K - 21 Late Pregnancy Bleeding (Obgyn)

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Late Pregnancy Bleeding

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

Classification
• Complete placenta previa
• Partial placenta previa
• Marginal placenta previa
• Low Laying placenta previa

Placenta Previa

Low-Lying

Marginal

Complete

4

Etiology


1.
2.
3.
4.

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

Diagnosis
Can you see the placenta previa?

placenta
cervix

Diagnosis
More examples…

Diagnosis
And more…

• Placenta accreta
 Accreta  adherent to endometrial cavity
 Increta  placental tissue invades
myometrium
 Percreta  placental tissue grows through
uterine wall

Differential Diagnosis


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

Maternal abdomen
Fundal height
Leopold’s: estimated fetal weight, fetal lie
Location of tenderness
Tetanic contractions
19

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

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