Antepartum Hemorraghe

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Antepartum Hemorraghe

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FIRST TRIMESTER BLEEDING

• Vaginal bleeding is common in the first
  trimester, occurring in 20 to 40 percent of
  pregnant women
• It may be any combination of light or heavy,
  intermittent or constant, painless or painful.

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FIRST TRIMESTER BLEEDING

• The four major sources of bleeding in early
  pregnancy are
• Ectopic pregnancy
• Miscarriage (threatened, inevitable, incomplete,
  complete)
• Implantation of the pregnancy
• Cervical, vaginal, or uterine pathology (eg,
  polyps, inflammation/infection, trophoblastic
  disease

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SECOND AND THIRD TRIMESTER BLEEDING

• Vaginal bleeding is less common in the second and
  third trimesters. The major causes of bleeding at
  these times are
• Bloody show associated with cervical
  insufficiency or labor
• Placenta previa
• Abruptio placenta
• Uterine rupture
• Vasa previ

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Abruptio Placenta
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Definition

• Placental abruption is defined as decidual
  hemorrhage leading to the premature separation of
  the placenta prior to delivery of the fetus.

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Causes

• The immediate cause of the premature placental
  separation is often the rupture of maternal
  vessels in the decidua basalis, where it
  interfaces with the anchoring villi in the
  placenta

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Incidence

• Placental abruption complicates about 1 in 100
  births, and an abruption severe enough to result
  in stillbirth occurs in about 1 in 830 deliveries

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COMPLICATIONS OF PLACENTAL ABRUPTION

• Maternal
• Hypovolemia related to blood loss
• Need for blood transfusion
• Disseminated intravascular coagulopathy
• Renal failure
• Adult Respiratory Distress Syndrome
• Multisystem organ failure
• Death

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COMPLICATIONS OF PLACENTAL ABRUPTION

• Fetal
• Growth restriction (with chronic abruption) 1-6
• Fetal hypoxemia or asphyxia
• Preterm birth 1,2
• Perinatal mortalit

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INITIAL MANAGEMENT

• Patients suspected to have a placental abruption
  should have a rapid initial evaluation
• Subsequent management is determined on a
  case-by-case basis, and will depend upon the
  severity of the abruption, the gestational age,
  and maternal and fetal status

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INITIAL MANAGEMENT

• Continuous fetal monitoring should be initiated
  immediately, given the high likelihood of
  diminished placental perfusion
• Most serious maternal risks are due to
  hypovolemia
• It is important to immediately secure two
  wide-bore intravenous lines

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INITIAL MANAGEMENT

• The mother's hemodynamic status is closely
  monitored
• In severe cases, a Foley catheter should be
  inserted to monitor maternal urine output hourly.
  The urine output should be maintained at above 30
  ml/hour.

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INITIAL MANAGEMENT

• A complete blood count, blood type and Rh, and
  coagulation studies are obtained
• A low fibrinogen level is the most sensitive
  indicator of coagulopathy related to abruption
• Prolongation of the prothrombin time (PT) and
  partial thromboplastin time (PTT) does not occur
  with small degrees of placental separation

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INITIAL MANAGEMENT

• Blood loss should be evaluated carefully
• It is frequently underestimated since the
  bleeding may be largely concealed, and the actual
  loss may be much more than observed
• Blood and blood coagulation replacement products
  should be readily available

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INITIAL MANAGEMENT

• Ultra Sound should be performed in stable
  patients, if possible
• While some studies have reported poor sensitivity
  of ultrasound in the diagnosis of placental
  abruption, others have found that ultrasound can
  be an accurate tool in diagnosis
• The presence of sonographic features of abruption
  has a very high positive predictive value, and
  may influence management

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Blood and Blood Product Replacement

• Maintain the hematocrit above 30 percent
• Each unit of 300 mL PRBCs contains approximately
  200 mL of red cells and will raise the hematocrit
  by roughly 3 to 4 percent
• Give six units of platelets to patients with
  marked thrombocytopenia (lt20) or moderate
  thrombocytopenia (lt 50) with serious bleeding or
  planned cesarean deliver

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Blood and Blood Product Replacement

• Fresh frozen plasma or cryoprecipitate is
  indicated for fibrinogen level lt 150 mg/dL, with
  the goal of raising he level to 150 to 200 mg/dL
• Fresh frozen plasma provides more volume than
  cryoprecipitate depending on the patient's
  cardiovascular status

