Ministry of Health and Family Welfare, Government of India has issued the standard Treatment Guidelines for Ante Partum Haemorrhage. Following are the major recommendations :
APH is defined as bleeding from or into the genital tract occurring from 24th week of pregnancy and prior to the birth of the baby.
Why it occurs?
The causes of APH include placenta previa,abruption placenta,local causes and unexplained causes. Local causes comprise vasa previa and cervical or vaginal causes.
Commonly it is due to:
It may also be due to:
– Exaggerated show,
– Trauma to cervix or vagina
– Cervical ectropion,
– Carcinoma of cervix or polyps
– Vasa previa
How to diagnose Placenta Previa?
The term placenta previa refers to a placenta that overlies or is proximate to the internal os of the cervix. The placenta normally implants in the upper uterine segment. In placenta previa, the placenta either totally or partially lies within the lower uterine segment.
1 in 300 pregnancies
Maternal morbidity and mortality is high if it is not treated properly.
Perinatal morbidity and mortality also are primarily related to the complications of placenta previa, because the hemorrhage is maternal.
o Advancing maternal age
o Prior caesarean delivery
o Prior placenta previa
Abruptio placentae, other probable causes.
Optimal Diagnostic Criteria, investigations, treatment and referral criteria
Situation 1: At Secondary Hospital/ Non-Metro situation: (Optimal Standards of Treatment in Situations where technology and resources are limited)-
a) Clinical Diagnosis:
It is on the basis of history, physical examination and investigations.
History: Nature of bleeding: Painless, recurrent, bright red. Initial bleeding may not be profuse enough to cause death; but it is a warning sign and requires close monitoring or refer the patient to higher centre.
On physical examination: Patient might be in shock
– Abdominal examination: Height of uterus proportionate to gestational age, presenting part may be felt high up (not engaged).
– Malpresentations, malpositions usually present.
– Uterine contraction may or may not be present. Some degree of uterine irritability is present in about 20% of the cases.
– Fetal heart sound may or may not be present, depending upon theamount of blood loss.
If you suspect placenta previa, do not perform a vaginal examination without preparation. Per vaginal examination should be done in theatre but without any anesthesia with all preparations of immediate cesarean section.
Blood investigations (Full blood count, blood group and type)
Ultrasound examination: Rules out types of placenta previa; fetal anomalies, fetal parameters, presentation and position.
Transabdominal ultrasonography (TAS):
It should be with partially full bladder.
It is a simple, precise, and safe method to visualize the placenta.
TAS has an accuracy of 93-98%.
Four types of placenta praevia according to abdominal sonography
Type I- Dips in to lower segment
Type II – Reaches lower border of uterus up to cervical os but not covering completely.
Type III- covers the internal os
Type IV – Covers the internal os, even on full dilatation of the cervix. At 18 weeks, 5-10% of placentas are low lying. Most ‘migrate’ with development of the lower uterine segment.
False-positive results can occur secondary to focal uterine contractions or bladder distention.
Transvaginal ultrasonography (TVS):
Recent studies have shown that the transvaginal method is safer and more accurate than the transabdominal method. Transvaginal ultrasonography is also considered more accurate than transabdominal ultrasonography.
– Skilled person should only do.
– The os–placental edge distance on TVS after 35 weeks’ gestation is valuable in planning route of delivery. When the placental edge lies > 20 mm away from the internal cervical os, women can be offered a trial of labour with a high expectation of success. A distance of 20 to 0 mm away from the os is associated with a higher CS rate, although vaginal delivery is still possible depending on the clinical circumstances.
– In general, any degree of overlap (> 0 mm) after 35 weeks is an indication for Caesarean section as the route of delivery
c) Treatment :
Assess the blood loss
Start IV Line
Restore blood volume by infusing normal saline
Explain the need of blood transfusion
Arrangements made to shift to higher centres.
d) Referral criteria:
Shift to hospitals where blood bank, neonatal and emergency cesarean section facilities are available.
(At Super Specialty Facility in Metro location where higher-end technology is available)
a) Clinical diagnosis: Diagnosis reached by history, physical examination and sonographic examination After initial assessment further investigations need to be performed to ascertain cause , degree of bleeding, plan the on-going care and to decide mode and time of delivery.
b) Investigations: As above.
Blood investigations (Full blood count, blood group and type)
Ultrasound examination : Best investigative tool to diagnose placenta previa.
Rule out all Four types of placenta previa:
o Type I- Dips in to lower segment
o Type II – Reaches lower border of uterus up to cervical os but not covering completely.
o Type III- covers the internal os
o Type IV – Covers the internal os, even on full dilatation of the cervix.
– At 18 weeks, 5-10% of placentae are low lying. Most ‘migrate’ with 16 development of the lower uterine segment.
– MRI: MRI has been suggested as a safe and alternate method and may be useful in determining the presences of placenta accreta/increta/percreta.
NO VAGINAL EXAMINATION
Assess the amount of bleeding.
Start IV line
Restore blood volume by blood products
The definitive treatment depends upon the duration of pregnancy, fetal and maternal status and extent of hemorrhage:
Type I and Type II anterior – vaginal delivery can be expected. Trial of vaginal delivery can be given and caesarean is done if patient bleeds
Type II -b, III & IV – Elective/emergency caesarean section has to be done at the earliest.
Guideline Source: Ministry of Health and Family Welfare
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