Antepartum Hemorrhage

1
Antepartum Hemorrhage

• Lecture
• Petrenko N., MD, PhD

2
Introduction

• Definition
• Vaginal bleeding which occurs after fetal
  viability.
• Incidence
• 2 6 .

3
ANTEPARTUM HEMORRHAGE

• Per vagina blood loss after 20 weeks gestation.
• Complicates close to 4 of all pregnancies and is
  a MEDICAL EMERGENCY!
• Is one of the leading causes of antepartum
  hospitalization, maternal morbidity, and
  operative intervention.

4
Causes

• Placental
• Abruptio placenta.
• Placenta previa.

• Non-placental
• Vasa previa.
• Bloody show.
• Trauma.
• Uterine rupture.
• Cervicitis.
• Carcinoma.
• Idiopathic.

5
Abruptio Placenta
6
Introduction

• Definition
• It is the separation of the placenta from its
  site of implantation before delivery of the
  fetus.
• Incidence
• 1 in 200 deliveries.

7
Risk Factors

• Increased age parity.
• Hypertensive disorders.
• Preterm ruptured membranes.
• Multiple gestation.
• Polyhydramnios.

• Smoking.
• Thrombophilia.
• Cocaine use.
• Prior abruption.
• Uterine fibroid.
• Trauma.

8
Types

• Total or partial.
• Concealed or reveiled.

9
Placental Abruption

• external hemorrhage
• concealed hemorrhage
• Total
• Partial

10
Presentation

• Vaginal bleeding.
• Uterine tenderness or back pain.
• Fetal distress.
• High frequency contractions.
• Uterine hypertonus.
• Idiopathic PTL.
• IUFD.

11
Diagnosis

• The diagnosis is primarily clinical, but may be
  supported by radiologic, laboratory, or
  pathologic findings.
• It is generally obvious in severe cases.
• In milder forms the diagnosis is often made by
  exclusion.

12
Diagnosis

• The echogenic appearance depends upon the onset
  of symptoms
• Acute hemorrhage is hyperechoic to isoechoic
  compared with the placenta.
• Resolving hematomas is hypoechoic within one week
  and sonolucent within two weeks.

13
Diagnosis

• Laboratory testing is not useful in making the
  diagnosis
• Kleihauer-Betke test sensitivity 17.
• CA-125 elevated.
• D-dimer sensitivity 67, specificity 93
• Thrombomodulin sensitivity 88, specificity 77.
• Hypofibrinogenemia lt 200 mg/dL.
• Thrombocytopenia lt 100,000/microL.

14
Diagnosis

• Gross examination of the placenta often reveals a
  clot and/or depression in the maternal surface.
• It may be absent with acute abruption.

15
Initial Management

• Stabilization of the maternal cardiopulmonary
  status.
• Blood work
• - CBC.
• - Coagulation profile.
• - Fibrinogen.
• - Blood type and Rh.

16
Initial Management

• Large-bore intravenous lines and continuous fetal
  monitoring
• Correction of the intravascular fluid deficit via
  crystalloid /- PRBC.
• If the PT and PTT gt 1.5x control ? 2u FFP.
• If the platelet count is lt 50,000/microL ? 6u
  plt.

17
Initial Management

• Heparin or other anticoagulants ?
• Tocolysis is generally contraindicated.
• Delivery is the optimal treatment. DIC
  hemorrhage will resolve over 12 hours when the
  placenta is removed.

18
Initial Management

• Medical treatment of coagulopathy for
• Marked thrombocytopenia (lt 20,000/microL)
• Moderate thrombocytopenia(lt50,000/microL)
  serious bleeding or planned cesarean delivery.
• FFP or cryoprecipitate if fibrinogen is lt100
  mg/dL

19
Mild Abruption

• Expectant management with short term
  hospitalization.
• Corticosteroid.
• Tocolysis may be of value in mild cases.

20
Delivery

• The mode and timing of delivery depend upon
• GA.
• The condition of the fetus.
• The condition of the mother (eg, hypotension,
  coagulopathy, hemorrhage).
• The status of the cervix.

