Prof. Dr. Daulat Sibuea SpOG (K)
Dr. Makmur Sitepu SpOG (K)
Divisi FetoMaternal
Departemen Obgin FKUSU/RS. HAM
Objectives
• 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
2
Causes of Late Pregnancy
Bleeding
Placenta Previa
Abruption
Ruptured vasa previa LifeThreatening
Uterine scar disruption
Cervical polyp
Bloody show
Cervicitis or cervical ectropion
Vaginal trauma
Cervical cancer
Placenta Previa
•
•
Definition
In placenta previa, the placenta is
implanted
in
the
lower
uterine
segment and
located over the
internal
os.
It
constitutes
an
obstruction
of
descent
of
the
presenting part.
Main cause of obstetrical hemorrhage
Uncertain
High risk factors
maternal age: >35 years
multiparity: 85% - 90%
prior cesarean delivery: 5 times
smoking
Etiology
•
Causes
1.
Endometrial abnormality
Scared or poorly vascularized
endometrium in the corpus.
Curettage, Delivery, CS and infection
of endometrium
Placental abnormality
Large placenta (multiple
pregnancy), succenturiate lobe
Delayed development of trophoblast
2.
3.
4.
5.
6.
Manifestation
•
1.
2.
3.
4.
Painless hemorrhage
The most characteristic
symptom
Time: late pregnancy (after the
28th week) and delivery
Characteristics: sudden,
painless and profuse
Cause of bleeding
Manifestation
•
•
Anemia or shock
repeated bleeding→ anemia
heavy bleeding→ shock
Abnormal fetal position
a high presenting part
breech presentation (often)
Diagnosis
•
1.
2.
3.
History
Painless hemorrhage
At late pregnancy or delivery
History of curettage or CS
Diagnosis
•
Signs
1)
Uterus is soft, relaxed and nontender.
Contraction may be palpated.
A high presenting part can’t be
pressed into the pelvic inlet. Breech
presentation
Fetal heart tones maybe disappear
(shock or abruption)
2)
3)
4)
Diagnosis
•
•
•
Speculum examination
Rule out local causes of bleeding, such
as cervical erosion or polyp or cancer.
Limited vaginal examination (seldom
used)
Palpation of the vaginal fornices to
learn if there is an intervening bogginess
between the fornix and presenting part.
Rectal examination is useless and
dangerous
Diagnosis
•
1.
2.
•
•
Ultrasonography
The most useful diagnostic method:
95%
Not make the diagnosis at the mid
pregnancy. (≥32 weeks)
MRI
Check the placenta and membrane
after delivery
Placental abruption
vagina bleeding with pain,
tenderness of uterus.
•
•
Vascular previa
Abnormality of cervix
cervical erosion or polyp or cancer
Treatments
•
1.
2.
3.
4.
Expectant therapy
Rest: keep the bed
Controlling the contraction: tocolytic
Treatment of anemia
Preventing infection
Treatments
•
1.
1)
2)
3)
Termination of pregnancy
CS
total placenta previa (37th week),
Partial placenta previa (37th week)
and heavy bleeding with shock
Preventing postpartum
hemorrhage: pitocin and PG
Hysterectomy: Placenta accreta
or uncontroled bleeding
Treatments
2.
Vaginal delivery
Marginal placenta previa
Vaginal bleeding is limited
Management
Placental Abruption
• Occurs in 1-2% of pregnancies
• 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
Risk Factors for
Abruption
Hypertensive disorders of pregnancy
MgSO4 to treat preeclampsia reduces abruption by
27%
Smoking or substance abuse (e.g. cocaine)
Trauma
Over-distention of the uterus
Previous abruption
Placental insufficiency
Thrombophilias / metabolic abnormalities
Altman D et al.; Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their
babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebocontrolled trial. Lancet. 2002;359:1877-1890
Bleeding from
Abruption
1. Externalized hemorrhage
2. Bloody amniotic fluid
3. Retroplacental clot
a. 20% occult
b. “uteroplacental apoplexy” or “Couvelaire”
uterus
4. Look for consumptive
coagulopathy
17
Placental Abruption
Visible bleeding
bleeding
Concealed
Diagnosis
Placental abruption after delivery
Patient 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 bloody show
Risk factors
Trauma, hypertension, drugs
18
Physical Exam Abruption
Signs of circulatory instability
Mild tachycardia
Signs and symptoms of shock represent > 30% blood loss
Ultrasound - Abruption
•Abruption is a clinical
diagnosis!
•Possible US findings
Retroplacental echolucency
Abnormal thickening of
placenta
“Torn” edge of placenta
20
Ultrasound - Abruption
Sher’s Classification Abruption
• Grade I
• Grade II
• Grade III
– III A
– III B
Mild, often identified at
delivery with retroplacental
clot
Symptomatic, tender
abdomen and live fetus
Severe, with fetal demise
- without coagulopathy
(2/3)
- with coagulopathy (1/3)
Sher G, Statland BE. Abruptio placentae with coagulopathy: a rational basis for
management. Clin Obstet Gynecol 1985;28(1):15-23.
22
Treatment – Grade II
Abruption
• Assess fetal and maternal stability
• Amniotomy
• IUPC to detect elevated uterine
tone
• Expeditious operative or vaginal
delivery
• Maintain urine output > 30 cc/hr,
hematocrit > 30%
• Prepare for neonatal resuscitation
Kayani SI, Walkinshaw SA, Preston C. Pregnancy outcome in severe placental abruption. BJOG 2003;110:679-683
23
Treatment – Grade III
Abruption
Assess mother for hemodynamic
and coagulation status
Vigorous replacement of fluid and
blood products
Vaginal delivery preferred, unless
severe hemorrhage
24
Conclusion
Previa vs. Abruption
Characteristic
Previa
Abruption
Amt. Blood loss
Variable
Variable
Duration
Usu. 1-2 hrs.
Usu. Continuous
Abdominal pain
None
Usu. Present
FHR Pattern
Normal
Often Abnormal
Coag. Defects
Rare
DIC possible, but
infrequent
Assoc. history
None
See risk factors
• Any pregnant woman who presents with vaginal
bleeding must be evaluated
• Never do digital exam without knowing placental
placement!
– Ultrasound
Vasa Previa
1. Rarest cause of hemorrhage
2. Associated with
In vitro fertilization
Placenta previa in 2nd or 3rd
trimester
Bilobed and succenturiate lobe
placentas
Velamentous insertion of the cord
31
Velamentous Insertion
Partially dilated cervix, seen from above
32
Velamentous
Insertion
Vasa Previa
1. Bleeding occurs with membrane
rupture
2. Blood loss is fetal
1. 56% mortality when undetected before
onset of labor
2. 3% mortality when detected prenatally
32A
Antepartum Diagnosis –
Vasa Previa
1. Amnioscopy
2. Ultrasound
a. Vasa previa is highly associated with
placenta previa on 2nd trimester US
b. Perform follow-up US with color-flow
Doppler to R/O vasa previa
3. Palpate vessels during vaginal
examination
Summary
1. Late pregnancy bleeding may herald
diagnoses with significant morbidity/
mortality
2. Determining diagnosis important, as
treatment dependent on cause
3. Avoid vaginal exam when placental
location not known