Late Pregnancy Bleeding

Prof. Dr. Daulat Sibuea SpOG (K)Dr. Makmur Sitepu SpOG (K)

Divisi FetoMaternalDepartemen Obgin FK-USU/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

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Life-Threatening

Causes of Late Pregnancy Bleeding

Placenta Previa Abruption Ruptured vasa previa 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

Low-Lying Marginal Complete 4

Placenta Previa

Etiology• Uncertain• High risk factors1. maternal age: >35 years2. multiparity: 85% - 90%3. prior cesarean delivery: 5 times4. smoking

Etiology• Causes1. Endometrial abnormality2. Scared or poorly vascularized endometrium in the

corpus.3. Curettage, Delivery, CS and infection of

endometrium4. Placental abnormality5. Large placenta (multiple pregnancy),

succenturiate lobe 6. Delayed development of trophoblast

Manifestation

• Painless hemorrhage1. The most characteristic symptom2. Time: late pregnancy (after the 28th week)

and delivery3. Characteristics: sudden, painless and

profuse4. Cause of bleeding

Manifestation• Anemia or shock repeated bleeding→ anemia heavy bleeding→ shock• Abnormal fetal position a high presenting part breech presentation (often)

Diagnosis

• History1. Painless hemorrhage2. At late pregnancy or delivery3. History of curettage or CS

Diagnosis

• Signs1) Uterus is soft, relaxed and nontender. 2) Contraction may be palpated.3) A high presenting part can’t be pressed into the

pelvic inlet. Breech presentation4) Fetal heart tones maybe disappear (shock or

abruption)

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

• Ultrasonography1. The most useful diagnostic method: 95%2. 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 • Expectant therapy1. Rest: keep the bed2. Controlling the contraction: tocolytic3. Treatment of anemia4. Preventing infection

Treatments

• Termination of pregnancy1. CS1) total placenta previa (37th week), Partial

placenta previa (37th week) and heavy bleeding with shock

2) Preventing postpartum hemorrhage: pitocin and PG

3) 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 placebo-controlled trial. Lancet. 2002;359:1877-1890

Bleeding from Abruption 1. Externalized hemorrhage2. Bloody amniotic fluid3. Retroplacental clot

a. 20% occultb. “uteroplacental apoplexy” or “Couvelaire” uterus

4. Look for consumptive coagulopathy

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Placental Abruption

Visible bleeding Concealed bleeding

Diagnosis

Placental abruption after delivery

Patient History - Abruption

Pain = hallmark symptomVaries from mild cramping to severe painBack pain – think posterior abruption

BleedingMay not reflect amount of blood lossDifferentiate from exuberant bloody show

Risk factorsTrauma, hypertension, drugs

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Physical Exam - Abruption

Signs of circulatory instabilityMild tachycardia Signs and symptoms of shock represent > 30% blood loss

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

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Ultrasound - Abruption

•Abruption is a clinical diagnosis!•Possible US findings

Retroplacental echolucencyAbnormal thickening of placenta“Torn” edge of placenta

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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 fetusSevere, 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.

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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 resuscitationKayani SI, Walkinshaw SA, Preston C. Pregnancy outcome in severe placental abruption. BJOG 2003;110:679-683

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Treatment – Grade III Abruption

Assess mother for hemodynamic and coagulation status

Vigorous replacement of fluid and blood products

Vaginal delivery preferred, unless severe hemorrhage

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Conclusion

CharacteristicCharacteristic Previa Previa AbruptionAbruptionAmt. Blood lossAmt. Blood loss VariableVariable VariableVariableDurationDuration Usu. 1-2 hrs.Usu. 1-2 hrs. Usu. ContinuousUsu. ContinuousAbdominal pain Abdominal pain NoneNone Usu. PresentUsu. PresentFHR PatternFHR Pattern NormalNormal Often AbnormalOften AbnormalCoag. DefectsCoag. Defects RareRare DIC possible, but DIC possible, but

infrequentinfrequentAssoc. historyAssoc. history NoneNone See risk factorsSee risk factors

Previa vs. Abruption

• 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 hemorrhage2. Associated with

In vitro fertilization Placenta previa in 2nd or 3rd trimester Bilobed and succenturiate lobe placentas Velamentous insertion of the cord

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Velamentous Insertion

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Partially dilated cervix, seen from above

Velamentous Insertion

Vasa Previa

1. Bleeding occurs with membrane rupture2. 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. Amnioscopy2. 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