atony , which
complicates 1 in 20 births and is responsible for at least
80 percent of cases of PPH.
• An atonic uterus may be related to:
– Over distension (multple gestaton, polyhydramnios,
macrosomia)
– Uterine infecton
– Drugs (uterine relaxants) "Uterine fatgue" after a prolonged
or induced labor Uterine inversion
– Retained placenta (either a normally attached placenta or
placenta accreta).
 Trauma
• Trauma-related bleeding can be due to
– laceratons (perineal, vaginal, cervical, uterine),
– incisions (hysterotomy, episiotomy), or
– uterine rupture.
• Laceratons are more common after
instrumental delivery.
 Tissue
• Delay of placental delivery > 30 minutes seen
in ~ 6% of deliveries.
• Prior retained placenta increases risk.
• Risk increased with: prior C/S, curettage ,
uterine infecton, or increased parity.
• Prior C/S scar & previa increases risk (25%)
 Trombin(bleeding disorder)
• Acquired and congenital bleeding diatheses may be associated
with thrombocytopenia and/or haemostatc defects.
• Acquired causes include
– severe preeclampsia,
– HELLP syndrome,
– abrupton placenta,
– fetal demise,
– amniotc fluid embolism, and
– sepsis
• Consumptve coagulopathy may develop in women with
severe hemorrhage.
 Clinical features
Excessive bleeding after delivery

Swelling and pain in the tssue in vagina and

perineal areas
State of the uterus
 After atonic hemorrhage
 After traumatc hemorrahge
 Management
• The treatment of patents with PPH has 2
major components:
– resuscitaton and management of obstetric
hemorrhage and, possibly, hypovolemic shock and
– identficaton and management of the underlying
cause(s) of the hemorrhage.
• Successful management of PPH requires that
both components be simultaneously and
systematcally addressed.
• Shout for help—mobilize personnel
• Evaluate woman’s conditon including vital
signs
• If shock suspected, immediately begin
treatment
• Massage uterus to expel clots and feel to see
that it is contracted—recheck intermittently
• Give oxytocin 10 units IM
 Complicatons
• Hypotension
• Dilutonal coagulopathies
• Anemia
• Occult myocardial ischemia and mult organ
failure
• In sever case anterior pitutary ischemia may
occur and results in delay or failure of
lactaton
 Referance
• WILLIAMS OBSTETRIC 24th EDITION
• MANAGEMENT PROTOCOL ON SELECTED
OBSTETRICS TOPICS
THANK U