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Blood and Blood Product Replacement

• If multiple transfusions are given because of
  severe bleeding, the coagulation system should be
  frequently monitored with measurements of the PT,
  PTT and platelet count, preferably after each
  five units of blood are replaced
• If the PT and PTT exceed 1.5 times the control
  value, the patient should be transfused with two
  units of fresh frozen plasma
• If the platelet count falls below 50,000/microL,
  six units of platelets should be given

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SUBSEQUENT MANAGEMENT

• Subsequent management of pregnancies complicated
  by abruption depends primarily on
• The fetus (alive or dead)
• Maternal status

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Live fetus at or near term

• The fetus should be delivered by the quickest,
  safest method if it is alive, the pregnancy is at
  least 34 weeks of gestation, and abruption is
  suspected

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Live fetus at or near term

• Vaginal delivery requirements
• Maternal status is stable
• Fetal heart tracing is reassuring with continuous
  monitoring
• Preparating for emergency cesarean section

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Live fetus at or near term

• Cesarean delivery indications
• Fetal heart tracing is nonreassuring
• There is ongoing major blood loss or other
  serious maternal complications

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Fetal Demise

• The mode of delivery should be one that minimizes
  the risk of maternal morbidity or mortality
• Vaginal delivery is preferable unless urgent
  delivery is needed to enable stabilization of the
  mother or there are obstetrical contraindications
  to vaginal birth
• Since the patient is often contracting
  vigorously, amniotomy may be all that is required
  to expedite delivery
• Oxytocin can be given, if needed to augment labor

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Fetal Demise

• The frequency of coagulopathy is much higher in
  abruptions in which fetal death has occurred
• Blood pressure, pulse, urine output and blood
  loss should be monitored closely
• Blood, fresh frozen plasma, platelets, and
  cryoprecipitate should be readily available and
  given liberally.

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Placenta Previa
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INTRODUCTION

• The management of pregnancies complicated by
  placenta previa is best considered in terms of
  the clinical setting
• Asymptomatic women
• Women who are actively bleeding
• Women who are stable after one or more episodes
  of active bleeding

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ASYMPTOMATIC PLACENTA PREVIA

• Sonographic reassessment to determine placental
  position (serial transvaginal ultrasound
  evaluations at four-week intervals beginning at
  28 weeks of gestation)
• Development of the lower uterine segment over
  time often relocates the stationary lower edge of
  a marginal or low-lying placenta away from the
  internal os

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ASYMPTOMATIC PLACENTA PREVIA

• Sonographic measurement of cervical length
• It provides useful information about the risk of
  hemorrhage
• Studis found that a short cervix was associated
  with a significantly increased frequency of
  delivery because of hemorrhage
• 64 percent of women with a cervical length
  greater than 3 cm had no bleeding episodes and
  progressed to term

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ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA

• An actively bleeding placenta previa is
  anobstetrical emergency
• These women should be admitted to the Labor and
  Delivery Unit for maternal and fetal monitoring
• Intravenous access should be established (two
  large bore IV lines)

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ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA

• Blood Bank and Laboratory Monitoring
• A blood type and antibody screen should be
  performed
• If bleeding is heavy or increasing, or difficulty
  in procuring compatible blood is anticipated,
  then we advise cross-matching two to four units
  of packed red blood cells

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ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA

• Fetal monitoring 
• The fetal heart rate is continuously monitored
• Loss of reactivity, persistent minimal
  variability, or fetal tachycardia, recurrent late
  decelerations are nonreassuring signs suggesting
  the potential presence of fetal hypoxia or anemia

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ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA

• Maternal monitoring
• Use a cardiac monitor and automated blood
  pressure cuff to follow maternal heart rate and
  blood pressure
• Urine output is evaluated hourly with a Foley
  catheter attached to a urimeter

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ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA

• Maternal monitoring
• Vaginal blood loss can be estimated by weighing
  or counting perineal pads
• Visual estimations of blood loss in obstetrics
  have historically been inaccurate

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ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA

• Tocolysis
• Generally tocolysis is not used with actively
  bleeding patients
• Tocolysis may be considered if contractions are
  present, bleeding is diminishing or has ceased,
  and delivery is not otherwise mandated by the
  maternal or fetal condition

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ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA

