bleeding in early & late pregnancy
TRANSCRIPT
bleeding in Early & Late
pregnancy
Dr. Rabi Narayan Satapathy
Asst. Professor
Dept. of Ob. & Gynae.
SCB Medical College, CuttackMob. 09861281510
Causes of early bleeding in pregnancy
Abortion
Ectopic pregnancyHydatidiform mole
Abortion/Miscarriage
Definition: any fetal loss from conception until the time of
fetal viability at 24 weeks gestation.
OR:
Expulsion of a fetus or an embryo weighing 500 gm or less
Incidence: 15 - 20% of pregnancies total reproductive losses
are much higher if one considers losses that occur prior to
clinical recognition.
Classification:
1. spontaneous:
occurs without medical or mechanical means.
2. induced abortion
Pathology
Haemorrhage into the decidua basalis.
Necrotic changes in the tissue adjacent to
the bleeding.
Detachment of the conceptus.
The above will stimulate uterine
contractions resulting in expulsion.
Causes of miscarriage
Fetal causes:
Chromosome Abnormality:
- 50% of spontaneous losses are associated with fetal chromosome
abnormalities.
- autosomal trisomy (nondisjunction/balanced translocation): is the
single largest category of abnormality and → recurrence.
- monosomy (45, X; turner): occurs in 7% of spontaneous abortions
and it is caused by loss of the paternal sex chromosome.
- triploids: found in 8 to 9% of spontaneous abortions. it is the
consequence of either dispermy or failure of extrusion of the
second polar body,
Causes of miscarriage
Maternal causes:
1. Immunological:
- alloimmune response: failure of a normal immune response in the
mother to accept the fetus for a duration of a normal pregnancy.
- autoimmune disease: antiphospholipid antibodies especially lupus
anticoagulant (LA) and the anticardiolipin antibodies (ACL)
2. uterine abnormality:
- congenital: septate uterus → recurrent abortion.
- fibroids (submucus): → (1) disruption of implantation and
development of the fetal blood supply, (2) rapid growth and
degeneration with release of cytokines, and (3) occupation of space
for the fetus to grow. Also polyp > 2 cm diameter.
- cervical incompetence: → second trimester abortions.
Causes of miscarriage
Maternal causes:
3. Endocrine :
- poorly controlled diabetes (type 1/type 2).
- hypothyroidism and hyperthyroidism.
- Luteal Phase Defect (LPD): a situation in which the endometrium is
poorly or improperly hormonally prepared for implantation and is
therefore inhospitable for implantation. (questionable).
4. Infections (maternal/fetal): as TORCH infections, Ureaplasma
urealyticum, listeria
Environmental toxins: alcohol, smoking, drug abuse, ionizing
radiation……
Types of abortion
Threatened abortion.
Inevitable abortion.
Incomplete abortion.
Complete abortion.
Missed abortion
Septic abortion: Any type of
abortion, which is complicated by
infection
Recurrent abortion: 3 or more
successive spontaneous abortions
Clinical features/management
Threatened abortion:
- Short period of amenorrhea.
- Corresponding to the duration.
- Mild bleeding (spotting).
- Mild pain.
- P.V.: closed cervical os.
- Pregnancy test (hCG): + ve.
- US: viable intra uterine fetus.
Management
- reassurance.
- Rest.
- Repeated U/S
Inevitable abortion
Clinical feature:
- Short period of amenorrhea.
- heavy bleeding accompanied
with clots (may lead to shock).
- Severe lower abdominal pain.
- P.V.: opened cervical os.
- Pregnancy test (hCG): + ve.
- US: non-viable fetus and blood
inside the uterus.
Management:
- fluids…..blood.
- ergometrinn & sentocinon.
- evacuation of the uterus
(medical/surgical).
Incomplete abortion
Clinical feature:
- Partial expulsion of
products
- Bleeding and colicky pain
continue.
- P.V.: opened cervix…
retained products may be
felt through it.
- US: retained products of
conception.
Treatment
as inevitable abortion
Complete abortion
- expulsion of all products of conception.
- Cessation of bleeding and abdominal pain.
- P.V.: closed cervix.
- US: empty uterus.
Missed abortion
Feature:
- gradual disappearance of pregnancy Symptoms Signs.
- Brownish vaginal discharge.
- Milk secretion.
- Pregnancy test: negative but it may be + ve for 3-4 weeks after the death of the fetus.
- US: absent fetal heart pulsations.
Complications
- Infection (Septic abortion)
- DIC
Treatment- Wait 4 weeks for spontaneous
expulsion
- evacuate if:
Spontaneous expulsion does not occur after 4 weeks.
Infection.
DIC.
- Manage according to size of uterus
- Uterus < 12 weeks : dilatation and evacuation.
- Uterus > 12 weeks : try Oxytocin or PGs.