21
Delivery

• The term or near term fetus should be
  expeditiously delivered.
• Amniotomy with placement of a fetal scalp
  electrode.
• Oxytocin may be used to augment uterine activity.

22
Delivery

• C/S is performed in the presence of a
  nonreassuring fetal heart rate pattern when
  delay in delivery will endanger the mother or
  fetus.
• It should be done after rapid maternal
  hemodynamic and clotting factor stabilization.

23
Complications

• Maternal
• Hypovolemia.
• DIC.
• Renal failure.
• Death.

• Fetal
• IUGR.
• IUFD.

24
Placenta Previa
25
Introduction

• Definition
• The presence of placental tissue overlying or
  proximate to the internal cervical os after
  viability.
• Incidence
• Complicates approximately 1 in 300 pregnancies.

26
Risk Factors

• Increasing parity incidence 0.2 percent in
  nulliparas versus up to 5 percent in grand
  multiparas.
• Maternal age incidence 0.03 percent in
  nulliparous women aged 20 to 29 versus 0.25
  percent in nulliparous women 40 years of age.
• Number of prior cesarean deliveries incidence 10
  percent after four or more.
• Number of curettages for spontaneous or induced
  abortions.

27
Independent Risk Factors

• Maternal smoking
• Residence at higher altitudes
• Male fetus
• Multiple gestation 3.9 and 2.8 previas per 1000
  live twin and singleton births, respectively
• Gestational age the prevalence of placenta
  previa is much higher early in pregnancy than at
  term

28
Classification

• Complete placenta previa The placenta completely
  covers the internal os.
• Partial placenta previa The placental edge does
  not completely cover the internal cervical os but
  partially covers it.
• Marginal placenta previa The placenta is
  proximate to the internal os.
• Low-lying placenta in which placental edge lies
  within 2 to 3 cm of the internal os. (reference)

29
Maggie Myles Textbook for Midwives
30
Clinical Manifestations

• Painless vaginal bleeding occurs in 70 to 80
  percent of patients.
• 10 to 20 percent present with uterine
  contractions associated with bleeding.
• Fewer than 10 percent are incidentally detected
  by ultrasound.

31
Associated Conditions

• Malpresentation.
• PPROM.
• Congenital anomalies.
• IUGR.

32
Diagnosis

• The diagnosis is based upon results of ultrasound
  examination.
• Clinical findings are used to support the
  sonographic diagnosis.
• Placenta previa should be suspected in any woman
  beyond 24 weeks of gestation who presents with
  painless vaginal bleeding.

33
Transabdominal US

• It has a diagnostic accuracy as high as 95 in
  detecting placenta previa, with a false negative
  rate of 7.
• Sagittal, parasagittal and transverse sonographic
  views should be obtained.

34
Transabdominal US

• It requires the identification of echogenic
  placental tissue overlying or proximate to the
  internal cervical os (a distance gt2 cm).

35
Transvaginal US

• It has become the gold standard for the diagnosis
  of placenta previa.
• It is a safe and effective technique, with
  diagnostic accuracy greater than 99 percent.
• The probe does not need to come into contact with
  the cervix to provide a clear image.

36
Ultrasound

• Both the transabdominal and transvaginal US
  should be used as complementary studies.
• Initial transabdominal examination, with
  transvaginal sonography if there is any ambiguity
  in the placental position.
• Translabial ultrasound imaging is an alternative
  technique.

37
Antepartum Management

• Avoidance of coitus and digital cervical
  examination.
• Counseling to seek immediate medical attention if
  there is any vaginal bleeding.
• Women are also encouraged to avoid exercise,
  decrease their activity, and notify the physician
  of uterine contractions.
• Serial ultrasound evaluations every two to four
  weeks to assess placental location and fetal
  growth.

38
Acute Care of Symptomatic Placenta Previa

• Large bore IV access administration of
  crystalloid.
• Type and cross-match for four units of PRBC.
• Transfuse to maintain a Hct of 30 if the patient
  is actively bleeding.
• Maternal pulse and blood pressure every 15
  minutes to 1 hour depending upon the degree of
  blood loss.