• Indications for delivery
• A nonreassuring fetal heart rate tracing
  unresponsive to maternal oxygen therapy,
  left-sided positioning, and intravascular volume
  replacement
• Life-threatening refractory maternal hemorrhage
• Significant vaginal bleeding after 34 weeks of
  gestation

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ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA

• Anesthesia
• General anesthesia is typically administered for
  emergency cesarean delivery, especially in
  hemodynamically unstable women or if the fetal
  status is nonreassuring
• However, regional anesthesia is an acceptable
  choice in hemodynamically stable women with
  reassuring fetal heart rate tracings

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CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED

• Most women who initially present with symptomatic
  placenta previa respond to supportive therapy and
  do not require immediate delivery
• Fifty percent of women with a symptomatic previa
  (any amount of bleeding) are not delivered for at
  least four
• A large bleed does not preclude conservative
  management 

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CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED

• Symptomatic women often remain hospitalized from
  their significant bleeding episode until delivery
• Since recurrent bleeding episodes are
  unpredictable, keeping close to the hospital
  minimizes the risk of complications by enabling
  fast access to transfusion therapy and emergency
  cesarean delivery when needed
• Select women with placenta previa may be
  discharged if bleeding has stopped for a minimum
  of 48 hours and there are no other pregnancy
  complications

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CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED

• Candidates for outpatient care should
• Be able to return to the hospital within 20
  minutes
• 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
  managemen

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CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED

• Correction of anemia
• Iron supplementation may be needed for optimal
  correction of anemia
• Stool softeners and a high-fiber diet help to
  minimize constipation and avoid excess straining
  that might precipitate bleeding

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CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED

• Autologous blood donation
• Autologous blood donation is acceptable in stable
  women who meet usual criteria (hemoglobin 11.0
  g/dL)
• A program of autologous blood collection and
  transfusion can result in a decrease in
  homologous blood transfusion
• Most women who have bled from a placenta previa,
  however, will not meet standard criteria for
  autologous donation

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CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED

• Antenatal corticosteroids
•  
• A course of antenatal corticosteroid therapy
  should be administered to symptomatic women
  between 24 and 34 weeks to improve fetal
  pulmonary maturity
• Do not administer steroids to asymptomatic women
  or those whose first bleed is after 34 weeks of
  gestation

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CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED

• Fetal assessment 
• There is value of nonstress testing or BPP in the
  asymptomatic placenta previa patient who has no
  evidence of uteroplacental insufficiency or other
  signs of distress
• Active vaginal bleeding is an indication for
  fetal assessment

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DELIVERY

• Timing
• Severe persistent hemorrhage is an indication for
  delivery, regardless of gestational age
• The delivery of a pregnancy with uncomplicated
  placenta previa should be accomplished at 36 to
  37 weeks, without documentation of fetal lung
  maturity by amniocentesis
• The rationale behind this is that the risks of
  continuing the pregnancy were greater than the
  risks of complications from prematurity

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DELIVERY

• Women with increasing frequency or volume of
  bleeding or with signs of imminent labor are
  delivered at 36 weeks if they have received a
  steroid course
• However, women whose first bleed occurred after
  34 weeks may not have received a course of
  betamethasone
• If a course of antenatal steroids has not been
  given, an amniocentesis is performed and deliver
  the baby at 36 weeks if pulmonary indices are
  mature

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Route of Delivery

• Complete previa
• A cesarean delivery is always indicated when
  there is sonographic evidence of a complete
  placenta previa and a viable fetus
• Vaginal delivery may be considered in rare
  circumstances, such as in the presence of a fetal
  demise or a previable fetus, as long as the
  mother remains hemodynamically stable

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Route of Delivery

• Low-lying placenta
• Rates of cesarean delivery and antepartum
  bleeding decrease as the distance between the
  placental edge and internal os increases.
• There is a reasonable possibility of vaginal
  delivery when the placenta is more than 2 cm from
  the internal os, so a trial of labor is
  appropriate
• When this distance is between 1 and 20 mm, the
  rate of cesarean delivery ranges from 40 to 90
  percent

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Route of Delivery

• Marginal previa
• Historically, it was believed that vaginal
  delivery could occasionally be performed safely
  in women with marginal previa because the fetal
  head tamponades the adjacent placenta
• However most women with marginal previa will end
  up with a cesarean delivery
• Scheduled cesarean delivery is done for these
  pregnancies to minimize the risk of emergent
  delivery and hemorrhage

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