What are the causes of APH? How will you diagnose the probable cause? Describe management of accidental hemorrhage at PHC Level

Antepartum hemorrhage (APH) refers to vaginal bleeding that occurs after 24 weeks of gestation but before the onset of labor.

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It can be caused by various factors related to pregnancy, maternal health, or placental abnormalities. Diagnosing the probable cause of APH involves a comprehensive assessment of the mother and fetus, including medical history, physical examination, and diagnostic tests. Management of accidental hemorrhage at the primary healthcare (PHC) level involves prompt assessment, stabilization, and referral to higher levels of care as needed. Here’s a breakdown of the causes, diagnosis, and management of APH:

Causes of Antepartum Hemorrhage (APH):

1. Placental Abruption:

• Premature separation of the placenta from the uterine wall before delivery, leading to bleeding behind the placenta.
• Risk factors include hypertension, trauma, advanced maternal age, smoking, cocaine use, and previous history of placental abruption.

1. Placenta Previa:

• Implantation of the placenta in the lower uterine segment, partially or completely covering the internal cervical os.
• Risk factors include previous cesarean section, multiparity, advanced maternal age, and uterine scarring.

1. Placental Pathology:

• Conditions such as placenta accreta, placenta increta, or placenta percreta, where the placenta abnormally adheres to the uterine wall, increasing the risk of bleeding during pregnancy or childbirth.

1. Cervical Ectropion or Polyps:

• Benign lesions or abnormalities of the cervix, such as cervical ectropion (erosion) or cervical polyps, which may cause bleeding during pregnancy.

1. Uterine Rupture:

• Rare but serious complication involving a tear or rupture of the uterine wall, often associated with previous uterine surgery, trauma, or prolonged labor.

1. Other Causes:

• Trauma, including motor vehicle accidents, falls, physical assault, or iatrogenic injury during procedures such as cervical cerclage or amniocentesis.
• Vaginal or cervical infections, sexually transmitted infections, or other inflammatory conditions affecting the reproductive tract.

Diagnosis of Antepartum Hemorrhage:

1. History and Physical Examination:

• Obtain a detailed medical history, including the onset, duration, and severity of bleeding, associated symptoms, obstetric history, and risk factors for placental abnormalities.
• Perform a thorough physical examination, including abdominal palpation, assessment of uterine contractions, fetal heart rate monitoring, and speculum examination to evaluate the cervix and vaginal canal.

1. Diagnostic Tests:

• Order laboratory tests, including complete blood count (CBC), blood typing and crossmatching, coagulation studies, and serum biochemical markers (e.g., hCG, fibrinogen) to assess maternal and fetal status and rule out complications.
• Perform obstetric ultrasound (transabdominal and/or transvaginal) to evaluate placental location, integrity, and fetal well-being, and to assess for signs of placental abruption, placenta previa, or other placental abnormalities.

Management of Accidental Hemorrhage at PHC Level:

1. Initial Assessment and Stabilization:

• Assess the mother’s vital signs, level of consciousness, and degree of vaginal bleeding.
• Administer supplemental oxygen via face mask to maintain oxygenation and perfusion.
• Establish intravenous (IV) access and initiate fluid resuscitation with crystalloid solutions to maintain maternal hemodynamic stability.

1. Fetal Monitoring:

• Perform continuous fetal heart rate monitoring to assess fetal well-being and response to maternal hemorrhage.
• Monitor for signs of fetal distress, including non-reassuring heart rate patterns, decreased fetal movement, or abnormal biophysical profile.

1. Blood Transfusion:

• If indicated based on clinical assessment and laboratory findings, arrange for blood transfusion with compatible blood products (packed red blood cells, fresh frozen plasma, platelets) to correct maternal anemia and coagulopathy.

1. Referral and Transfer:

• Determine the need for referral to a higher level of care (e.g., secondary or tertiary healthcare facility) for further evaluation, management, and obstetric intervention.
• Arrange for timely transfer to a facility with obstetric expertise, facilities for cesarean section, and neonatal intensive care services if required.

1. Supportive Care:

• Provide emotional support, reassurance, and counseling to the mother and family members, addressing their concerns and ensuring clear communication regarding the diagnosis, prognosis, and treatment plan.
• Involve a multidisciplinary team, including obstetricians, midwives, nurses, and other healthcare providers, to coordinate care and optimize maternal and fetal outcomes.

1. Follow-Up and Monitoring:

• Schedule follow-up appointments for ongoing antenatal care, monitoring of maternal and fetal well-being, and assessment of any complications or sequelae of antepartum hemorrhage.
• Educate the mother about signs and symptoms of potential complications (e.g., preterm labor, fetal distress) and encourage adherence to recommended prenatal care and preventive measures.

1. Preventive Measures:

• Promote health education and awareness programs to educate women and communities about risk factors for antepartum hemorrhage, early warning signs, and the importance of seeking timely medical care during pregnancy.
• Emphasize the benefits of prenatal care, regular antenatal visits, appropriate screening tests, and lifestyle modifications to reduce the risk of obstetric complications and adverse pregnancy outcomes.

By promptly diagnosing and managing accidental hemorrhage at the PHC level, healthcare providers can stabilize the mother, optimize fetal well-being, and facilitate timely referral and transfer to higher levels of care when necessary, ensuring comprehensive management and favorable maternal and neonatal outcomes.