ANTEPARTUM HEMORRHAGE

Yenny Saputra0710006

Preceptor :dr. Roni Rowawi, SpOG (K)

CASE 1

A 40-year-old woman, 29 weeks pregnant, presented to the emergency room with painless vaginal bleeding . This is the patient's fourth pregnancy (G4 P3), and three prior births were by cesarean section.

WHAT’S THE DIAGNOSIS??

Placenta previa

WHAT’S THE PRESENTATION FOR PLACENTA PREVIA?? Sudden, painless, and profuse vaginal

bleeding in pregnancy during the second/third trimester (usually after 28 weeks)Thought to occur from placental

detachment due to thinning of lower uterine segment in preparation for labor and/or during labor

Often bright red blood First bleed

Usually not significant to cause homodynamic instability or threaten fetus

Rarely maternal death

HOW MANY TYPES OF PP ARE THERE??

ClassificationComplete: Placenta completely

covers the osPartial: Placenta partially covers the

osMarginal: Placenta edge lies within

2 cm of the osLow lying: Placenta edge lies 2 to

3.5 cm from the os

PLACENTA PREVIA

WHAT’S THE RISK FACTORS OF PLACENTA PREVIA IN THIS CASE?

Multiparity Increased maternal agePrevious cesarean delivery

WHAT ARE THE WORKUP YOU WOULD SUGGEST?? Evaluation

History and Physical Never do digital exam without knowing

placental placement! Could cause life-threatening hemorrhage

Most common imaging study used for diagnosis is ultrasound (ultrasonography)Most useful and inexpensiveTransvaginal provides almost 100% accuracy in

identification, transabdominal 95% Sterile speculum exam can be done to

evaluate for ruptured membrane

ULTRASOUND Imaging method that uses high-frequency sound

waves to produce precise images of structures Cyclic sound pressure that is greater then the

upper limit of human hearing (~20 kilohertz) Images shown as thin flat sections of the body

Advancements include 3-D images and 4-D images with motion

Does not use ionizing radiation (x-ray) Main imaging study used throughout

pregnancy Little risk to mother or fetus

Doppler ultrasound is a special ultrasound technique that evaluates blood as it flows through a vessel

CAN YOU SEE THE PLACENTA PREVIA?

placenta cervix

DIAGNOSIS

More examples…

DIAGNOSIS

And more…

DIAGNOSIS

T2

MANAGEMENT FOR PLACENTA PREVIA???

Women with significant vaginal bleeding are hospitalized for evaluation

Bleeding will usually resolve, but may return with the onset of labormaternal/fetal status unstable → delivery by c-

sectionMaternal/fetal status stable → expected management

Cesarean is the method of delivery for placenta previa This decision is not made until after 36 weeks because

often the placenta will migrate

MANAGEMENT

CASE 2

30-year-old woman, gravida 3, para 2 presented at 32 weeks' gestation with a history of dull aching pain in the abdomen radiating to her back. There was no history suggestive of tightening. There was no history of vaginal bleeding. Fetal movements were normal. Patient has a history of cocaine abuse.

WHAT’S THE DIAGNOSIS??

Placental Abruption (Abruptio placentae )

THE DEFINITION OF ABRUPTIO PLACENTAE

Placental Abruption is the separation of the placenta from the uterine wall before delivery

HOW MANY TYPES??Marginal separation Partial separationComplete separation with concealed hemorrhage

THE CLASSIFICATION OF ABRUPTIO PLACENTAE

Class 0 is asymptomatic Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta

Class 1 is mild (48% cases)No vaginal bleeding to mild vaginal bleeding

Class 2 is moderate (27% cases)No vaginal bleeding to moderate vaginal bleeding

Class 3 is severe (24% cases)No vaginal bleeding to heavy vaginal bleeding

PLACENTAL ABRUPTION

Visible bleeding Concealed bleeding

RISK FACTORS OF ABRUPTION Chronic

hypertension Multiparity Preeclampsia Advanced

maternal age Previous

abruption Short umbilical

cord Sudden

decompression of an overdistended uterus

Thrombophilias Tobacco, cocaine, or

methamphetamine use

Trauma: blunt abdominal or sudden deceleration

Unexplained elevated maternal alpha fetoprotein level

Uterine fibroids

PRESENTATION OF ABRUPTIO PLACENTAE

Women often present with the following:Painful vaginal bleeding

Bleeding may not be visibleAbdominal or back pain and uterine

tenderness Fetal distress

Non-reassuring fetal heart rateAbnormal uterine contractions

( hypertonic, high frequency) Idiopathic premature laborFetal death

DIAGNOSIS

Can you see the abruption?

Abruption

DIAGNOSIS

More examples….

DIAGNOSIS

And more….

DIAGNOSIS

MRI – abruption with incidental previa

T2 T1

MANAGEMENTIf fetus is mature, homodynamic

stabilization is warranted with prompt delivery

If fetus is premature, may observe with close monitoring as long as no fetal/maternal distressCareful monitoring for uteroplacental

insufficiency is essentialMust rule out coagulopathy - Check PT/PTT,

platelet, fibrinogen, fibrin split productsDIC can occur as a result of abruption

CONCLUSION PREVIA VS ABRUPTION

CharacteristicCharacteristic Previa Previa AbruptionAbruption

Amt. Blood lossAmt. Blood loss VariableVariable VariableVariable

DurationDuration Usu. 1-2 hrs.Usu. 1-2 hrs. Usu. ContinuousUsu. Continuous

Abdominal pain Abdominal pain NoneNone Usu. PresentUsu. Present

FHR PatternFHR Pattern NormalNormal Often AbnormalOften Abnormal

Coag. DefectsCoag. Defects RareRare DIC possible, but DIC possible, but infrequentinfrequent

Assoc. historyAssoc. history NoneNone See risk factorsSee risk factors

REFERENCE

Fontaine P, Leeman L, Sakornbut E. Late Pregnancy Bleeding. American Family Physician 2005;75:8

Bleeding During Pregnancy. The American College of Obstetricians and Gynecologist; http://www.acog.org/

Blueprints Obstetric and Gynecology, 4th edition, Lippincott Williams and Wilkins

Department of Obstetrics and Gynecology, University of South Carolina (Mark Wild,MD)