Title: Vaginal Bleeding in Late Pregnancy
1Vaginal Bleeding in Late Pregnancy
2Objectives
- Identify major causes of vaginal bleeding in the
second half of pregnancy - Describe a systematic approach to identifying the
cause of bleeding - Describe specific treatment options based on
diagnosis
3Causes of Late Pregnancy Bleeding
- Placenta Praevia
- Abruption
- Ruptured vasa praevia
- Uterine scar disruption
- Cervical polyp
- Bloody show
- Cervicitis or cervical ectropion
- Vaginal trauma
- Cervical cancer
Life-threatening
4Prevalence of Placenta Praevia
- Occurs in 1/200 pregnancies that reach 3rd
trimester - Low-lying placenta seen in 50 of ultrasound
scans at 16-20 weeks - 90 will have normal implantation when scan
repeated at gt 30 weeks - No proven benefit to routine screening ultrasound
for this diagnosis
5Risk Factors for Placenta Praevia
- Previous caesarean delivery
- Previous uterine instrumentation
- High parity
- Advance maternal age
- Smoking
- Multiple gestation
6Morbidity and Placenta Praevia
- Maternal haemorrhage
- Operative delivery complications
- Transfusion
- Placenta accreta, increta or percreta
- Prematurity
7Patient History Placenta Praevia
- Painless bleeding
- 2nd or 3rd trimester, or at term
- Often following intercourse
- May have preterm contractions
- Sentinel bleed
8Physical Exam Placenta Praevia
- Vital signs
- Assess fundal height
- Fetal lie
- Estimated fetal weight (Leopold)
- Presence of fetal heart tones
- Gentle speculum exam
- No digital vaginal exam unless placental location
known
9Laboratory Placenta Praevia
- Haematocrit or complete blood count
- Blood type and Rh
- Coagulation tests
10Ultrasound Placenta Praevia
- Can confirm diagnosis
- Full bladder can create false appearance of
anterior praevia - Presenting part may overshadow posterior praevia
- Transvaginal scan can locate placental edge and
internal os
11Treatment Placenta Praevia
- With no active bleeding
- Expectant management
- No intercourse, digital exams
- With late pregnancy bleeding
- Assess overall status, circulatory stability
- Full dose Rhogam if Rh-
- Consider maternal transfer if premature
- May need corticosteroids, tocolysis,
amniocentesis
12Double Set-Up Exam
- Appropriate only in marginal praevia with vertex
presentation - Palpation of placental edge and fetal head with
set up for immediate surgery - Caesarean delivery under regional anaesthesia if
- complete praevia
- fetal head no engaged
- non-reassuring tracing
- brisk or persistent bleeding
- mature foetus
13Placental Abruption
- Premature separation of placenta from uterine
wall - Partial or complete
- Marginal sinus separation or marginal sinus
rupture - Bleeding, but abnormal implantation or abruption
never established
14Epidemiology of Abruption
- Occurs in 1-2 of pregnancies
- Risk factors
- hypertensive diseases of pregnancy
- smoking or substance abuse (e.g. cocaine)
- trauma
- overdistension of the uterus
- history of previous abruption
- unexplained elevation of MSAFP
- placental insufficiency
- maternal thrombophilia/metabolic abnormalities
15Abruption and Trauma
- Can occur with blunt abdominal trauma and rapid
deceleration without direct trauma - Complications inculde prematurity, growth
restriction, stillbirth - Fetal evaluation after trauma
- Increased use of FHR monitoring may decrease
mortality
16Bleeding from Abruption
- Externalized hemorrhage
- Bloody amniotic fluid
- Retroplacental clot
- 20 occult
- Couverlaire uterus
- Look for consumptive coagulopathy
17Patient History - Abruption
- Pain hallmark symptom
- Varies from mild cramping to severe pain
- Back pain think posterior abruption
- Bleeding
- May not reflect amount of blood loss
- Differentiate from exuberant blood show
- Trauma
- Other risk factors (e.g. hypertension)
- Membrane rupture
18Physical Exam - Abruption
- Signs of circulatory instability
- Mild tachycardia normal
- Signs and symptoms of shock represent gt 30
blood test - Maternal abdomen
- Fundal height
- Leopolds estimated fetal weight, fetal lie
- Location of tenderness
- Tetanic contractions
19Ultrasound - Abruption
- Abruption is a clinical diagnosis!
