Obstetric Hemorrhage

Dr mukhamad Nooryanto,SpOG

Placental Abruption

Risk FactorsTrauma (usually shearing, such as a car accident), preeclampsia (and maternal HTN), smoking, cocaine abuse, high parity, previous history of abruption

Clinical PresentationVaginal bleeding (maternal and fetal blood present)Constant and severe back pain or uterine tendernessIrritable, tender, and typically hypertonic uterusEvidence of fetal distressMaternal shock

Figure 9-3. Placental abruption

Diagnosis

Ultrasound will show retroplacental hematoma only part of the time

Clinical and pathological findings

Management Correct shock (packed RBCs, fresh frozen

plasma, cryoprecipitate, platelets)

Expectant management: Close observation of mother and fetus with ability to intervene immediately

If there is fetal distress, perform C-section

Placenta Previa

A condition in which the placenta is implanted in the immediate vicinity of the cervical canal. It can be classified into three types:

1. Complete placenta previa: The placenta covers the entire internal cervical os

2. Partial placenta previa: The placenta partially covers the internal cervical os

3. Marginal placenta previa: One edge of the placenta extends to the edge of the internal cervical os

Figure 9-4.

Incidence0,5 to 1 %

EtiologyUnknown, but associated with: Increased parity Older mothers Previous abortions Previous history of placenta previa Fetal anomalies

Clinical Presentation Painless, profuse bleeding in T3 Postcoital bleeding Spotting during T1 and T2 Cramping (10% of cases)

Diagnosis

Transabdominal ultrasound (95% accurate)

Double set-up exam: Take the patient to the operating room and prep for a C-section. Do speculum exam: If there is local bleeding, do a C-section; if not, palpate fornices to determine if placenta is covering the os. The double set-up exam is performed only on the rare occasion that the ultrasound is inconclusive

Management

Cesarean section is always the delivery method of choice for placenta previa. The specific management is geared toward different situations

For Preterm If there is no pressing need for delivery, monitor in hospital or send home after

bleeding has ceased Transfusions to replace blood loss, and tocolytics to prolong labor to 36 weeks if

necessary

Even after the bleeding has stopped, repeated small hemorrhages may cause IUGRFor Mature Fetus C-section

For a Patient in Labor C-section

If Severe Hemorrhage C-section regardless of fetal maturity

Fetal Vessel Rupture

Two conditions caused third-trimester bleeding resulting from fetal vessel rupture:

1. Vasa previa

2. Velamentous cord insertion

These two conditions often occur together

Vasa Previa

A condition in which the fetal cord vessels unprotectedly pass over the internal os, making them susceptible to rupture and bleeding

Incidence0.03 to 0.05%

PresentationRapid vaginal bleeding and fetal distress (sinusoidal variation of fetal

heart rate)

ManagementCorrection of shock and immediate C-section

Velamentous Cord Insertion

The velamentous insertion of the umbilical cord into the fetal membrane other words, the fetal vessels insert between amnion and chorion. This cause them susceptible to ripping when the amniotic sac ruptures

Epidemiology 1% of single pregnancies 10% of twins 50% of triplets

Clinical PresentationVaginal bleeding with fetal distress

ManagementCorrection of shock and immediate C-section

Uterine Rupture

The ripping of the uterine musculature through all of its layers, usually part of the fetus protruding through the opening

Incidence

0,5%

Risk Factors

Prior uterine scar is associated with 40% of cases:

Vertical scar:5% risk

Transverse scar:0,5% risk

Presentation and Diagnosis Sudden cessation of uterine contractions with a “tearing” Recession of the fetal presenting part Increased suprapubic pain and tenderness with labor Vaginal bleeding (or bloody urine) Sudden, severe fetal heart rate decelerations Sudden disappearance of fetal heart tones Maternal hypovolemia from concealed hemorrhage

Management Total abdominal hysterectomy is treatment of choice If childbearing is important to the patient, rupture repair

is risky

Other obstetric causes of Third-

Trimester bleeding

Circumvillate placenta: The chorionic plate (on fetal side of placenta)is smaller than the basal plate