K - 21 Late Pregnancy Bleeding (Obgyn)
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Transcript of K - 21 Late Pregnancy Bleeding (Obgyn)
Late Pregnancy Bleeding
Prof. Dr. Daulat Sibuea SpOG (K)Dr. Makmur Sitepu SpOG (K)
Divisi FetoMaternalDepartemen Obgin FK-USU/RS. HAM
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
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Life-Threatening
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
Placenta Previa
• Definition In placenta previa, the placenta is implanted in the
lower uterine segment and located over the internal os. It constitutes an obstruction of descent of the presenting part.
• Main cause of obstetrical hemorrhage
Classification
• Complete placenta previa
• Partial placenta previa
• Marginal placenta previa
• Low Laying placenta previa
Low-Lying Marginal Complete 4
Placenta Previa
Etiology• Uncertain• High risk factors1. maternal age: >35 years2. multiparity: 85% - 90%3. prior cesarean delivery: 5 times4. smoking
Etiology• Causes1. Endometrial abnormality2. Scared or poorly vascularized endometrium in the
corpus.3. Curettage, Delivery, CS and infection of
endometrium4. Placental abnormality5. Large placenta (multiple pregnancy),
succenturiate lobe 6. Delayed development of trophoblast
Manifestation
• Painless hemorrhage1. The most characteristic symptom2. Time: late pregnancy (after the 28th week)
and delivery3. Characteristics: sudden, painless and
profuse4. Cause of bleeding
Manifestation• Anemia or shock repeated bleeding→ anemia heavy bleeding→ shock• Abnormal fetal position a high presenting part breech presentation (often)
Diagnosis
• History1. Painless hemorrhage2. At late pregnancy or delivery3. History of curettage or CS
Diagnosis
• Signs1) Uterus is soft, relaxed and nontender. 2) Contraction may be palpated.3) A high presenting part can’t be pressed into the
pelvic inlet. Breech presentation4) Fetal heart tones maybe disappear (shock or
abruption)
Diagnosis
• Speculum examination Rule out local causes of bleeding, such as
cervical erosion or polyp or cancer. • Limited vaginal examination (seldom used) Palpation of the vaginal fornices to learn if
there is an intervening bogginess between the fornix and presenting part.
• Rectal examination is useless and dangerous
Diagnosis
• Ultrasonography1. The most useful diagnostic method: 95%2. Not make the diagnosis at the mid pregnancy.
(≥32 weeks)• MRI• Check the placenta and membrane after delivery
Diagnosis
Can you see the placenta previa?
placenta cervix
Diagnosis
More examples…
Diagnosis
And more…
• Placenta accreta Accreta adherent to endometrial cavity Increta placental tissue invades myometrium Percreta placental tissue grows through uterine wall
Differential Diagnosis
• Placental abruption vagina bleeding with pain, tenderness of uterus. • Vascular previa• Abnormality of cervix cervical erosion or polyp or cancer
Treatments • Expectant therapy1. Rest: keep the bed2. Controlling the contraction: tocolytic3. Treatment of anemia4. Preventing infection
Treatments
• Termination of pregnancy1. CS1) total placenta previa (37th week), Partial
placenta previa (37th week) and heavy bleeding with shock
2) Preventing postpartum hemorrhage: pitocin and PG
3) Hysterectomy: Placenta accreta or uncontroled bleeding
Treatments
2. Vaginal delivery Marginal placenta previa Vaginal bleeding is limited
Management
Placental Abruption
• Occurs in 1-2% of pregnancies• 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
Risk Factors for Abruption
Hypertensive disorders of pregnancy
MgSO4 to treat preeclampsia reduces abruption by 27%
Smoking or substance abuse (e.g. cocaine)
Trauma
Over-distention of the uterus
Previous abruption
Placental insufficiency
Thrombophilias / metabolic abnormalities Altman D et al.; Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their babies, benefit
from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet. 2002;359:1877-1890
Bleeding from Abruption 1. Externalized hemorrhage2. Bloody amniotic fluid3. Retroplacental clot
a. 20% occultb. “uteroplacental apoplexy” or “Couvelaire” uterus
4. Look for consumptive coagulopathy
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Placental Abruption
Visible bleeding Concealed bleeding
Diagnosis
Placental abruption after delivery
Patient History - Abruption
Pain = hallmark symptomVaries from mild cramping to severe painBack pain – think posterior abruption
BleedingMay not reflect amount of blood lossDifferentiate from exuberant bloody show
Risk factorsTrauma, hypertension, drugs
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Physical Exam - Abruption
Signs of circulatory instabilityMild tachycardia Signs and symptoms of shock represent > 30% blood loss
Maternal abdomen Fundal height Leopold’s: estimated fetal weight, fetal lieLocation of tenderness Tetanic contractions
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Ultrasound - Abruption
•Abruption is a clinical diagnosis!•Possible US findings
Retroplacental echolucencyAbnormal thickening of placenta“Torn” edge of placenta
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Ultrasound - Abruption
Sher’s Classification - Abruption• Grade I
• Grade II
• Grade III– III A– III B
Mild, often identified at delivery with retroplacental clot Symptomatic, tender abdomen and live fetusSevere, with fetal demise
- without coagulopathy (2/3) - with coagulopathy (1/3)
Sher G, Statland BE. Abruptio placentae with coagulopathy: a rational basis for management. Clin Obstet Gynecol 1985;28(1):15-23.
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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,
hematocrit > 30% • Prepare for neonatal resuscitationKayani SI, Walkinshaw SA, Preston C. Pregnancy outcome in severe placental abruption. BJOG 2003;110:679-683
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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
24
Conclusion
CharacteristicCharacteristic Previa Previa AbruptionAbruptionAmt. Blood lossAmt. Blood loss VariableVariable VariableVariableDurationDuration Usu. 1-2 hrs.Usu. 1-2 hrs. Usu. ContinuousUsu. ContinuousAbdominal pain Abdominal pain NoneNone Usu. PresentUsu. PresentFHR PatternFHR Pattern NormalNormal Often AbnormalOften AbnormalCoag. DefectsCoag. Defects RareRare DIC possible, but DIC possible, but
infrequentinfrequentAssoc. historyAssoc. history NoneNone See risk factorsSee risk factors
Previa vs. Abruption
• Any pregnant woman who presents with vaginal bleeding must be evaluated
• Never do digital exam without knowing placental placement!– Ultrasound
Vasa Previa
1. Rarest cause of hemorrhage2. Associated with
In vitro fertilization Placenta previa in 2nd or 3rd trimester Bilobed and succenturiate lobe placentas Velamentous insertion of the cord
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Velamentous Insertion
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Partially dilated cervix, seen from above
Velamentous Insertion
Vasa Previa
1. Bleeding occurs with membrane rupture2. Blood loss is fetal
1. 56% mortality when undetected before onset of labor
2. 3% mortality when detected prenatally
32A
Antepartum Diagnosis – Vasa Previa
1. Amnioscopy2. Ultrasound
a. Vasa previa is highly associated with placenta previa on 2nd trimester US
b. Perform follow-up US with color-flow Doppler to R/O vasa previa
3. Palpate vessels during vaginal examination
Summary
1. Late pregnancy bleeding may herald diagnoses with significant morbidity/ mortality
2. Determining diagnosis important, as treatment dependent on cause
3. Avoid vaginal exam when placental location not known