- Placental location and appearance
- Retroplacental echolucency
- Abnormal thickening of placenta
- Torn edge of placenta
- Fetal lie
- Estimated fetal weight
20Laboratory - Abruption
- Complete blood count
- Type and Rh
- Coagulation tests
- Kleihauer-Betke not diagnostic, but useful to
determine Rhogam dose - Preeclampsia labs, if indicated
- Consider using drug screen
21Shers Classification - Abruption
Grade I mild, often retroplacental clot identified at delivery
Grade II tense, tender abdomen and live fetus
Grade III III A III B with fetal demise without coagulopathy (2/3) with coagulopathy (1/3)
22Treatment Grade II Abruption
- Assess fetal and maternal stability
- Amniotomy
- IUPC to detect elevated uterine tone
- Expeditious operative or vaginal delivery
- Maintain urine output gt 30cc/hr and haematocrit gt
30 - Prepare for neonatal resuscitation
23Treatment Grade III Abruption
- Assess mother for hemodynamic and coagulation
status - Vigorous replacement of fluid and blood products
- Vaginal delivery preferred, unless severe
haemorrhage
24Coagulopathy with Abruption
- Occurs in 1/3 of Grade III abruption
- Usually not seen if live fetus
- Etiologies consumption, DIC
- Administer platelets, FFP
- Give factor VIII if severe
25Epidemiology of Uterine Rupture
- Occult dehiscence vs. symptomatic rupture
- 0.03-0.08 of all women
- 0.3-1.7 of women with uterine scar
- Previous caesarean incision most common reason
for scar disruption - Other causes previous uterine curettage or
perforation, inappropriate oxytocin usage, trauma
26Risk Factors Uterine Rupture
- adenomyosis
- fetal anomaly
- vigorous uterine pressure
- difficult placental removal
- placenta increta or percreta
- pervious uterine surgery
- congenital uterine anomaly
- uterine overdistension
- gestational trophoblastic neoplasia
27Morbidity with Uterine Rupture
- Maternal
- haemorrhage with anaemia
- bladder rupture
- hysterectomy
- maternal death
- Fetal
- respiratory distress
- hypoxia
- acidaemia
- neonatal death
28Patient History Uterine Rupture
- Vaginal bleeding
- Pain
- Cessation of contractions
- Absence of FHR
- Loss of station
- Palpable fetal parts through maternal abdomen
- Profound maternal tachycardia and hypotension
29Uterine Rupture
- Sudden deterioration of FHR pattern is most
frequent finding - Placenta may play a role in uterine rupture
- Transvaginal ultrasound to elevate uterine wall
- MRI to confirm possible placenta accreta
- Treatment
- Asymptomatic scar disruption expectant
management - Symptomatic rupture emergent caesarean delivery
30Vasa Praevia
- Rarest cause of haemorrhage
- Onset with membrane rupture
- Blood loss is fetal, with 50 mortality
- Seen with low lying placenta, velamentous
insertion of the cord or succenturiate lobe - Antepartum diagnosis
- amnioscopy
- colour doppler ultrasound
- palpate vessels during vaginal examination
31Diagnostic Tests Vasa Praevia
- Apt test based on colorimetric response of
fetal haemoglobin - Wright stain of vaginal bleed for nucleated
RBCs - Kleihauer-Betke test 2 hour delay prohibits its
use
32Management Vasa Praevia
- Immediate caesarean delivery if fetal hear rate
non-assuring - Administer normal saline 10-20 cc/kg bolus to
newborn, if found to be in shock after delivery
33Summary
- Late pregnancy bleeding may herald diagnoses with
significant morbidity/ mortality - Determining diagnosis important, as treatment
dependent on cause - Avoid vaginal exam when placental location not
known