39
Acute Care of Symptomatic Placenta Previa

• The fetal heart rate is continuously monitored.
• Quantitative monitoring of vaginal blood loss.
• The source of the vaginal blood (maternal versus
  fetal) is intermittently assessed by either an
  Apt test or Kleihauer-Betke analysis.
• Urine output is evaluated hourly with a Foley
  catheter should be at least 30 mL/hour.

40
Acute Care of Symptomatic Placenta Previa

• Hb Hct.
• Serum electrolytes and indices of renal function.
• Coagulation profile (fibrinogen, Plt, PT PTT)
  are checked especially if there is a suspicion of
  coexistent abruption.

41
Delivery

• Tocolysis is not administered to actively
  bleeding patients.
• Delivery is indicated if          (1) there is
  a nonreassuring fetal heart rate.
•          (2) life threatening refractory
  maternal hemorrhage.

42
Mode of Delivery

• Cesarean delivery is the delivery route of
  choice.
• Vaginal delivery may be considered in the
  presence of
• a fetal demise
• previable fetus
• some cases of marginal previa, as long as the
  mother remains hemodynamically stable.

43
Conservative Management of Stable Preterm
Patients

• The patient is hospitalized at bedrest with
  bathroom privileges.
• Stool softeners and a high-fiber diet help to
  minimize constipation and avoid excess straining.
• Periodic assessment of the maternal hematocrit.
• Ferrous gluconate supplements (300 mg orally
  three or four times per day) are given with
  vitamin C to improve intestinal iron absorption.

44
Conservative Management of Stable Preterm Patients

• Cross match to provide two to four units of
  packed red blood cells.
• Prophylactic transfusions to maintain the
  maternal hematocrit above 30 percent in stable
  asymptomatic patients in anticipation of future
  blood loss.

45
Conservative Management of Stable Preterm Patients

• A single course of corticosteroid between 24 and
  34 w.
• Rh(D)-negative women should receive Rh(D)-immune
  globulin if they bled.
• Readministration is not necessary if delivery or
  rebleeding occurs within three weeks, unless a
  large fetomaternal hemorrhage is detected by KBT.

46
Conservative Management of Stable Preterm Patients

• Fetal growth, amniotic fluid volume, and
  placental location are evaluated sonographically
  every two to four weeks.
• Tocolysis may be safely utilized if contractions
  are present and delivery is not otherwise
  mandated by the maternal or fetal condition.

47
Conservative Management of Stable Preterm Patients

• Amniocentesis can be done at 36 weeks to assess
  pulmonary maturity.
• Scheduled abdominal delivery is suggested _at_ 37w
  or upon confirmation of pulmonary maturity.

48
Delivery

• Abdominal delivery.
• Two to four units of PRBC should be available for
  the delivery.
• Appropriate surgical instruments for performance
  of a cesarean hysterectomy should also be
  available since there is a 5 to 10 percent risk
  of placenta accreta.

49
C/S

• The surgeon should try to avoid disrupting the
  placenta when entering the uterus.
• If the placenta is encountered upon opening the
  uterus then it is necessery to cut through the
  placental tissue to deliver the fetus.

50
Outpatient Managaement

• Women who have never bled.
• Women with placenta previa if bleeding has
  stopped for more than one week.
• There are no other pregnancy complications, such
  as fetal growth restriction.

51
Outpatient Management

• Live within 15 minutes of the hospital.
• Have an adult companion available 24 hours a day
  who can immediately transport the woman to the
  hospital if there is light bleeding or call an
  ambulance for severe bleeding.
• Be reliable and able to maintain bed rest at
  home.
• Understand the risks entailed by outpatient
  management.

52
Outcome

• The maternal and perinatal mortality rates in
  pregnancies complicated by placenta previa have
  been reduced over the past few decades because
  of
• The introduction of conservative obstetrical
  management.
• The liberal use of cesarean rather than vaginal
  delivery.
• Improved neonatal care.

