Bleeding in late pregnancy

DR.KHALED AL GHAIDANY

Antepartum hemorrhage

Vaginal bleeding in the third trimester

Complicates 4 % of all pregnancies

Causes of APH

1. Placenta previa(PP)2. Abruptio placenta(AP)3. Uterine rupture4. Fetal vessel rupture5. Cervical lesions \ lacerations6. Vaginal lesions \ lacerations7. Congenital bleeding disorders8. Unknown

Placenta previa

Painless vaginal bleeding in a previously normal pregnancy

Usually at age of 30 weeks (1\3 occurs before 30

Mechanism of bleeding:

development and thinning of the lower uterine segment in the 3rd trimester disruption of the placental attachment

Placenta previa

Incidence : 0.5 % (20 % of all APH)

Presentation:

1. Painless vaginal bleeding (70 %)

2. Bleeding with contractions (20 %)

3. incidental diagnosis “by U\S or at term”

(10 %)

PP: Predisposing factors

Multiparty

Increasing maternal age

Prior placenta previa

Multiple gestation

Previous history of PP (4-8 % risk)

PP: Classification

According to the relationship of the placenta to the internal cervical os:

1. Total “ complete” = centralis

2. Partial

3. Marginal “ marginalis”

4. Low implantation “ lateralis”

PP: Diagnosis

The most accurate tool is U\S

Transabdominal U\S (95 % sensitivity)

Transvaginal U\S: ( 100 % sensitivity, it should be done in hospital !!!)

Double set-up examination (???)

PP: prognosis

4 -6 % of patients have some degree of previa on U\S before 20 weeks gestation

With the development of the lower uterine segment, there is a relative upward placental migration, with 90 % of these resolving by 3rd trimester

However, only 10 % of complete PP resolve

PP: Management

Initially stabilize the patient

The goal is to obtain fetal maturation without compromising the mother’s health

Expectant management

Elective C\S after 36 wks gestation

(Blood loss might reach >1500 ml)

Abruptio placenta (AP)

Premature separation of the normally implemented placenta

Complicates 0.5 to 1.5 % of all pregnancies

Result in fetal death in 1 per 500 deliveries

AP: Predisposing factors

Hypertension (the most common)

Trauma

Polyhydramnios with rapid decompression on membrane rupture

Cocaine use

Tobacco use

Preterm premature rupture of membrane

A short umbilical cord

AP: pathophysiology

Hemorrhage into the decidua basalis formation of a decidual hematoma placental separation further separation and destruction of placental tissue

2 types: 1. Concealed hemorrhage (20%): when

blood dissect upward toward the fundus2. Revealed(external) hemorrhage: if

extend downward toward the cervix

AP: diagnosis

Primarily a clinical one Vaginal bleeding in association with

uterine tenderness, hyperactivity, and increased tone

Increased fundal height Abdominal pain (66% of cases) Fetal distress (60%) U\S will detect only 2% of abruptions Do U\S only to detect the coexisting PP

AP: Maternal-fetal risks

Perinatal mortality rate: 35 % Accounts for 15% of 3rd stillbirths 15% of live born infants have significant

neurological impairment AP is the most common cause of DIC in

pregnancy (20% of cases) Recurrence risk: 10 % after one AP,

and 25 % after 2 AP

AP: Management

Careful maternal hemodynamic monitoring, fetal monitoring, serial evaluation of the hematocrit and coagulation profile, and delivery

C\S should be reserved for obstetric indications only

Active delivery is the treatment of most cases

As a GP

Follow the guidelines in referring high risk pregnancies

Have a high index of suspicion Stabilize the patient before referral as

much as you can Remember “ information has no side

effects”

Build up your safety netting