Bleeding Late in Pregnancy
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Transcript of Bleeding Late in Pregnancy
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Bleeding Late in Pregnancy
When the placenta misbehaves
Grace Cavallaro MD, FACOG
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ObjectivesObjectives
• Identify major causes of vaginal bleeding second half of pregnancy
• Describe a systematic approach to identify the cause of bleeding
• Describe specific treatment options based on diagnosis
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Causes of Late Pregnancy Bleeding
• Placenta Previa• Abruption• Ruptured Vasa Previa• Uterine Scar Disruption• Cervical Polyp• Bloody Show• Cervicitis• Vaginal Trauma• Cervical Cancer
LifeThreatening*
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Placenta Previas
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Placenta Previas
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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 @ >30 weeks– No proven benefit to routine screening
ultrasound for this diagnosis.
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Risk factors for previa
• Previous Cesarean Sections• Previous Uterine Instrumentation• High Parity• Advancing Maternal Age
– Women over 40 have a RR of 9.0
• Smoking• Multiple Gestation
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Morbidity with Placenta Previa
• Maternal Hemorrhage
• Operative Delivery Complications
• Transfusion
• Placenta accreta, increta or percreta
• Prematurity
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Placenta Migration
• Migration means the dynamic relationship between the placenta and the internal os
• Trophotropism vs elongating lower uterine segment!
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Previous C-sections and Previas
Number of Previous C-sections
Relative Risk for a Previa
1 4.5
2 7.4
3 6.5
4 or more 44.9
Anath ObGyn 1996
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Patient History - Placenta Previa
• Painless Bleeding*– 2nd or 3rd trimester, or at term– Often following intercourse– May have preterm contractions*
• Sentinel Bleed– From large central previa– @ 26-28 weeks gestation
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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 exam unless placental location known
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Speculum exam revealing an anterior placenta previa
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Laboratory - Placenta Previa
• Hematocrit or complete blood count
• Blood Type and Rh
• Coagulation tests
• (While waiting - serum clot tube taped to the wall)
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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
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The Placenta’s Ultrasound Appearance
Echodense placental tissue
Echolucent myometrialArea rich in blood supply
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Vagina and Cervix meet at 90 degrees
Careful insertion of the vaginal probe midway into the vagina will image the LUS and the cervical os
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Complete Previa - Ultrasound
c
c
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Posterior Previa
Transvaginal ScanPosterior PlacentaPrevia
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False Previa
Lower placental border
c
Full bladderNo Previa
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False Previa - Overdistended Bladder
Bladder
c
Cervical canal
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Placental Edge by U/S and Route of Delivery
• >2 cm os - placenta edge = safe for vaginal delivery
• <1cm os - placenta edge - Cesarean delivery
• 1-2 cm = may be able to deliver vaginal
– Dawson et al Jultrasound Medicine 1996
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Ultrasound’s Role
• Previa = usually definitive except in very low lying posterior placentas in the obese patient
• Abruption - definitive diagnosis is not possible
• Transvaginal Scanning is safe in the bleeding patient
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Clinical Signs and Clinical Signs and SymptomsSymptoms
• Painless Bleeding = Previa
• Painful Bleeding = Abruption
• Painless Fetal Bleeding = Vasa Previa
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Initial managementInitial management
• 1) ABC’s1) ABC’s– Amount of bleeding noted is Amount of bleeding noted is
unreliableunreliable
• 2) Fetal Well Being2) Fetal Well Being• 3) No Vaginal Exams3) No Vaginal Exams
– Until you know where the Until you know where the placenta is!placenta is!
• 4) Ultrasound4) Ultrasound
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Fetal/Neonatal Considerations
• Gestational Age of Fetus dictates local of care
• SGA/Prematurity are major problems
• Communication with consultants is key!
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Cesarean Sections and Previas
• Pre-op Scan• Patients with Previas
undergoing C-Section– Bleed More– Require More Blood
Transfusion– Require More C-
Hysterectomies– Placenta accreta may
accompany 10%• Bladder invasion may be
associated with– DIC and massive hemorrhage
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Treatment Placenta Previa
• With no active bleeding– Expectant management
– No intercourse, digital exam
– Rescan after 30 weeks
• With late pregnancy bleeding– Assess overall status, circulatory stability
– Full dose Rhogam if Rh -
– Consider maternal transfer if premature
– May need corticosteroids, tocolysis, amniocentesis
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Expectant Management
• May discharge home if stable after 72 hours of inpatient observation.
• Reduces stay in hospital by average of 14 days.
• No increase in– Hemorrhage– Need for transfusion– Poor maternal or neonatal outcomes
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Tocolytics in Placenta Previa
• Greatest morbidity and mortlity related to prematurity.