Vaginal Bleeding in
Late Pregnancy
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
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
Life-Threatening
Prevalence of Placenta Previa
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 >30 weeks
No proven benefit to routine screening ultrasound for this diagnosis
Risk Factors for Placenta Previa
Previous cesarean delivery
Previous uterine instrumentation
High parity
Advanced maternal age
Smoking
Multiple gestation
Morbidity with Placenta Previa
Maternal hemorrhage
Operative delivery complications
Transfusion
Placenta accreta, increta, or percreta
Prematurity
Patient History – Placenta Previa
Painless bleeding
2nd or 3rd trimester, or at term
Often following intercourse
May have preterm contractions
“Sentinel bleed”
Physical Exam – Placenta Previa
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
Laboratory – Placenta Previa
Hematocrit or complete blood count
Blood type and Rh
Coagulation tests
While waiting – serum clot tube taped to wall
Ultrasound – Placenta Previa
Can confirm diagnosis
Full bladder can create false appearance of
anterior previa
Presenting part may overshadow posterior previa
Transvaginal scan can locate placental edge and
internal os
Treatment – Placenta Previa
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
Double Set-Up Exam
Appropriate only in marginal previa with vertex
presentation
Palpation of placental edge and fetal head with set
up for immediate surgery
Cesarean delivery under regional anesthesia if:
Complete previa
Fetal head not engaged
Non-reassuring tracing
Brisk or persistent bleeding
Mature fetus
Placental 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
Epidemiology of Abruption
Occurs in 1-2% of pregnancies
Risk factors
Hypertensive diseases of pregnancy
Smoking or substance abuse (e.g. cocaine)
Trauma
Overdistention of the uterus
History of previous abruption
Unexplained elevation of MSAFP
Placental insufficiency
Maternal thrombophilia/metabolic abnormalities
Abruption and Trauma
Can occur with blunt abdominal trauma and
rapid deceleration without direct trauma
Complications include prematurity, growth
restriction, stillbirth
Fetal evaluation after trauma
Increased use of FHR monitoring may decrease
mortality
Bleeding from Abruption
Externalized hemorrhage
Bloody amniotic fluid
Retroplacental clot
20% occult
“uteroplacental apoplexy” or “Couvelaire” uterus
Look for consumptive coagulopathy
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
Trauma
Other risk factors (e.g. hypertension)
Membrane rupture
Physical Exam - Abruption
Signs of circulatory instability
Mild tachycardia normal
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
Ultrasound - 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
Laboratory - Abruption
Complete blood count
Type and Rh
Coagulation tests + “Clot test”
Kleihauer-Betke not diagnostic, but useful to
determine Rhogam dose
Preeclampsia labs, if indicated
Consider urine drug screen
Sher’s Classification - Abruption
Grade I
Grade II
Grade III with fetal demise
III A - without coagulopathy (2/3)
III B - with coagulopathy (1/3)
mild, often retroplacental
clot identified at delivery
tense, tender abdomen and
live fetus
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 and hematocrit > 30%
Prepare for neonatal resuscitation
Treatment – Grade III Abruption
Assess mother for hemodynamic and
coagulation status
Vigorous replacement of fluid and blood
products
Vaginal delivery preferred, unless severe
hemorrhage
Coagulopathy 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
Epidemiology 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 cesarean incision most common
reason for scar disruption
Other causes: previous uterine curettage or
perforation, inappropriate oxytocin usage,
trauma
Risk Factors – Uterine Rupture
Previous uterine surgery Adenomyosis
Congenital uterine
anomaly
Fetal anomaly
Uterine overdistension Vigorous uterine
pressure
Gestational trophoblastic
neoplasia
Difficult placental
removal
Placenta increta or
percreta
Morbidity with Uterine Rupture
Maternal
Hemorrhage with anemia
Bladder rupture
Hysterectomy
Maternal death
Fetal
Respiratory distress
Hypoxia
Acidemia
Neonatal death
Patient 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
Uterine Rupture
Sudden deterioration of FHR pattern is most frequent finding
Placenta may play a role in uterine rupture
Transvaginal ultrasound to evaluate uterine wall
MRI to confirm possible placenta accreta
Treatment
Asymptomatic scar disruption – expectant management
Symptomatic rupture – emergent cesarean delivery
Vasa Previa
Rarest cause of hemorrhage
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
Color doppler ultrasound
Palpate vessels during vaginal examination
Diagnostic Tests – Vasa Previa
Apt test – based on colorimetric response of
fetal hemoglobin
Wright stain of vaginal blood – for nucleated
RBCs
Kleihauer-Betke test – 2 hours delay prohibits its
use
Management – Vasa Previa
Immediate cesarean delivery if fetal heart rate is
non-reassuring
Administer normal saline 10 – 20 cc/kg bolus to
newborn, if found to be in shock after delivery
Summary
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