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
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