• Tocolytics can add an additional 11 days to pregnancy.– Allows for administration of corticosteroids– No increase in maternal or fetal complications– Increase birth weights average of 320 grams
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Double Set-up Exam: digital exam in OR with ability to do immediate CD
• Appropriate only in marginal (anterior) 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 Persistant bleeding– Mature fetus
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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
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Epidemiology of Abruption*
• Occurs in 1-2% of all pregnancies• Risk Factors
– Hypertensive diseases of pregnancy– Smoking or substance abuse*– Trauma*– Overdistension of the Uterus*– History of Previous Abruption*– Unexplained elevation of MSAFP– Placental insufficiency– Maternal Thrombophilia/Metabolic abnormalities
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Abruptions and Trauma
• Can occur with blunt abdominal trauma and rapid deceleration without direct trauma
• Complications include prematurity, growth restriction and stillbirth
• Fetal evaluation after trauma– Increased use of FHR monitoring may decrease
mortality
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Bleeding from Abruption
• Externalized hemorrhage
• Bloody amniotic fluid
• Retroplacental clot– 20% occult
– “uteroplacental apoplexy or Couvelaire uterus
• Look for consumptive coagulopathy
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““Uteroplacental apoplexy or Couvelaire” uterusUteroplacental apoplexy or Couvelaire” uterus
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Cigarette Smoking as Risk factor
• Nova Scotia Registry of 87, 184 pregnancies
• 33% smoked• 2.05 Relative Risk of Abruption• 1.75 Relative Risk of Previa• No dose effect noted
• Anath AmJ of Epidemiology 1996
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Cocaine/Metamphetamine
• Associated with – chorionic villous
hemorrhage– Villous edema– Even in the absence of
clinical abruption placenta
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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/drugs)• Membrane rupture
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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
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Fetal/Uterine Monitor in an Abruption
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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
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Placental Abruption
Hemorrhage isoechoic with placenta Hematoma retroplacental
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Abruption - Retroplacental Hematoma
Retro placental hematoma day1 7 days later
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False Abruption? Contraction Mimicking Abruption
Contraction
No Contraction 30 minutes later
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Placenta Lakes
Subchorionic Placental Lake
Doppler revealing flow through the lake
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Laboratory-Abruption
• Complete blood count• Type and Rh• Coagulation tests + “Clot test”• Kleihauer-Betke test not
diagnostic, but useful to determine Rhogam dose
• Pre-eclampsia labs, if indicated• Consider urine drug screen
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Sher’s Classification
Grade IMild, often retroplacental clot identified at delivery
Grade IITense, tender abdomen and live fetus
Grade III
-IIIA
-IIIB
With fetal demise
-without coagulopathy (2/3)
-with coagulopathy (1/3)
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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 and hemotocrit > 30%
• Prepare for neonatal resuscitation
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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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Coagulopathy with Abruption
• Occurs in 1/3 of Grade III abruptions
• Usually not seen if live fetus
• Etiologies: consumption, DIC
• Administer platelets, FFP
• Give Factor VIII if severe
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Epidemiology of Uterine Rupture*
• Occult dehiscence vs.. symptomatic rupture• .03%-.08% of all women• .03%-1.7% of all women with uterine scar• Previous cesarean incision most common
reason for scar disruption• Other causes: previous uterine curettage or
perforation, inappropriate oxytocin usage, trauma, drugs*
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Risk Factors - Uterine Rupture*
• Previous Uterine Surgery*
• Congenital Uterine Anomalies
• Uterine Overdistension*
• Gestational Trophoblastic Disease
• Adenomyosis• Fetal Anomaly• Vigorous Uterine
Pressure• Difficult Placental
Removal• Placenta Increta or
Percreta (US/MRI)
During labor or delivery
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Extension of Transverse
Scar
Midline Classical Rupture
CatastrophicRupture
Uterine Scar Disruption
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Morbidity with Uterine Rupture
• Maternal– Hemorrhage with anemia– Bladder rupture– Hysterectomy– Maternal Death
• Fetal– Respiratory distress– Hypoxia– Acidemia– Neonatal death
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Patient History -Uterine Rupture*
• Vaginal Bleeding• Pain• Cessation of contractions*• Absences FHR• Loss of Station• Palpable fetal parts through
maternal abdomen• Profound maternal tachycardia
and hypotension
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Uterine Rupture• Sudden deterioration of FHR pattern is a
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
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Vasa Previa
Bridging vessels
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Vasa Previa
• Rarest cause of hemorrhage• Onset with membrane rupture• Blood Loss is fetal, with 56% mortality (3%)• Associated with placenta previa, velamentous
insertion of the cord, bilobed/succenturiate lobe, or IVF
• Antepartum diagnosis– Amnioscopy– Color doppler ultrasound– Palpate vessels during vaginal examination
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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 hour delay prohibits its use
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Modified Apt Test
• Several cc’s of blood from vagina
• Mix with Tap water
• Centrifuge
• Mix supernatant with NaOH
• Read Color in Two minutes
• Fetal = pink
• Adult = brown
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Management Vasa Previa
• Immediate Cesarean Delivery if fetal heart non-reassuring
• Administer normal saline 10-20 cc/kg bolus to newborn, if found to be in shock after delivery
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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!
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Transvaginal Predictive Value
• TVS Overlap of 10 mm or more @ 15-20 weeks predictive 100% previa at term
– Lauria US ObGyn Nov 1996
• TVS Overlap of 15 mm @ 12-16 weeks predictive at birth 5.1 %
– Taipale ObGyn 1997
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Risk factors for Abruptions
• Younger Women RR 1.4– Parity > 3 RR 10– May reflect effects of close pregnancy
spacing
• Previous Abruption RR 10• Chronic Hypertension• Preeclampsia RR 1.7• PROM RR 3.0