53
Vasa Previa
54
Introduction

• Vasa previa refers to vessels that traverse the
  membranes in the lower uterine segment in advance
  of the fetal head.
• Rupture of these vessels can occur with or
  without rupture of the membranes and result in
  fetal exsanguination.
• The incidence is 1 in 2000 3000 deliveries.

55
Associated Conditions

• Low-lying placenta.
• Bilobed placenta.
• Multi-lobed placenta.
• Succenturiate-lobed placenta.
• Multiple pregnancies.
• Pregnancies resulting from IVF.

56
Diagnosis

• The diagnosis of vasa previa is considered if
  vaginal bleeding occurs upon rupture of the
  membranes.
• Concomitant fetal heart rate abnormalities,
  particularly a sinusoidal pattern.
• Ideally, vasa previa is diagnosed antenatally by
  US with color flow Doppler.

57
Antenatal Management

• Consider hospitalization in the third trimester
  to provide proximity to facilities for emergency
  cesarean delivery.
• Fetal surveillance to detect compression of
  vessels.
• Antenatal corticosteroids to promote lung
  maturity.
• Elective cesarean delivery at 35 to 36 weeks of
  gestation.

58
Antepartum Management

• Immediate C/S.
• Avoid amniotomy as the risk of fetal mortality is
  60-70 with rupture of the membranes.

59
Uterine Rupture
60
Risk Factors

• The most common risk factor is a previous uterine
  incision.
• The rate is higher with classical T-shape
  uterine incision in comparison to low vertical
  transverse incisions.
• The rate increases with the number of previous
  uterine incisions.

61
Risk Factors

• High parity.
• Labor complications
• CPD.
• Abnormal presentation.
• Unusual fetal enlargement (hydrocephalus).

• Trauma.
• Delivery complications
• Difficult forceps.
• Breech extraction.
• Internal podalic version.

62
Presentation

• Sudden severe fetal heart decelerations.
• Abdominal pain PV bleeding ( lt10).
• Diaphragmatic irritation.
• Loss of fetal station.
• Cessation of uterine contractions.

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Prognosis

• Fetal death 50-75.
• Maternal mortality is high if not diagnosed
  managed promptly.
• Maternal morbidity hemorrhage infection.

64
Management

• stabilization of maternal hemodynamics.
• Prompt C/S with either repair of the uterine
  defect or hysterectomy.
• Antibiotics.

65

• A 23-y-o PG, _at_ 29w comes to AE for evaluation
  following a RTA in which a restrained passenger
  in the back seat. She denies any symptoms
  examination is normal with fetal heart rate of
  150bpm. Before discharging the patient your
  recommendation regarding electronic fetal
  monitoring
• Do none.
• Monitor for 2-6h.
• Monitor for 6-12h.
• Monitor for 12-18h.
• Monitor for 18-24h.

66

• In counseling a woman with a prior C/S regarding
  IOL, you tell her that the highest risk of
  uterine rupture is associated with
• Osmotic cervical dilator.
• Transcervical Foley balloon placement.
• Prostaglandins.
• Oxytocin.

67

• A 34-y-o woman G3P2, present _at_38w in early labor.
  V/E 3cm with a firm ridge in the membranes by
  palpation. U/S placenta located both anteriorly
  posteriorly in the lower uterine segment. There
  is no placenta previa. A tocolytic is
  administered. What should be the next step in
  management?
• Allow continued labor.
• Speculum examination.
• Amniocentesis.
• Color flow Doppler U/S.
• Amniotomy.

68

• A 19y-o PG admitted _at_ 34w with heavy vaginal
  bleeding regular contractions. She reports no
  leakage of fluid. BP156/98. F Ht 35cm. CTG is
  reactive. U/S anterior placenta no
  retroplacental sonolucency. V/E 4cm. The most
  likely Dx is
• Vasa previa.
• Placental abruption.
• Chorioangioma.
• Placenta accreta.
• Placental succenturiate lob.

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